Screening for pulmonary hypertension in preterm infants with bronchopulmonary dysplasia: when, how often and does it matter?

Objective: Bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (BPD-PH) is the most severe endotype of BPD; there is insufficient evidence to support the optimal screening strategy in at-risk infants. We hypothesised that serial echocardiography throughout hospitalisation would improve PH detection with increased negative predictive value (NPV) beyond 36 week's postmenstrual age (PMA).

Study design: This was a single centre cohort study conducted between 2017 and 2023. In infants with BPD-PH, all echocardiograms preceding a diagnostic echocardiogram were included and considered false negatives for prediction of later PH. In infants with BPD alone, all echocardiograms were included and were considered true negatives. These indices were then used to estimate the sensitivity and NPV of echocardiographic screening for PH. In addition, we compared the performance of four different potential echocardiographic screening approaches on the ability to identify infants with BPD-PH.

Results: Data from 394 infants were available for this analysis of whom 258 had BPD alone and 136 had BPD-PH. 2542 echocardiograms were used in estimates of diagnostic accuracy. The highest NPVs occurred with echocardiographic screening starting at 36 weeks' and continuing monthly until discharge. Detection of BPD-PH among infants with BPD differed by screening strategy: 34.5% for comprehensive screening, 20.0% for early screening, 15.0% for singular screening and 30.7% for late screening (p<0.05).

Conclusions: While the diagnostic accuracy of echocardiographic screening increases at and beyond 36 weeks' PMA, obtaining a singular echocardiogram may be an insufficient screening strategy for the detection of BPD-PH in at-risk infants.