Hemodynamic Phenotyping Redefines Bronchopulmonary Dysplasia as a Complex Cardiopulmonary Syndrome

Bronchopulmonary dysplasia (BPD), a major complication of extreme prematurity, causes significant long-term respiratory, cardiovascular, and neurodevelopmental morbidity. Traditionally viewed as solely a parenchymal lung disorder, emerging evidence highlights its complex nature as a cardiopulmonary syndrome. This involves disrupted vascular development, abnormal transitional circulation, and ventricular dysfunction, which current standard-of-care often overlooks in its focus on lung mechanics. Understanding these hemodynamic mechanisms, particularly pulmonary vascular disease (PVD) and BPD-associated pulmonary hypertension (BPD-PH), is crucial for improving outcomes.

This study conducted a narrative review, synthesizing current experimental, translational, and clinical studies. The researchers focused on key areas including pulmonary vascular development, transitional hemodynamics, the role of patent ductus arteriosus (PDA), and ventricular function in preterm infants. They also examined the utility of targeted neonatal echocardiography and biomarker-based risk stratification, such as NT-proBNP, for early detection. The review further explored evidence supporting phenotype-based classification and individualized therapeutic strategies for BPD.

Abnormal pulmonary vascular growth in BPD begins early, often during the transitional circulatory period, and is significantly aggravated by factors like hyperoxia, mechanical ventilation, inflammation, and placental dysfunction. Prolonged exposure to hemodynamically significant left-to-right shunts, particularly patent ductus arteriosus, contributes to pulmonary overcirculation, edema, and vascular remodeling. Elevated pulmonary vascular resistance (PVR) leads to right ventricular pressure overload, while left ventricular diastolic dysfunction and pulmonary venous congestion further worsen pulmonary edema and gas exchange. Early hemodynamic assessment using targeted neonatal echocardiography and biomarkers such as NT-proBNP enables detection of subclinical PVD and ventricular dysfunction. This allows for a shift towards phenotype-based classification and precision management strategies. The review underscores that BPD is not just a lung disease but a systemic cardiopulmonary issue. > Early hemodynamic assessment using targeted neonatal echocardiography and biomarkers like NT-proBNP is critical for detecting subclinical PVD and ventricular dysfunction, enabling phenotype-based precision management.