Early targeted neonatal echocardiography identifies biventricular dysfunction and pulmonary hypertension associated with death or severe bronchopulmonary dysplasia in infants born before 29 weeks' gestation

Background Extremely preterm infants are at increased risk of haemodynamic instability during early postnatal transition. The contribution of early biventricular dysfunction and pulmonary hypertension to mortality and severe respiratory morbidity remains incompletely defined. Objectives To determine whether early targeted neonatal echocardiography (TNE) markers of biventricular function and pulmonary hypertension are associated with death or severe bronchopulmonary dysplasia (BPD) in infants born before 29 weeks' gestation. Methods We conducted a retrospective cohort study of inborn infants <29 weeks' gestation admitted to a tertiary neonatal intensive care unit between October 2023 and June 2025. All infants underwent standardized TNE within 72 h of birth. Echocardiographic indices of left and right ventricular systolic function, ductal shunt direction, and pulmonary hypertension were compared between survivors and non-survivors, and among survivors with and without severe BPD (Jensen grade 3). The primary outcome was death before 36 weeks' postmenstrual age or severe BPD. Results Of 122 infants included, 24 (19.7%) died and 33 of 98 survivors (33.7%) developed severe BPD. Survivors demonstrated significantly better biventricular systolic performance and more favourable pulmonary haemodynamics, including higher ventricular outputs, greater tricuspid annular plane systolic excursion, higher pulmonary artery acceleration time–to–right ventricular ejection time ratios, and lower eccentricity indices (all p < 0.001). Non-survivors more frequently exhibited bidirectional or right-to-left ductal shunting, higher estimated right ventricular systolic pressure, and septal bowing. Among survivors, severe BPD was associated with worse right ventricular systolic function and higher pulmonary hypertension markers, while left ventricular systolic indices did not differ. Conclusions In extremely preterm infants, early TNE markers of biventricular dysfunction and pulmonary hypertension were associated with death and severe respiratory morbidity. These findings suggest that early haemodynamic phenotype may have prognostic relevance and warrant further prospective investigation.