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Diminished Cardiac Performance and Left Ventricular Dimensions in Neonates with Congenital Diaphragmatic Hernia

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Abstract

Introduction

Newborns with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH), and there is limited evidence that cardiac dysfunction is present. We sought to study early neonatal biventricular function and performance in these patients by reviewing early post-natal echocardiography (ECHO) measurements and comparing them to normal term newborns.

Methods

Retrospective case–control study reviewing clinical and ECHO data on term newborns with CDH and normal controls born between 2009 and 2016. Patients were excluded if major anomalies, genetic syndromes, or no ECHO available. PH was assessed by ductal shunting and tricuspid regurgitant jet velocity. Speckle-tracking echocardiography was used to assess myocardial deformation using velocity vector imaging.

Results

Forty-four patients with CDH and 18 age-matched controls were analyzed. Pulmonary pressures were significantly higher in the CDH cohort (systolic pulmonary arterial pressure to systolic blood pressure of 103 ± 13 vs. 78 ± 29%, p = 0.0001). CDH patients had decreased RV fractional area change (FAC − 28.6 ± 11.1 vs. 36.2 ± 9.6%, p = 0.02), tricuspid annular plane of systolic excursion (TAPSE—5.6 ± 1.6 vs. 8.6 ± 1.6 mm, p = 0.0001), and RV outflow tract stroke distance (8.6 ± 2.7 vs. 14.0 ± 4.5 cm, p = 0.0001) compared with controls. The left ventricular (LV) ejection fraction was similar in both groups, but CDH patients had a decreased LV end-diastolic volume by Simpson’s rule (2.7 ± 1.0 vs. 5.0 ± 1.8 mL, p = 0.0001) and LVOT stroke distance (9.7 ± 3.4 vs. 12.6 ± 3.6 cm, p = 0.004). Biventricular global longitudinal strain (GLS) was markedly decreased in the CDH population compared to controls (RV-GLS: − 9.0 ± 5.3 vs. − 19.5 ± 1.4%, p = 0.0001; LV GLS: − 13.2 ± 5.8 vs. − 20.8 ± 3.5%, p = 0.0001).

Conclusion

CDH newborns have evidence of biventricular dysfunction and decreased cardiac output. Abnormal function may be a factor in the non-response to pulmonary arterial vasodilators in CDH patients. A two-pronged management strategy aimed at improving cardiac function, as well as reducing pulmonary artery pressure in CDH newborns, may be warranted.

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Abbreviations

BP:

Blood pressure

CDH:

Congenital diaphragmatic hernia

DICOM:

Digital imaging and communications in medicine format

EDSR:

Early diastolic strain rate

EF:

Ejection fraction

EDV:

End-diastolic volume

ECMO:

Extracorporeal membrane oxygenation

FAC:

Fractional area change

GLS:

Global longitudinal strain

GLSR:

Global longitudinal strain rate

LV:

Left ventricle

EI:

Eccentricity index

LVOT:

Left ventricular outflow tract

MPA:

Main pulmonary artery

PDA:

Patent ductus arteriosus

PAP:

Pulmonary artery pressure

RV:

Right ventricle

RVOT:

Right ventricular outflow tract

STE:

Speckle-tracking echocardiography

SD:

Standard deviation

TAPSE:

Tricuspid annular plane systolic excursion

TR:

Tricuspid regurgitant jet velocity

VTI:

Velocity time integral

VVI:

Velocity vector imaging

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Author information

Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, McGill University – Montreal Children’s Hospital, 1001 Decarie, Montreal, QC, H4A 3J1, Canada

    Gabriel Altit

  2. Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

    Shazia Bhombal & Krisa Van Meurs

  3. Neonatal ECMO Program, Lucile Packard Children’s Hospital at Stanford, Stanford, CA, USA

    Krisa Van Meurs

  4. Division of Cardiology, Echocardiography Laboratory, Department of Pediatrics, Stanford University - Lucile Packard Children’s Hospital, Stanford, CA, USA

    Theresa A. Tacy

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  1. Gabriel Altit
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  2. Shazia Bhombal
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  4. Theresa A. Tacy
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Correspondence to Gabriel Altit.

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Conflict of interest

We have no conflicts of interest related to the content of this study. Gabriel Altit is the author that wrote the first draft. There was no payment, grant, or honorarium given to anyone to produce the manuscript.

Ethical Approval

This study was approved by the institutional review board of Stanford University (protocol—IRB-39501).

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Altit, G., Bhombal, S., Van Meurs, K. et al. Diminished Cardiac Performance and Left Ventricular Dimensions in Neonates with Congenital Diaphragmatic Hernia. Pediatr Cardiol 39, 993–1000 (2018). https://doi.org/10.1007/s00246-018-1850-7

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  • DOI: https://doi.org/10.1007/s00246-018-1850-7

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