Diminished Cardiac Performance and Left Ventricular Dimensions in Neonates with Congenital Diaphragmatic Hernia
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.
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.
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).
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.
KeywordsSpeckle-tracking echocardiography Congenital diaphragmatic hernia Neonatal cardiac function Pulmonary hypertension Strain analysis Velocity vector imaging
Congenital diaphragmatic hernia
Digital imaging and communications in medicine format
Early diastolic strain rate
Extracorporeal membrane oxygenation
Fractional area change
Global longitudinal strain
Global longitudinal strain rate
Left ventricular outflow tract
Main pulmonary artery
Patent ductus arteriosus
Pulmonary artery pressure
Right ventricular outflow tract
Tricuspid annular plane systolic excursion
Tricuspid regurgitant jet velocity
Velocity time integral
Velocity vector imaging
Compliance with Ethical Standards
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.
This study was approved by the institutional review board of Stanford University (protocol—IRB-39501).
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