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Altit G, Lapointe A, Kipfmueller F, Patel N. Cardiac function in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151438. [PMID: 39018716 DOI: 10.1016/j.sempedsurg.2024.151438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Cardiac function is known to play critical role in the pathophysiological progression and ultimate clinical outcome of patients with congenital diaphragmatic hernia (CDH). While often anatomically normal, the fetal and neonatal heart in CDH can suffer from both right and left ventricular dysfunction. Here we explore the abnormal fetal heart, early postnatal right and left ventricular dysfunction, the interplay between cardiac dysfunction and pulmonary hypertension, evaluation and echocardiographic assessment of the heart, and therapeutic strategies for managing and supporting the pathophysiologic heart and CDH. Further, we take a common clinical scenario and provide clinically relevant guidance for the diagnosis and management of this complex process.
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MESH Headings
- Humans
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hernias, Diaphragmatic, Congenital/physiopathology
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Infant, Newborn
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/diagnosis
- Echocardiography
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/diagnosis
- Fetal Heart/diagnostic imaging
- Fetal Heart/physiopathology
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Affiliation(s)
- Gabriel Altit
- Division of Neonatology, Montreal Children's Hospital, McGill University Health Centre, Montréal, Canada
| | - Anie Lapointe
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Medicine, Children's Hospital University of Bonn, Germany
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK.
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Fraga MV, Hedrick HL, Rintoul NE, Wang Y, Ash D, Flohr SJ, Mathew L, Reynolds T, Engelman JL, Avitabile CM. Congenital Diaphragmatic Hernia Patients with Left Heart Hypoplasia and Left Ventricular Dysfunction Have Highest Odds of Mortality. J Pediatr 2024; 271:114061. [PMID: 38636784 PMCID: PMC11239301 DOI: 10.1016/j.jpeds.2024.114061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/18/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES To describe the scope of left ventricular (LV) dysfunction and left heart hypoplasia (LHH) in infants with congenital diaphragmatic hernia (CDH), to determine associations with CDH severity, and to evaluate the odds of extracorporeal membrane oxygenation (ECMO) and death with categories of left heart disease. STUDY DESIGN Demographic and clinical variables were collected from a single-center, retrospective cohort of patients with CDH from January 2017 through May 2022. Quantitative measures of LV function and LHH were prospectively performed on initial echocardiograms. LHH was defined as ≥2 of the following: z score ≤ -2 of any left heart structure or LV end-diastolic volume <3 mL. LV dysfunction was defined as shortening fraction <28%, ejection fraction <60%, or global longitudinal strain <20%. The exposure was operationalized as a 4-group categorical variable (LV dysfunction +/-, LHH +/-). Logistic regression models evaluated associations with ECMO and death, adjusting for CDH severity. RESULTS One hundred eight-two patients (80.8% left CDH, 63.2% liver herniation, 23.6% ECMO, 12.1% mortality) were included. Twenty percent demonstrated normal LV function and no LHH (LV dysfunction-/LHH-), 37% normal LV function with LHH (LV dysfunction-/LHH+), 14% LV dysfunction without LHH (LV dysfunction+/LHH-), and 28% both LV dysfunction and LHH (LV dysfunction+/LHH+). There was a dose-response effect between increasing severity of left heart disease, ECMO use, and mortality. LV dysfunction+/LHH + infants had the highest odds of ECMO use and death, after adjustment for CDH severity [OR (95% CI); 1.76 (1.20, 2.62) for ECMO, 2.76 (1.63, 5.17) for death]. CONCLUSIONS In our large single-center cohort, patients with CDH with LV dysfunction+/LHH + had the highest risk of ECMO use and death.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA.
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Devon Ash
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Sabrina J Flohr
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jenny L Engelman
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Catherine M Avitabile
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA; Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
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Tydén KÖ, Mesas Burgos C, Jonsson B, Nordenstam F. Left atrial strain in neonates with congenital diaphragmatic hernia and length of stay in pediatric intensive care unit. Front Pediatr 2024; 12:1404350. [PMID: 38895191 PMCID: PMC11183789 DOI: 10.3389/fped.2024.1404350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction The role of cardiac left ventricle (LV) dysfunction in children with congenital diaphragmatic hernia (CDH) has gained increasing attention. The hernia allows abdominal mass to enter thorax and subsequently both dislocating and compressing the heart. The pressure on vessels and myocardium alters blood flow and may interfere with normal development of the LV. A dysfunctional LV is concerning and impacts the complex pathophysiology of CDH. Hence, assessing both the systolic and diastolic LV function in the newborn with CDH is important, and it may add value for medical treatment and prognostic factors as length of stay (LOS) in pediatric intensive care unit (PICU). LV strain is considered an early marker of systolic dysfunction used in the pediatric population. Left atrial (LA) strain is an echocardiographic marker of LV diastolic dysfunction used in the adult population. When filling pressure of the LV increases, the strain of the atrial wall is decreased. We hypothesized that reduced LA strain and LV strain are correlated with the LOS in the PICU of newborns with CDH. Methods This retrospective observational cohort study included data of 55 children born with CDH between 2018 and 2020 and treated at Karolinska University Hospital, Sweden. Overall, 46 parents provided consent. Echocardiograms were performed in 35 children <72 h after birth. The LA reservoir strain (LASr), LV global longitudinal strain, LV dimensions, and direction of blood flow through the patent foramen ovale (PFO) were retrospectively assessed using the echocardiograms. Results Children with LASr <33% (n = 27) had longer stays in the PICU than children with LA strain ≥33% (n = 8) (mean: 20.8 vs. 8.6 days; p < 0.002). The LASr was correlated with the LOS in the PICU (correlation coefficient: -0.378; p = 0.025). The LV dimension was correlated with the LOS (correlation coefficient: -0.546; p = 0.01). However, LV strain was not correlated to LOS. Conclusion Newborns with CDH and a lower LASr (<33%) had longer stays in the PICU than children with LASr ≥33%. LASr is a feasible echocardiographic marker of diastolic LV dysfunction in newborns with CDH and may indicate the severity of the condition.
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Affiliation(s)
- Katarina Övermo Tydén
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Cardiology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Carmen Mesas Burgos
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Baldvin Jonsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Felicia Nordenstam
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Cardiology Unit, Karolinska University Hospital, Stockholm, Sweden
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Duggal M, Moore SS, Simoneau J, Girard G, Gernet IB, Oettingen JEV, Sant'Anna G, Altit G. Pulmonary Hypertension and Necrotizing Enterocolitis in Neonates Treated with Diazoxide. Am J Perinatol 2024; 41:e1435-e1444. [PMID: 36882098 DOI: 10.1055/s-0043-1764385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE This study aimed to evaluate the prevalence of adverse outcomes, specifically pulmonary hypertension (PH) and suspected or confirmed necrotizing enterocolitis (NEC), and their associated risk factors, in neonates treated with diazoxide. STUDY DESIGN A retrospective study in infants born ≥ 316/7 weeks and admitted between January 2014 and June 2020. Combined adverse outcomes possibly associated to diazoxide were PH (systolic pulmonary pressure of ≥40 mm Hg or an eccentricity index ≥1.3) and suspected or confirmed NEC (suspected: stop feeds and antibiotics and confirmed: modified Bell stage ≥2). Echocardiography data extractors were masked to infants' characteristics. RESULTS A total of 63 infants were included; 7 (11%) with suspected and 1 (2%) with confirmed NEC. Of the 36 infants with an available echocardiography after initiation of diazoxide treatment, 12 (33%) had PH. All infants with suspected or confirmed NEC were males (p = 0.01), whereas PH occurred mostly in females (75%, p = 0.02). The combined adverse outcome occurred in 14/26 (54%) infants exposed to >10 mg/kg/day, compared to 6/37 (16%) exposed to ≤10 mg/kg/day (p = 0.006). This association remained significant after adjustment for sex, small for gestational age status, and gestational age at birth (odds ratio: 6.1, 95% confidence interval: 1.7-21.7, p = 0.005). Left ventricular dysfunction was found in 19 infants (30%) but was not discriminative for the combined outcome. CONCLUSION PH and suspected or confirmed NEC were identified frequently in neonates treated with diazoxide. A total dose >10 mg/kg/day was associated with an increased occurrence of these complications. KEY POINTS · PH and suspected or confirmed NEC were frequently found in neonates treated with diazoxide.. · A total dose >10 mg/kg/day was associated with an increased occurrence of these complications.. · Echocardiography screening should be considered in neonates exposed to diazoxide..
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Affiliation(s)
- Mounya Duggal
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Shiran S Moore
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Jessica Simoneau
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Gabrielle Girard
- Department of Pharmacy, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Irène B Gernet
- Department of Pharmacy, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julia E Von Oettingen
- Division of Endocrinology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Guilherme Sant'Anna
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Gowda SH, Patel N. "Heart of the Matter": Cardiac Dysfunction in Congenital Diaphragmatic Hernia. Am J Perinatol 2024; 41:e1709-e1716. [PMID: 37011900 DOI: 10.1055/a-2067-7925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Despite advances in caring for neonates with congenital diaphragmatic hernia (CDH), mortality and morbidity continues to be high. Additionally, the pathophysiology of cardiac dysfunction in this condition is poorly understood. Postnatal cardiac dysfunction in neonates with CDH may be multifactorial with origins in fetal life. Mechanical obstruction, competition from herniated abdominal organs into thoracic cavity combined with redirection of ductus venosus flow away from patent foramen ovale leading to smaller left-sided structures may be a contributing factor. This shunting decreases left atrial and left ventricular blood volume, which may result in altered micro- and macrovascular aberrations affecting cardiac development in the prenatal period. Direct mass effect from herniated intra-abdominal contents restricting cardiac growth and/or reduced left ventricular preload may contribute independently to left ventricular dysfunction in the absence of right ventricular dysfunction and or pulmonary hypertension. With variable clinical phenotypes of cardiac dysfunction, pulmonary hypertension, and respiratory failure in patients with CDH, there is increased need for individualized diagnosis and tailored therapy. Routine use of therapy such as inhaled nitric oxide and sildenafil that induces significant pulmonary vasodilation may be detrimental in left ventricle dysfunction, whereas in a patient with pure right ventricle dysfunction, they may be beneficial. Targeted functional echocardiography serves as a real-time tool for defining the pathophysiology and aids optimization of vasoactive therapy in affected neonates. KEY POINTS: · Cardiac dysfunction in neonates with CDH is multifactorial.. · Postnatal cardiac dysfunction in patients with CDH has its origins in fetal life.. · Right ventricular dysfunction contributes to systemic hypotension.. · Left ventricular dysfunction contributes to systemic hypotension.. · Supportive therapy should be tailored to clinical phenotype..
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MESH Headings
- Humans
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/physiopathology
- Infant, Newborn
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/diagnostic imaging
- Echocardiography
- Nitric Oxide
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/physiopathology
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Affiliation(s)
- Sharada H Gowda
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
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Moore SS, Keller RL, Altit G. Congenital Diaphragmatic Hernia: Pulmonary Hypertension and Pulmonary Vascular Disease. Clin Perinatol 2024; 51:151-170. [PMID: 38325939 DOI: 10.1016/j.clp.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
This review provides a comprehensive summary of the current understanding of pulmonary hypertension (PH) in congenital diaphragmatic hernia, outlining the underlying pathophysiologic mechanisms, methods for assessing PH severity, optimal management strategies, and prognostic implications.
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Affiliation(s)
- Shiran S Moore
- Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Weizamann 6, Tel-Aviv, Jaffa 6423906, Israel.
| | - Roberta L Keller
- Neonatology, UCSF Benioff Children's Hospital, 550 16th Street, #5517, San Francisco, CA 94158, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Gabriel Altit
- Neonatology, McGill University Health Centre, Montreal Children's Hospital, 1001 Décarie boulevard, Montreal, H4A Quebec; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Huntley ES, Hernandez-Andrade E, Papanna R, Bergh E, Espinoza J, Soto E, Lopez SM, Harting MT, Johnson A. Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2024; 51:191-202. [PMID: 38194948 DOI: 10.1159/000536171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/03/2024] [Indexed: 01/11/2024]
Abstract
INTRODUCTION The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH). METHODS CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated. RESULTS Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02). CONCLUSION Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eric Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Maternal Fetal Medicine, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Suzanne M Lopez
- Department of Pediatrics, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Altit G, Bonifacio SL, Guimaraes CV, Bhombal S, Sivakumar G, Yan B, Chock V, Meurs KV. Cardiac Dysfunction in Neonatal HIE Is Associated with Increased Mortality and Brain Injury by MRI. Am J Perinatol 2023; 40:1336-1344. [PMID: 34492719 DOI: 10.1055/s-0041-1735618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Describe the association between cardiac dysfunction and death or moderate-to-severe abnormalities on brain magnetic resonance imaging (MRI) in neonates undergoing therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective study in neonates with moderate or severe HIE undergoing therapeutic hypothermia between 2008 and 2017. Primary outcome was death or moderate-to-severe brain injury using the Barkovich score. Conventional and speckle-tracking echocardiography measures were extracted from available echocardiograms to quantify right (RV) and left (LV) ventricular functions. RESULTS A total of 166 newborns underwent therapeutic hypothermia of which 53 (36.5%) had echocardiography performed. Ten (19%) died prior to hospital discharge, and 11 (26%) had moderate-to-severe brain injury. There was no difference in chronologic age at echocardiography between the normal and adverse outcome groups (22 [±19] vs. 28 [±21] hours, p = 0.35). Cardiac findings in newborns with abnormal outcome included lower systolic and diastolic blood pressure (BP) at echocardiography (p = 0.004) and decreased tricuspid annular plane systolic excursion (a marker of RV systolic function; p = 0.01), while the ratio of systolic pulmonary artery (PA) pressure to systolic BP indicated isosystemic pressures (>2/3 systemic) in both groups. A multilogistic regression analysis, adjusting for weight and seizure status, indicated an association between abnormal outcome and LV function by longitudinal strain, as well as by ejection fraction. CONCLUSION Newborns who died or had moderate-to-severe brain injury had a higher incidence of cardiac dysfunction but similar PA pressures when compared with those who survived with mild or no MRI abnormalities. KEY POINTS · Newborns with HIE with functional LV/RV dysfunction are at risk for death or brain injury.. · All neonates with HIE had elevated pulmonary pressure, but neonates with poor outcome had RV dysfunction.. · When evaluating newborns with HIE by echocardiography, beyond estimation of pulmonary pressure, it is important to assess biventricular function..
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Affiliation(s)
- Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Carolina V Guimaraes
- Division of Pediatric Radiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Ganesh Sivakumar
- Division of Neonatal and Developmental Medicine Stanford University, Lucile Packard Children's Hospital, Palo Alto, California
| | - Beth Yan
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Valerie Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Krisa V Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California
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10
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Altit G, Bonifacio SL, Guimaraes CV, Sivakumar G, Yan B, Chock V, Van Meurs K, Bhombal S. Altered biventricular function in neonatal hypoxic-ischaemic encephalopathy: a case-control echocardiographic study. Cardiol Young 2023; 33:1587-1596. [PMID: 36065722 DOI: 10.1017/s1047951122002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In newborns with hypoxic-ischaemic encephalopathy, more profound altered right and left ventricular function has been associated with mortality or brain injury. Mechanisms underlying cardiac dysfunction in this population are thought to be related to the persistence of increased pulmonary vascular resistance and myocardial ischaemia. We sought to compare cardiac function in newborns with hypoxic-ischaemic encephalopathy to controls using echocardiography. METHODS We did a retrospective case-control study with moderate or severe hypoxic-ischaemic encephalopathy between 2008 and 2017. Conventional and speckle-tracking echocardiography measures were extracted to quantify right and left ventricular systolic and diastolic function. Fifty-five newborns with hypoxic-ischaemic encephalopathy were compared to 28 controls. RESULTS Hypoxic-ischaemic encephalopathy newborns had higher estimated systolic pulmonary pressure (62.5 ± 15.0 versus 43.8 ± 17.3 mmHg, p < 0.0001) and higher systolic pulmonary artery pressure/systolic blood pressure ratio [101 ± 16 (iso-systemic) versus 71 ± 27 (2/3 systemic range) %, p < 0.0001]. Tricuspid annular plane systolic excursion was decreased (7.5 ± 2.2 versus 9.0 ± 1.4 mm, p = 0.002), E/e' increased (7.9 ± 3.3 versus 5.8 ± 2.0, p = 0.01), and right ventricle-myocardial performance index increased (68.1 ± 21.5 versus 47.8 ± 9.5, p = 0.0001) in hypoxic-ischaemic encephalopathy. Conventional markers of left ventricle systolic function were similar, but e' velocity (0.059 ± 0.019 versus 0.070 ± 0.01, p = 0.03) and left ventricle-myocardial performance index were statistically different (77.9 ± 26.2 versus 57.9 ± 11.2, p = 0.001). The hypoxic-ischaemic encephalopathy group had significantly altered right and left ventricular deformation parameters by speckle-tracking echocardiography. Those with decreased right ventricle-peak longitudinal strain were more likely to have depressed left ventricle-peak longitudinal strain. CONCLUSION Newborns with hypoxic-ischaemic encephalopathy have signs of increased pulmonary pressures and altered biventricular systolic and diastolic function.
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Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Carolina V Guimaraes
- Clinical Professor of Radiology Division Chief of Pediatric Radiology Pediatric Neuroradiology University of North Carolina, School of Medicine, Department of Radiology, Chapel Hill, North Carolina 2006 Old Clinic Building, CB# 7510, Chapel Hill, NC, 27599-7510, USA
| | - Ganesh Sivakumar
- Division of Neonatal and Developmental Medicine, Stanford University - Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Beth Yan
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Valerie Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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11
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Le LS, Kinsella JP, Gien J, Frank BS. Failure to Normalize Biventricular Function Is Associated with Extracorporeal Membrane Oxygenation Use in Neonates with Congenital Diaphragmatic Hernia. J Pediatr 2023; 260:113490. [PMID: 37201678 DOI: 10.1016/j.jpeds.2023.113490] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/03/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
We examined postnatal echocardiograms for 62 infants with congenital diaphragmatic hernia born from 2014 through 2020. Left and right ventricular dysfunction on D0 were sensitive, whereas persistent dysfunction on D2 was specific for extracorporeal membrane oxygenation requirement. Biventricular dysfunction had the strongest association with extracorporeal membrane oxygenation. Serial echocardiography may inform prognosis in congenital diaphragmatic hernia.
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Affiliation(s)
- Lisa S Le
- Heart Institute, Children's Hospital Colorado, Aurora CO
| | - John P Kinsella
- Department of Pediatrics Section of Neonatology, University of Colorado, Aurora CO
| | - Jason Gien
- Department of Pediatrics Section of Neonatology, University of Colorado, Aurora CO
| | - Benjamin S Frank
- Department of Pediatrics Section of Cardiology, University of Colorado, Aurora CO.
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12
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Pugnaloni F, Bo B, Hale L, Capolupo I, Dotta A, Bagolan P, Schroeder L, Berg C, Geipel A, Mueller A, Patel N, Kipfmueller F. Early Postnatal Ventricular Disproportion Predicts Outcome in Congenital Diaphragmatic Hernia. Am J Respir Crit Care Med 2023; 208:325-328. [PMID: 37311245 DOI: 10.1164/rccm.202212-2306le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/08/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
- Flaminia Pugnaloni
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Bartolomeo Bo
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Lennart Hale
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine and
- Department of Obstetrics and Prenatal Medicine, University Hospital Cologne, Cologne, Germany; and
| | | | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Division of Congenital Malformations, Center for Rare Diseases Bonn, University Hospital Bonn, Bonn, Germany
| | - Neil Patel
- Department of Neonatology, The Royal Hospital for Children, Glasgow, United Kingdom
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Division of Congenital Malformations, Center for Rare Diseases Bonn, University Hospital Bonn, Bonn, Germany
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13
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Moore SS, De Carvalho Nunes G, Villegas Martinez D, Dancea A, Wutthigate P, Simoneau J, Beltempo M, Sant'Anna G, Altit G. Association of Gestational Age at Birth With Left Cardiac Dimensions at Near-Term Corrected Age Among Extremely Preterm Infants. J Am Soc Echocardiogr 2023; 36:867-877. [PMID: 37044171 DOI: 10.1016/j.echo.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Remodeling and altered ventricular geometry have been described in adults born preterm. Although they seem to have an adverse cardiac phenotype, the impact of various degrees of prematurity on cardiac development has been scarcely reported. In this study, we evaluated the impact of gestational age (GA) at birth on cardiac dimensions and function at near-term age among extremely preterm infants. METHODS This is a retrospective single-center cohort study of infants born at <29 weeks of GA between 2015 and 2019. Infants with available clinically acquired echocardiography between 34 and 43 weeks were included. Two groups were investigated: those born <26 weeks and those born ≥26 weeks. All measurements were done by an expert masked to clinical data using the raw images. The primary outcome was measurements of cardiac dimensions and function based on GA group. Secondary outcomes were the association between cardiac dimensions and postnatal steroid exposure and with increments of GA at birth. RESULTS A total of 205 infants were included (<26 weeks, n = 102; ≥26 weeks, n = 103). At time of echocardiography, weight (2.4 ± 0.5 vs 2.5 ± 0.5 kg, P = .86) and age (37.2 ± 1.6 vs 37.1 ± 1.9 weeks, P = .74) were similar between groups. There was no difference in metrics of right-sided dimensions and function. However, left-sided dimensions were decreased in infants born <26 weeks, including systolic left ventricle (LV) diameter (1.06 ± 0.20 cm vs 1.12 ± 0.18 cm, P = .02), diastolic LV length (2.85 ± 0.37 vs 3.02 ± 0.57 cm, P = .02), and estimated LV end-diastolic volume (5.36 ± 1.69 vs 6.01 ± 1.79 mL, P = .02). CONCLUSIONS In our cohort of very immature infants, birth at the extreme of prematurity was associated with smaller left cardiac dimensions around 36 weeks of corrected age. Future longitudinal prospective studies should evaluate further the impact of prematurity on LV development and performance and their long-term clinical impact.
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Affiliation(s)
- Shiran Sara Moore
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gabriela De Carvalho Nunes
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Daniela Villegas Martinez
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Adrian Dancea
- Department of Pediatric Cardiology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Punnanee Wutthigate
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- Department of Pediatric Cardiology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Guilherme Sant'Anna
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Gabriel Altit
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Department of Pediatrics, McGill University, Montreal, Quebec, Canada.
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14
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De Bie FR, Avitabile CM, Flohr S, Land S, Mathew L, Wang Y, Ash D, Rintoul NE, Hedrick HL. Treprostinil in Neonates with Congenital Diaphragmatic Hernia-Related Pulmonary Hypertension. J Pediatr 2023; 259:113420. [PMID: 37059388 DOI: 10.1016/j.jpeds.2023.113420] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/09/2023] [Accepted: 03/31/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE To describe our experience with treprostinil, evaluate correlations with cardiac function, and assess for adverse effects in neonates with congenital diaphragmatic hernia-related pulmonary hypertension (CDH-PH). STUDY DESIGN A retrospective review of a single-center prospective registry at a quaternary care children's hospital. Patients included in the study had CDH-PH treated with treprostinil between April 2013 and September 2021. Assessed outcomes were brain-type natriuretic peptide levels and quantitative echocardiographic parameters collected at baseline, 1 week, 2 weeks, and 1 month after treprostinil initiation. Right ventricular (RV) function was assessed by tricuspid annular plane systolic excursion Z-score and speckle tracking echocardiography (global longitudinal and free wall strain). Septal position and left ventricular (LV) compression were assessed by eccentricity index and M-mode Z-scores. RESULTS Fifty-one patients were included, with an average expected/observed lung-to-head ratio of 28.4 ± 9.0%. Most patients required extra-corporeal membrane oxygenation (n = 45, 88%). Survival to hospital discharge was 31/49 (63%). Treprostinil was initiated at a median age of 19 days with a median effective dose of 34 ng/kg/minute. Median baseline brain-type natriuretic peptide level decreased from 416.9 pg/mL to 120.5 pg/mL after 1 month. Treprostinil was associated with improved tricuspid annular plane systolic excursion Z-score, RV global longitudinal strain, RV free wall strain, LV eccentricity index, and LV diastolic and systolic dimensions, reflecting less compression by the RV, regardless of ultimate patient survival. No serious adverse effects were recorded. CONCLUSIONS In neonates with CDH-PH, treprostinil administration is well tolerated and is associated with improved RV size and function.
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Affiliation(s)
- Felix R De Bie
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA; My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.
| | - Catherine M Avitabile
- Division of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Cardiology, Children's Hospital of Philadelphia, PA, USA
| | - Sabrina Flohr
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Sierra Land
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Leny Mathew
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Yan Wang
- Division of Cardiology, Children's Hospital of Philadelphia, PA, USA
| | - Devon Ash
- Division of Cardiology, Children's Hospital of Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
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15
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Hong SM, Chen XH, Zhou SJ, Hong JJ, Zheng YR, Chen Q, Huang JX. Successful extracorporeal membrane oxygenation for postoperative cardiopulmonary failure in newborns with congenital diaphragmatic hernia: case reports and literature reviews. Front Pediatr 2023; 11:1158885. [PMID: 37441572 PMCID: PMC10333486 DOI: 10.3389/fped.2023.1158885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) is a structural defect caused by inadequate fusion of the pleuroperitoneal membrane that forms the diaphragm, allowing peritoneal viscera to protrude into the pleural cavity. Up to 30% of newborns with CDH require extracorporeal membrane oxygenation (ECMO) support. As with all interventions, the risks and benefits of ECMO must be carefully considered in these patients. Cardiopulmonary function has been shown to worsen rather than improve after surgical CDH repair. Even after a detailed perioperative assessment, sudden cardiopulmonary failure after surgery is dangerous and requires timely and effective treatments. Method Three cases of cardiopulmonary failure after surgical CDH treatment in newborns have been reported. ECMO support was needed for these three patients and was successfully discontinued. We report our treatment experience. Conclusion ECMO is feasible for the treatment of postoperative cardiopulmonary failure in newborns with CDH.
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16
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Gowda SH, Almaazmi A, Hagan J, Niemyjski E, Vogel AM, Jancelewicz T, Di Nardo M, Harting MT, Fernandes CJ, Nguyen DV, Guner YS. Inhaled Nitric Oxide Utilization in Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: A Propensity Score Analysis. ASAIO J 2023; 69:504-510. [PMID: 37040072 DOI: 10.1097/mat.0000000000001901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Although used commonly, ability of inhaled nitric oxide (iNO) to improve outcomes in infants with congenital diaphragmatic hernia (CDH) who receive extracorporeal life support (ECLS) remains controversial. We sought to determine the association between pre-ECLS use of iNO and mortality in infants with CDH from the Extracorporeal Life Support Organization (ELSO) Registry. Neonates who underwent ECLS for CDH were identified from the ELSO Registry from 2009 to 2019. Patients were categorized into those treated with iNO versus not prior to initiating ECLS. Patients were then matched 1:1 for case-mix based on pre-ECLS covariates using the propensity score (PS) for iNO treatment. The matched groups were compared for mortality. The matched cohorts were also compared for ELSO-defined systems-based complications as secondary outcomes. There were a total of 3,041 infants with an overall mortality of 52.2% and a pre-ECLS iNO use rate of 84.8%. With 1:1 matching, there were 461 infants with iNO use and 461 without iNO use. Following matching, use of iNO was not associated with a difference in mortality (odds ratio [OR] = 0.805; 95% confidence interval [CI], 0.621-1.042; p = 0.114). Results were similar in unadjusted analyses, and after controlling for covariates in the full cohort of patients and in the 1:1 matched data. Patients receiving iNO had significantly higher odds of renal complications (OR = 1.516; 95% CI, 1.141-2.014; p = 0.004), but no other significant differences were observed among secondary outcomes. ECLS use of iNO in CDH patients was not associated with a difference in mortality. Future randomized controlled studies are needed to delineate the utility of iNO in CDH patients.
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Affiliation(s)
- Sharada H Gowda
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ahmed Almaazmi
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Joseph Hagan
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Emily Niemyjski
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Adam M Vogel
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Caraciolo J Fernandes
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Irvine, California
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
- Department of Surgery, University of California Irvine Medical Center, Orange, California
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17
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de Carvalho Nunes G, Wutthigate P, Simoneau J, Dancea A, Beltempo M, Renaud C, Altit G. The biventricular contribution to chronic pulmonary hypertension of the extremely premature infant. J Perinatol 2023; 43:174-180. [PMID: 36008520 DOI: 10.1038/s41372-022-01497-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Evaluate factors associated with significant pulmonary hypertension [PH] (≥2/3 systemic) and its impact on ventricular function at 36 weeks postmenstrual age (PMA). STUDY DESIGN Retrospective cohort of infants born at <29 weeks who survived to their echocardiography screening for PH at 36 weeks PMA. Masked experts extracted conventional and speckle-tracking echocardiography [STE] data. RESULTS Of 387 infants, 222 were included and 24 (11%) categorized as significant PH. Significant PH was associated with a decrease in tricuspid annular plane systolic excursion (0.79 vs 0.87 cm, p = 0.03), right peak longitudinal strain [pLS] by STE (-19.6 vs -23.1%, p = 0.003) and left pLS (-25.0 vs -22.7%, p = 0.02). The association between biventricular altered function by STE and significant PH persisted after adjustment for potential confounders - LV-pLS (p = 0.007) and RV-pLS (p = 0.01). CONCLUSION Our findings are suggestive that premature newborns with significant PH at 36 weeks PMA have a biventricular cardiac involvement to their pathophysiology.
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Affiliation(s)
- Gabriela de Carvalho Nunes
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Neonatology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada
| | - Punnanee Wutthigate
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Neonatology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Neonatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Neonatology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada
| | - Adrian Dancea
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Pediatric Cardiology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada
| | - Marc Beltempo
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Neonatology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada
| | - Claudia Renaud
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.,Division of Pediatric Cardiology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada
| | - Gabriel Altit
- McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada. .,Division of Neonatology, McGill University Health Centre-Montreal Children's Hospital, Quebec, QC, Canada.
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18
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Soni R, Soni N, Chakkarapani A, Gupta S, Yajamanyam PK, Ali SKM, El Anbari M, Alhamad M, Anand D, More K. The Utility of Serial Echocardiography Parameters in Management of Newborns with Congenital Diaphragmatic Hernia (CDH) and Predictors of Mortality. Pediatr Cardiol 2023; 44:354-366. [PMID: 36163300 PMCID: PMC9895036 DOI: 10.1007/s00246-022-03002-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/29/2022] [Indexed: 02/06/2023]
Abstract
Ventricular dysfunction may be found in 40% of newborns with CDH, and is not only a predictor of disease severity, but also mortality and need for ECMO. We conducted this study to assess the utility of serial echocardiography in management of newborns with CDH and their survival outcomes. This is a retrospective study, wherein the demographic, clinical and echocardiographic data from our local CDH registry and hospital clinical database were analyzed to study the correlation of timed echocardiographic findings with mortality and other outcomes. Fourty-two newborns with CDH were admitted during the study period (M/F:19/23), with median gestation of 38 weeks (IQR:36-39) and birth weight of 2.83 kg (IQR 2.45-3.17). Thirty-one were left-sided, seven right, one central, and three bilateral hernias. Twelve infants (28%) died in early infancy. Three infants were excluded from analysis due to either palliation at birth or significant cardiac anomaly. A total of 137 echos from 39 infants were analyzed. Seventy percent of newborns who died and had an echo within the first 72 h, were noted to have suffered from moderate to severe PH. Birth weight < 2.8 kg, RVSP > 45.5 in the first 72 h and postoperative VIS > 23.5 and RSS > 4.3 were good predictors of mortality. Markers of elevated pulmonary pressures and cardiac function were useful in guiding therapy. Serial timed functional echocardiography (f-Echo) monitoring allows targeted therapy of patients with CDH. Birth weight, initial severity of pulmonary hypertension and postoperative RSS and VIS may be useful in predicting mortality.
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Affiliation(s)
- Roopali Soni
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar ,Neonatal Unit, Mediclinic Parkview Hospital, Dubai, UAE
| | - Naharmal Soni
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar
| | - Aravanan Chakkarapani
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar ,Weill Cornell Medicine, Al-Rayyan, Doha, Qatar
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar
| | - Phani Kiran Yajamanyam
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar
| | - Sanoj K. M. Ali
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar
| | - Mohammed El Anbari
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar
| | - Moath Alhamad
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar ,Weill Cornell Medicine, Al-Rayyan, Doha, Qatar
| | - Dhullipala Anand
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar ,Weill Cornell Medicine, Al-Rayyan, Doha, Qatar
| | - Kiran More
- Division of Neonatology, Sidra Medicine, Al Luqta Street, Education City North Campus, Qatar Foundation, Doha, Qatar.
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Hari Gopal S, Toy CL, Hanna M, Furtun BY, Hagan JL, Nassr AA, Fernandes CJ, Keswani S, Gowda SH. Inotropic score and vasoactive inotropic score as predictors of outcomes in congenital diaphragmatic hernia: A single center retrospective study. Front Pediatr 2023; 11:1101546. [PMID: 36816370 PMCID: PMC9929143 DOI: 10.3389/fped.2023.1101546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Neonates with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac dysfunction. These neonates frequently require vasoactive support and are at high risk for mortality and morbidity, including prolonged ventilator support, need for extracorporeal membrane oxygenation (ECMO), prolonged length of stay, and need for tracheostomy. However, identifying which infants are at increased risk can be challenging. In this study, we sought to investigate the utility of the inotropic score (IS) and vasoactive inotropic score (VIS) as tools to predict significant clinical outcomes and overall survival in patients with CDH. Additionally, we evaluated the correlation between IS/VIS and postnatal echocardiographic variables. METHODS This was a retrospective chart review of 57 patients with CDH whose postnatal care was based on a standardized institutional protocol. We calculated the IS/VIS at 6-, 12-, 24-, 48 hours of life (HOL), on the day of CDH repair and 24- and 48 hours after surgical repair. The association of these scores with postnatal echocardiographic markers was analyzed using Pearson's correlation and linear regression, while logistic regression was used for binary outcomes, and Cox proportional hazards regression was used to assess associations with survival. RESULTS We found that every one-unit increase in IS/VIS at 6 HOL was associated with 13% increase in the odds of ECMO (p = 0.034) and 10.1% increase in risk of death (p = 0.021). An increase in IS/VIS at 12-, 24- and 48-HOL was associated with posterior septal bowing in the first postnatal echocardiogram (p < 0.05 for all). Additionally, we noted an inverse relationship between IS (r = -0.281, p = 0.036) and VIS (r = -0.288, p = 0.031) on the day of repair and left ventricle (LV) systolic function in first postnatal echocardiogram. Increase in IS (r = -0.307, p = 0.024) and VIS (r = -0.285, p = 0.037) on the day of repair was associated with decreased LV function on the post-repair echocardiogram. CONCLUSION This retrospective study showed a significant association between IS/VIS obtained at various time points with clinical outcomes and echocardiographic findings in CDH, which could be used to guide prognosis and management in this patient population.
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Affiliation(s)
- Srirupa Hari Gopal
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Cynthia L Toy
- Department of Pharmacy, Texas Children's hospital, Houston, TX, United States
| | - Morcos Hanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Betul Yilmaz Furtun
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Joseph L Hagan
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine/Fetal Intervention Baylor College of Medicine, Houston, TX, United States
| | - Caraciolo J Fernandes
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Sundeep Keswani
- Department of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Sharada H Gowda
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
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Maia PD, Gien J, Kinsella JP, Zablah J, Morgan G, Ivy DD, Abman SH, Frank BS. Hemodynamic Characterization of Neonates With Congenital Diaphragmatic Hernia-Associated Pulmonary Hypertension by Cardiac Catheterization. J Pediatr 2022; 255:230-235.e2. [PMID: 36463937 DOI: 10.1016/j.jpeds.2022.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022]
Abstract
We examined the results of cardiac catheterization in infants with congenital diaphragmatic hernia (CDH) from 2009 to 2020. Catheterization confirmed pulmonary arterial hypertension in all cases (n = 17) and identified left ventricular (LV) diastolic dysfunction (LVDD) in 53%. LVDD was associated with greater respiratory morbidity. Preprocedural noninvasive assessment showed inconsistent agreement with catheterization results.
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Affiliation(s)
- Paula Dias Maia
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jenny Zablah
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Gareth Morgan
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Steven H Abman
- Pediatric Heart Lung Center, Section of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Abstract
Acute pulmonary hypertension (aPH) is a complex, physiology-driven disorder that causes critical illness in newborns, the hallmark of which is elevated pressure in the pulmonary vascular bed. Several underlying hemodynamic phenotypes exist, including classic arterial aPH with resistance-driven elevations in pulmonary arterial pressure (PAP), alongside flow-driven aPH from left-to-right shunt lesions, and primary left ventricular dysfunction with pulmonary venous hypertension and elevated left atrial pressure. Targeted neonatal echocardiography (TnECHO) is an important tool for evaluation of hemodynamics in aPH and is highly useful for evaluating modulators of disease and targeting cardiovascular therapy. The diagnostic approach to aPH includes confirmation of elevation of PAP, evaluation of the cause and exclusion of structural cardiac disease, assessment of the response of the myocardium to adverse loading conditions, and appraisal of the adequacy of systemic blood flow. Therapeutic goals include support of right ventricular (RV) function, RV afterload reduction, and selection of cardiotropic agents that support underlying pathophysiology without adverse effects on heart rate or pulmonary vascular resistance in addition to routine supportive intensive care. Training programs for TnECHO exist across multiple jurisdictions and strong correlation with pediatric cardiology assessment has been demonstrated. Future directions include adapting TnECHO training with a greater focus on achieving competency, and further research into the role of the modality in providing individualized cardiovascular care for patients with heterogenous underlying physiology, and its effect on key neonatal outcomes.
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22
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Quantitative cardiopulmonary magnetic resonance imaging in neonatal congenital diaphragmatic hernia. Pediatr Radiol 2022; 52:2306-2318. [PMID: 35556152 DOI: 10.1007/s00247-022-05384-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 03/15/2022] [Accepted: 04/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension, impaired cardiac function and lung hypoplasia are common in infants with congenital diaphragmatic hernia (CDH) and are associated with increased morbidity and mortality. Robust noninvasive methods to quantify these abnormalities in early infancy are lacking. OBJECTIVE To determine the feasibility of MRI to quantify cardiopulmonary hemodynamics and function in infants with CDH and to investigate left-right blood flow and lung volume discrepancies. MATERIALS AND METHODS We conducted a prospective MRI study of 23 neonates (isolated left CDH: 4 pre-repair, 7 post-repair, 3 pre- and post-repair; and 9 controls) performed on a small-footprint 1.5-tesla (T) scanner. We calculated MRI-based pulmonary arterial blood flow, left ventricular eccentricity index, cardiac function and lung volume. Using the Wilcoxon rank sum test for continuous data and Fisher exact test for categorical data, we made pairwise group comparisons. RESULTS The right-to-left ratios for pulmonary artery blood flow and lung volume were elevated in pre-repair and post-repair CDH versus controls (flow: P<0.005; volume: P<0.05 pre-/post-repair). Eccentricity index at end-systole significantly differed between pre-repair and post-repair CDH (P<0.01) and between pre-repair CDH and controls (P<0.001). CONCLUSION Cardiopulmonary MRI is a viable method to serially evaluate cardiopulmonary hemodynamics and function in critically ill infants and is useful for capturing left-right asymmetries in pulmonary blood flow and lung volume.
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23
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Wutthigate P, Simoneau J, Renaud C, Altit G. Early Echocardiography Predicts Intervention Need in Antenatal Suspicion of Coarctation of the Aorta. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:167-173. [PMID: 37969934 PMCID: PMC10642135 DOI: 10.1016/j.cjcpc.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/02/2022] [Indexed: 11/17/2023]
Abstract
Background Coarctation of the aorta (CoA) is challenging to diagnose in early postnatal life. We aimed to describe the resource utilization and predictors for the need of intervention in an antenatal suspicion of CoA. Methods A retrospective study of infants with an antenatal suspicion of CoA born at ≥37 weeks was performed. Those not requiring intervention (normal) were compared with those who required cardiac surgery (CoA). Strain was measured using speckle-tracking echocardiography. Results A total of 51 newborns were included; 40 (78%) were considered normal and 11 (22%) underwent intervention. Echocardiography occurred within the first day of life for both groups. Right ventricular (RV) predominance was present in the CoA group, as demonstrated by the left ventricular (LV) end-systolic eccentricity index (1.60 [0.28] vs 2.16 [0.45]; P < 0.001) and by a larger RV end-diastolic area (EDA) in apical 4-chamber (A4C) relative to LV-EDA-with a ratio of 1.56 [0.23] vs 1.02 [0.2]; P < 0.001. An RV/LV EDA ratio in A4C ≥1.3 had a high probability for CoA (area under the curve = 0.97). Newborns with CoA had a lower RV deformation (peak systolic strain rate: -0.98 [0.17] vs -0.83 [0.2]; P = 0.02). Intraclass correlation coefficient for the EDA ratio revealed a good inter-rater agreement (0.76; 95% confidence interval: 0.55-0.87). Analysis with rater #2 revealed that the EDA ratio ≥1.3 predicted 100% of CoA. Conclusions The majority of those with an antenatal suspicion of CoA did not require intervention but were high consumers of resources. Within the first day of life, the ventricular EDA ratio in A4C may help predicting those with true CoA requiring intervention.
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Affiliation(s)
- Punnanee Wutthigate
- Division of Neonatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Neonatology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Claudia Renaud
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Pediatric Cardiology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Gabriel Altit
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Neonatology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
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Diagnosis & management of pulmonary hypertension in congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101383. [PMID: 35995665 DOI: 10.1016/j.siny.2022.101383] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) contributes to neonatal morbidity and mortality worldwide. Pulmonary hypertension (PH) is a key component of CDH pathophysiology and critical consideration for management and therapeutic options. PH associated with CDH has traditionally been attributed to pulmonary vascular maldevelopment and associated lung parenchymal hypoplasia, leading to pre-capillary increase in pulmonary vascular resistance (PVR). However, there is increasing recognition that left ventricular hypoplasia, dysfunction and elevated end diastolic pressure may contribute to post-capillary pulmonary hypertension in CDH patients. The interplay of these mechanisms and associated dysfunction in the right and left ventricles results in variable hemodynamic phenotypes in CDH. Clinical assessment of individual phenotype may help guide personalized management strategies, including effective use of pulmonary vasodilators and extra-corporeal membrane oxygenation. Ongoing investigation of the underlying mechanisms of PH in CDH, and efficacy of physiology-based treatment approaches may support improvement in outcomes in this challenging condition.
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25
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More K, Soni R, Gupta S. The role of bedside functional echocardiography in the assessment and management of pulmonary hypertension. Semin Fetal Neonatal Med 2022; 27:101366. [PMID: 35718687 DOI: 10.1016/j.siny.2022.101366] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension is an emergency in neonatal intensive care units with high morbidity and mortality. Its timely assessment and management is crucial for intact survival. Over the last couple of decades, there have been significant advances in management and techniques, which have resulted in improved survival. The use of neonatologist-performed echocardiography (NPE) is now increasingly utilized on neonatal intensive care units to understand the pathophysiology of the disease and to direct the treatment to the underlying cause. Its use is now established not only in cases of congenital diaphragmatic hernia and in the newborn with refractory hypoxemia, but also in other conditions such as bronchopulmonary dysplasia and the premature infant with difficulty in oxygenation. The use of NPE, however, requires the availability of trained personnel, equipment, and a close working relationship with pediatric cardiology.
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Affiliation(s)
- Kiran More
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Department of Neonatology, BJ Wadia Children Hospital, Mumbai, India
| | - Roopali Soni
- Neonatal Unit, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Durham University, United Kingdom.
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26
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Larson AC, Didier R, Daszewska-Smith G, Chang J, Sridharan A, Agarwal D, Carreon CK, Sanders SP, Toba S, Partridge E. The fetal lamb model of congenital diaphragmatic hernia shows altered cerebral perfusion using contrast enhanced ultrasound. J Pediatr Surg 2022; 57:991-998. [PMID: 35346482 DOI: 10.1016/j.jpedsurg.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is common in survivors of congenital diaphragmatic hernia (CDH). Altered cerebral perfusion in utero may contribute to abnormal brain development in CDH patients. METHODS 5 fetal lambs with surgical left-CDH and 5 controls underwent transuterine cranial Doppler and contrast enhanced ultrasound (CEUS). Global and regional perfusion metrics were obtained. Biometric and perfusion data were compared between groups via nonparametric Mann Whitney U test and Spearman's rank order correlation. RESULTS No significant differences in cerebral Doppler measurements were identified between groups. By CEUS, CDH animals demonstrated significantly decreased global brain perfusion and increased transit time. With focal regions-of-interest (ROIs), there was a tendency towards decreased perfusion in the central/thalamic region in CDH but not in the peripheral brain parenchyma. Transit time was significantly increased in both ROIs in CDH, whereas flux rate was decreased in the central/thalamic region but not the peripheral brain parenchyma. Biometric CDH severity was correlated to perfusion deficit. There was no difference in cardiomyocyte histology. CONCLUSION The fetal lamb model of CDH shows altered cerebral perfusion as measured by CEUS, correlating to disease severity. This suggests a physiological abnormality in fetal cerebrovascular perfusion that may contribute to abnormal brain development and neurodevelopmental impairment in survivors.
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Affiliation(s)
- Abby C Larson
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Ryne Didier
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gabriela Daszewska-Smith
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Jonathan Chang
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Divyansh Agarwal
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chrystalle Katte Carreon
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Stephen P Sanders
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Shuhei Toba
- Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Emily Partridge
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
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27
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Prasad R, Saha B, Kumar A. Ventricular function in congenital diaphragmatic hernia: a systematic review and meta-analysis. Eur J Pediatr 2022; 181:1071-1083. [PMID: 34725730 DOI: 10.1007/s00431-021-04303-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 10/20/2022]
Abstract
There is emerging evidence supporting ventricular function as a prognostic factor in congenital diaphragmatic hernia (CDH). The present systematic review and meta-analysis aimed to determine the predictive value of early ventricular function for survival and extracorporeal membrane oxygenation (ECMO) requirement in newborns with CDH. PubMed, Google Scholar, Cochrane Central Register, Clinical Trial Registry, and Opengrey were accessed. Studies evaluating associations between echocardiographic ventricular function measured ≤ 48 h after birth and survival or ECMO requirement were included. Two independent authors extracted the following data: study and participant characteristics, prognostic factors, and outcome-related data. Eleven studies met the inclusion criteria. Five studies reported on survival, two on ECMO, and four on both outcomes. A moderate risk of bias was found in most of the studies, mainly because of selection, prognostic factors, and confounding biases. For survival (899 participants), pooled sensitivity and specificity were 86% (95% confidence interval [CI], 77-92%) and 44% (95% CI, 25-65%), respectively, in normal left ventricular function. For ECMO need (815 participants), pooled sensitivity and specificity were 39.8% (95% CI, 27-52%) and 88% (95% CI, 80-96%), respectively, in left ventricular dysfunction. Overall certainty of the evidence was graded very low for survival and low for ECMO. Inconsistent reporting of echocardiographic measurements and lack of adjustment for confounding factors were major limitations.Conclusion: Early ventricular dysfunction is a potential prognostic factor in CDH. Standardized echocardiographic measurement reporting and high-quality studies are needed to further elucidate its prognostic significance. What is Known: • Evidence supports the predictive value of echocardiographic measurements in CDH ≤ 24-48 h post-birth. • Ventricular dysfunction has been proposed as a prognostic risk factor. What is New: • Right and left ventricular functions were promising predictors of survival and ECMO requirement in neonates with CDH. • Test characteristics of ventricular function were determined as predictors of survival or need for ECMO. Specific echocardiographic markers of ventricular function can be valuable in determining prognosis.
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Affiliation(s)
- Rameshwar Prasad
- Department of Neonatology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India.
| | - Bijan Saha
- Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Amit Kumar
- Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi Jharkhand, India
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Amodeo I, Borzani I, Corsani G, Pesenti N, Raffaeli G, Macchini F, Condò V, Persico N, Ghirardello S, Colnaghi M, Mosca F, Cavallaro G. Fetal MRI mediastinal shift angle and respiratory and cardiovascular pharmacological support in newborns with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:323-334. [PMID: 34302257 DOI: 10.1007/s00431-021-04207-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
In newborns with congenital diaphragmatic hernia (CDH), the mediastinal shift caused by the herniated organs negatively affects lung development. Assessment of the fetal magnetic resonance imaging (MRI) mediastinal shift angle (MSA) was shown to have an inverse correlation with the total fetal lung volume (TFLV), being associated with neonatal survival. However, a possible association with postnatal morbidity has never been investigated. We hypothesize that the degree of the mediastinal shift could be associated with higher respiratory and cardiocirculatory impairment, requiring intensive treatments and extended hospitalization in survivors. We retrospectively consider a cohort of isolated, left-sided CDH, for whom we calculated the MSA and the observed/expected (O/E) TFLV at fetal MRI. We performed a data collection regarding inotropic or vasoactive support, treatment with pulmonary vasodilators, mechanical ventilation, and length of stay. General linear models were performed. The MSA and O/E TFLV were inversely correlated (Pearson's coefficient - 0.65, p < 0.001), and deceased patients showed higher MSA values then survivors (p = 0.011). Among survivors, an increase in MSA was associated with longer pharmacological treatments (dobutamine: p = 0.016; dopamine: p = 0.049; hydrocortisone: p = 0.003; nitric oxide: p = 0.002; sildenafil: p = 0.039; milrinone: p = 0.039; oxygen: p = 0.066), and mechanical ventilation (p = 0.005), with an increasing trend in the length of hospitalization (p = 0.089).Conclusion: The MSA indirectly reflects lung hypoplasia and is associated with a higher neonatal intensity of cares. However, further studies are needed to consolidate the results.Trial registration: The study is an exploratory post hoc analysis of the registered NeoAPACHE protocol at ClinicalTrials.gov with the identifier NCT04396028. What is Known: • In congenital diaphragmatic hernia, the lung size, liver position, and defect side are the most common prenatal prognostic parameters used in clinical practice for morbidity and mortality prediction. • Lung hypoplasia, strictly associated with lung size, is estimated by observed/expected lung to head ratio and observed/expected total fetal lung volume with prenatal ultrasound and fetal magnetic resonance imaging, respectively. What is New: • A new, faster, more straightforward, and less operator-dependent tool to assess CDH severity could be the mediastinal shift angle calculation with fetal magnetic resonance imaging. • Postnatal clinical severity, considered as a postnatal cardiovascular and respiratory impairment that indirectly reflects lung hypoplasia, is associated with an increased mediastinal shift angle calculation.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Corsani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Radiology Unit, Major Hospital, Crema, Italy
| | - Nicola Pesenti
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.,Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,NICU, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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Patel N, Massolo AC, Kraemer US, Kipfmueller F. The heart in congenital diaphragmatic hernia: Knowns, unknowns, and future priorities. Front Pediatr 2022; 10:890422. [PMID: 36052357 PMCID: PMC9424541 DOI: 10.3389/fped.2022.890422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
There is growing recognition that the heart is a key contributor to the pathophysiology of congenital diaphragmatic hernia (CDH), in conjunction with developmental abnormalities of the lung and pulmonary vasculature. Investigations to date have demonstrated altered fetal cardiac morphology, notably relative hypoplasia of the fetal left heart, as well as early postnatal right and left ventricular dysfunction which appears to be independently associated with adverse outcomes. However, many more unknowns remain, not least an understanding of the genetic and cellular basis for cardiac dysplasia and dysfunction in CDH, the relationship between fetal, postnatal and long-term cardiac function, and the impact on other parts of the body especially the developing brain. Consensus on how to measure and classify cardiac function and pulmonary hypertension in CDH is also required, potentially using both non-invasive imaging and biomarkers. This may allow routine assessment of the relative contribution of cardiac dysfunction to individual patient pathophysiological phenotype and enable better, individualized therapeutic strategies incorporating targeted use of fetal therapies, cardiac pharmacotherapies, and extra-corporeal membrane oxygenation (ECMO). Collaborative, multi-model approaches are now required to explore these unknowns and fully appreciate the role of the heart in CDH.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | | | - Ulrike S Kraemer
- Intensive Care Unit, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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30
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Right Ventricular Strain, Brain Natriuretic Peptide, and Mortality in Congenital Diaphragmatic Hernia. Ann Am Thorac Soc 2021; 17:1431-1439. [PMID: 32730099 DOI: 10.1513/annalsats.201910-767oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Brain-type natriuretic peptide (BNP) correlates with pulmonary hypertension as demonstrated by echocardiogram in congenital diaphragmatic hernia (CDH); however, its association with right ventricular (RV) function and mortality is unknown.Objectives: To characterize the relationships between echocardiogram-derived RV strain, BNP, and mortality in diaphragmatic hernia.Methods: We performed a single-center retrospective cohort study of infants with CDH and at least one BNP-echocardiogram pair within a 24-hour period. RV global longitudinal strain (GLS) and free-wall strain (FWS) were measured on existing echocardiograms. Associations among strain, BNP, and mortality were tested using mixed-effect linear and logistic regression models. Survival analysis was stratified by BNP and strain abnormalities.Results: There were 220 infants with 460 BNP-echocardiogram pairs obtained preoperatively (n = 237), ≤1 week postoperatively (n = 35), and >1 week postoperatively ("recovery"; n = 188). Strain improved after repair (P < 0.0001 for all periods). Higher BNP level was associated with worse strain in recovery but not before or immediately after operation (estimate [95% confidence interval] for recovery: GLS, 1.03 [0.50-1.57]; P = 0.0003; FWS, 0.62 [0.01-1.22]; P = 0.047). BNP and strain abnormalities were associated with an extracorporeal-membrane oxygenation requirement. Higher BNP level in recovery was associated with greater mortality (odds ratio, 11.2 [1.2-571.3]; P = 0.02). Abnormal strain in recovery had high sensitivity for detection of mortality (100% for GLS; 100% for FWS) but had low specificity for detection of mortality (28% for GLS; 48% for FWS).Conclusions: Persistent RV dysfunction after CDH repair may be detected by a high BNP level and abnormal RV strain.
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Dal Col AK, Bhombal S, Tacy TA, Hintz SR, Feinstein J, Altit G. Comprehensive Echocardiographic Assessment of Ventricular Function and Pulmonary Pressure in the Neonatal Omphalocele Population. Am J Perinatol 2021; 38:e109-e115. [PMID: 32198744 DOI: 10.1055/s-0040-1708048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) has been described in the neonatal omphalocele population. This study was aimed to describe cardiac function and PH severity using echocardiography in newborns with giant omphalocele (GO) and with non-GO and determine if right ventricular (RV) dysfunction is associated with mortality. STUDY DESIGN Retrospective, single-center analysis of first echocardiography among neonatal omphalocele patients born between 2004 and 2017 was conducted. Multivariate logistic and univariate Cox's regression was constructed to measure hazard ratio (HR) for death outcome. RESULTS There were 32 newborns, of whom 18 were GO and 7 died. GO had increased systolic pulmonary arterial to systolic systemic blood pressure ratio (97% [isosystemic] vs. 73% [three-fourths systemic] p = 0.03). RV performance parameters (tricuspid annular plane excursion, HR = 0.40; fractional area change, HR = 0.90; and RV peak global longitudinal strain, HR = 1.39) were associated with mortality. These RV performance parameters remained associated in a multiple logistic regression accounting for gestational age and GO status. The overall population had abnormal eccentricity index and pulmonary artery acceleration time to RV ejection time ratio, two markers of PH. CONCLUSION Patients with omphalocele have increased pulmonary pressure, with GO being worse than non-GO. RV dysfunction at initial echocardiography was significantly associated with mortality.
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Affiliation(s)
- Alexis K Dal Col
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Theresa A Tacy
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Jeffrey Feinstein
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Gabriel Altit
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada.,Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Khan U, Omdal TR, Matre K, Greve G. Speckle tracking derived strain in neonates: planes, layers and drift. Int J Cardiovasc Imaging 2021; 37:2111-2123. [PMID: 33710496 PMCID: PMC8286954 DOI: 10.1007/s10554-021-02200-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/22/2021] [Indexed: 12/20/2022]
Abstract
The aims of this study was to assess the effect of using a four chamber versus a three plane model on speckle tracking derived global longitudinal strain, the effects of drift compensation, the effect of assessing strain in different layers and finally the interplay between these aspects for the assessment of strain in neonates. Speckle tracking derived longitudinal strain was obtained from 22 healthy neonates. ANOVA, Bland-Altman analyses, coefficients of variation and assessment of intraclass correlation coefficients were conducted to assess the effect of the abovementioned aspects as well as assess both inter-observer and intra-observer variability. Neither the use of the three plane model versus the four chamber model nor the use of drift compensation had a substantial effect on global longitudinal strain (less than 1%, depending on which layer was being assessed). A gradient was seen with increasing strain from the epicardial to endocardial layers, similar to what is seen in older subjects. Finally, drift compensation introduced more discrepancy in segmental strain values compared to global longitudinal strain. Global longitudinal strain in healthy neonates remains reasonably consistent regardless of whether the three plane or four chamber model is used and whether drift compensation is applied. Its value increases when one moves from the endocardial to the epicardial layer. Finally, drift compensation introduces more discrepancy for regional measures of longitudinal strain compared to global longitudinal strain.
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Affiliation(s)
- Umael Khan
- Department of Clinical Science, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Hordaland, Norway.
| | - Tom R Omdal
- Department of Clinical Science, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Hordaland, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Knut Matre
- Department of Clinical Science, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Hordaland, Norway
| | - Gottfried Greve
- Department of Clinical Science, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Hordaland, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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Gupta VS, Patel N, Kipfmueller F, Lally PA, Lally KP, Harting MT. Elevated proBNP levels are associated with disease severity, cardiac dysfunction, and mortality in congenital diaphragmatic hernia. J Pediatr Surg 2021; 56:1214-1219. [PMID: 33745747 DOI: 10.1016/j.jpedsurg.2021.02.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac dysfunction is a key determinant of outcome in congenital diaphragmatic hernia (CDH). Pro-b-type natriuretic peptide (proBNP) is used as a prognosticator in heart failure and cardiomyopathy. We hypothesized that proBNP levels would be associated with ventricular dysfunction and high-risk disease in CDH. METHODS Patients in the CDH Study Group (CDHSG) from 2015-2019 with at least one proBNP value were included. Ventricular function was determined using echocardiograms from the first 48 h of life. RESULTS A total of 2,337 patients were identified, and 212 (9%) had at least one proBNP value. Of those, 3 (1.5%) patients had CDHSG stage A defects, 58 (29.6%) B, 111 (56.6%) C, and 24 (12.2%) D. Patients with high-risk defects (Stage C/D) had higher proBNP compared with low-risk defects (Stage A/B) (14,281 vs. 5,025, p = 0.007). ProBNP was significantly elevated in patients who died (median 14,100, IQR 4,377-22,900 vs 4,911, IQR 1,883-9,810) (p<0.001). Ventricular dysfunction was associated with higher proBNP than normal ventricular function (8,379 vs. 4,778, p = 0.005). No proBNP value was both sensitive and specific for ventricular dysfunction (AUC=0.61). CONCLUSION Among CDH patients, elevated proBNP was associated with high-risk defects, ventricular dysfunction, and mortality. ProBNP shows promise as a biomarker in CDH-associated cardiac dysfunction.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.528, Houston, TX 77030, United States.
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children Glasgow, United Kingdom
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University Bonn, Germany
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.528, Houston, TX 77030, United States
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.528, Houston, TX 77030, United States
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.528, Houston, TX 77030, United States
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Shinno Y, Terui K, Endo M, Saito T, Nakata M, Komatsu S, Oita S, Katsumata Y, Saeda Y, Ozeki G, Ohsone Y, Hishiki T. Optimization of surgical timing of congenital diaphragmatic hernia using the quantified flow patterns of patent ductus arteriosus. Pediatr Surg Int 2021; 37:197-203. [PMID: 33388956 PMCID: PMC7778689 DOI: 10.1007/s00383-020-04788-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The optimal timing of surgery for congenital diaphragmatic hernia (CDH) is controversial. We aimed to validate our protocol for the timing of CDH repair using the quantified patent ductus arteriosus (PDA) flow pattern. METHODS This retrospective comparative study analyzed patients with a prenatal diagnosis of isolated CDH between 2007 and 2020. We defined the "LR ratio" as the percentage of velocity-time integral (VTI) of the left-to-right flow of PDA against overall VTI on echocardiography. Since 2010, we followed the decision criterion of performing surgery when LR ratio of > 50% has been achieved in the patients (protocol group). The protocol group (2010-2020) was compared with the historical control group (2007-2009). RESULTS The average age at surgery was 104.1 ± 175.9 and 37.3 ± 30.6 h in the control and protocol groups, respectively (p = 0.11). Survival rate (88.9% vs. 95.0%, p = 0.53) and the rate of worsening of pulmonary hypertension within 24 h after surgery (22.2% vs. 10.0%, p = 0.57) were not different between the groups. The protocol group had a significantly shorter duration of tracheal intubation (26.9 ± 21.1 vs. 13.3 ± 9.5 days, p = 0.03). CONCLUSION Our decision criterion might have the advantage of facilitating early and safe surgery for patients with CDH.
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Affiliation(s)
- Yoshitaka Shinno
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Mamiko Endo
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Takeshi Saito
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Mitsuyuki Nakata
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Shugo Komatsu
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Satoru Oita
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yoshio Katsumata
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yukiko Saeda
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Genta Ozeki
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yoshiteru Ohsone
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Tomoro Hishiki
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
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Ferguson DM, Gupta VS, Lally PA, Luco M, Tsao K, Lally KP, Patel N, Harting MT. Early, Postnatal Pulmonary Hypertension Severity Predicts Inpatient Outcomes in Congenital Diaphragmatic Hernia. Neonatology 2021; 118:147-154. [PMID: 33849011 DOI: 10.1159/000512966] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/11/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is the major pathophysiologic consequence of congenital diaphragmatic hernia (CDH). We aimed to evaluate the association between early CDH-associated PH (CDH-PH) and inpatient outcomes. METHODS The CDH Study Group registry was queried for infants born 2015-2019 with echocardiograms before 48h of life. PH was categorized using echocardiographic findings: none, mild (right ventricular systolic pressure <2/3 systemic), moderate (between 2/3 systemic and systemic), or severe (supra-systemic). Univariate and multivariate analyses were performed. Adjusted Poisson regression was used to assess the primary composite outcome of mortality or oxygen support at 30 days. RESULTS Of 1,472 patients, 86.5% had CDH-PH: 13.9% mild (n = 193), 44.4% moderate (n = 631), and 33.2% severe (n = 468). On adjusted analysis, the primary outcome of mortality or oxygen support at 30 days occurred more frequently in infants with moderate (incidence rate ratio [IRR] 1.8, 95% confidence interval [CI], 1.2-2.6) and severe CDH-PH (IRR 2.0, 95% CI, 1.3-2.9). Extracorporeal life support (ECLS) utilization was associated only with severe CDH-PH after adjustment (IRR 1.8, 95% CI, 1.0-3.3). DISCUSSION/CONCLUSION Early, postnatal CDH-PH is independently associated with increased risk for mortality or oxygen support at 30 days and utilization of ECLS. Early echocardiogram is a valuable prognostic tool for early, inpatient outcomes in neonates with CDH.
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Affiliation(s)
- Dalya Munves Ferguson
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.,Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Vikas S Gupta
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.,Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Pamela A Lally
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Matias Luco
- School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - KuoJen Tsao
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.,Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Kevin P Lally
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.,Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Neil Patel
- Royal Hospital for Children, Glasgow, United Kingdom
| | - Matthew T Harting
- John P. and Katherine G. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.,Children's Memorial Hermann Hospital, Houston, Texas, USA
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Dao DT, Patel N, Harting MT, Lally KP, Lally PA, Buchmiller TL. Early Left Ventricular Dysfunction and Severe Pulmonary Hypertension Predict Adverse Outcomes in "Low-Risk" Congenital Diaphragmatic Hernia. Pediatr Crit Care Med 2020; 21:637-646. [PMID: 32168302 PMCID: PMC7335317 DOI: 10.1097/pcc.0000000000002318] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Given significant focus on improving survival for "high-risk" congenital diaphragmatic hernia, there is the potential to overlook the need to identify risk factors for suboptimal outcomes in "low-risk" congenital diaphragmatic hernia cases. We hypothesized that early cardiac dysfunction or severe pulmonary hypertension were predictors of adverse outcomes in this "low-risk" congenital diaphragmatic hernia population. DESIGN This is a retrospective cohort study using data from the Congenital Diaphragmatic Hernia Study Group registry. "Low-risk" congenital diaphragmatic hernia was defined as Congenital Diaphragmatic Hernia Study Group defect size A/B without structural cardiac and chromosomal anomalies. Examined risk factors included left ventricular dysfunction, right ventricular dysfunction, and severe pulmonary hypertension on the first postnatal echocardiogram. The primary outcome was composite adverse events, defined as either death, extracorporeal membrane oxygenation utilization, oxygen requirement on day 30 of life, or hospitalization greater than or equal to 8 weeks. Multivariable adjustment was performed with logistic regression and inverse probability weighting. SETTING Neonatal index hospitalization for congenital diaphragmatic hernia. PATIENTS "Low-risk" congenital diaphragmatic hernia infants born between January 2015 and December 2018. INTERVENTIONS First postnatal echocardiogram performed within 24 hours from birth. MEASUREMENTS AND MAIN RESULTS Seven-hundred seventy-eight patients were identified as "low-risk" congenital diaphragmatic hernia. Left ventricular dysfunction, right ventricular dysfunction, and severe pulmonary hypertension were present in 10.8%, 20.5%, and 57.5%, respectively. The primary outcome occurred in 21.3%. Death occurred in 3.0% and 9.1% used extracorporeal membrane oxygenation. On unadjusted analysis, all three risk factors were associated with the primary outcome. On all multivariable adjustment methods, left ventricular dysfunction and severe pulmonary hypertension remained significant predictors of adverse outcomes while right ventricular dysfunction no longer demonstrated any effect. CONCLUSIONS Early left ventricular dysfunction and severe pulmonary hypertension are independent predictors of adverse outcomes among "low-risk" congenital diaphragmatic hernia infants. Early recognition may lead to interventions that can improve outcome in this at-risk cohort.
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Affiliation(s)
- Duy T. Dao
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Vascular Biology Program, Boston Children’s Hospital, Boston, MA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Matthew T. Harting
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Pamela A. Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital, Houston, TX
| | - Terry L. Buchmiller
- Department of Surgery, Boston Children’s Hospital, Boston, MA,Corresponding Author: Terry L. Buchmiller, MD, Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave, Fegan 3, Boston, MA 02115, Phone: 617-355-6019, Fax: 617-730-0477,
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Yang MJ, Fenton S, Russell K, Yost CC, Yoder BA. Left-sided congenital diaphragmatic hernia: can we improve survival while decreasing ECMO? J Perinatol 2020; 40:935-942. [PMID: 32066841 DOI: 10.1038/s41372-020-0615-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/21/2020] [Accepted: 02/04/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Mortality and ECMO rates for congenital diaphragmatic hernia (CDH) remain ~30%. In 2016, we changed our CDH guidelines to minimize stimulation while relying on preductal oxygen saturation, lower mean airway pressures, stricter criteria for nitric oxide (iNO), and inotrope use. We compared rates of ECMO, survival, and survival without ECMO between the two epochs. DESIGN/METHODS Retrospective review of left-sided CDH neonates at the University of Utah/Primary Children's Hospital NICUs during pre (2003-2015, n = 163) and post (2016-2019, n = 53) epochs was conducted. Regression analysis controlled for defect size and intra-thoracic liver. RESULTS Following guideline changes, we identified a decrease in ECMO (37 to 13%; p = 0.001) and an increase in survival without ECMO (53 to 79%, p = 0.0001). Overall survival increased from 74 to 89% (p = 0.035). CONCLUSION(S) CDH management guideline changes focusing on minimizing stimulation, using preductal saturation and less aggressive ventilator/inotrope support were associated with decreased ECMO use and improved survival.
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Affiliation(s)
- Michelle J Yang
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA.
| | - Stephen Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Katie Russell
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Christian Con Yost
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
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Abstract
Congenital diaphragmatic hernia (CDH) is a neonatal pathology in which intrathoracic herniation of abdominal viscera via diaphragmatic defect results in aberrant pulmonary and cardiovascular development. Despite decades of study and many advances in the diagnosis and treatment of CDH, morbidity and mortality remain high, largely due to pulmonary hypertension (PH), along with pulmonary hypoplasia and cardiac dysfunction. In patients with CDH, hypoplastic pulmonary vasculature and alterations in multiple molecular pathways lead to pathophysiologic pulmonary vasculopathy and, for severe CDH, sustained, elevated pulmonary arterial pressures. This review addresses the multiple anatomic and physiologic changes that underlie CDH-associated PH (CDH-PH), along with the multimodal treatment strategies that exist currently and future therapies currently under investigation.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA.
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Abstract
There is increasing evidence that cardiac dysfunction is a key contributor to CDH pathophysiology. Dysfunction in both right and left ventricles is common in the early neonatal period, contributes to clinical disease severity, and is associated with adverse outcomes including death and ECMO use. Early and routine assessment of ventricular function and pulmonary artery pressure may guide individualized clinical decision-making, including use of pulmonary vasodilators, cardiotropes, ECMO, and timing of surgical repair. Minimizing cardiac dysfunction, whether by prenatal, postnatal or perinatal treatment strategies, may lead to improved outcome in CDH.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, UK.
| | - Anna Claudia Massolo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn, Bonn, Germany
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What is Left Ventricular Strain in Healthy Neonates? A Systematic Review and Meta-analysis. Pediatr Cardiol 2020; 41:1-11. [PMID: 31673733 DOI: 10.1007/s00246-019-02219-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/15/2019] [Indexed: 12/15/2022]
Abstract
Reference values for left ventricular systolic strain in healthy neonates are necessary for clinical application of strain. The objectives of this systematic review were to identify echocardiographic studies that presented left ventricular strain values in healthy neonates, perform a meta-analysis for speckle tracking-derived global longitudinal strain, and identify areas that require further investigation. A structured search was applied to MEDLINE, Embase, and Cochrane Central Register of Clinical Trials in search of echocardiographic studies that presented left ventricular strain in healthy neonates. 244 studies were identified, of which 16 studies including speckle tracking and tissue Doppler strain in the longitudinal, radial, and circumferential directions passed the screening process. Out of these 16 studies, a meta-analysis was performed on the 10 studies that reported speckle tracking global longitudinal strain. Mean speckle tracking-derived global longitudinal strain was 21.0% (95% Confidence Interval 19.6-22.5%, strain given as positive values). When the studies were divided into subgroups, mean speckle tracking global longitudinal strain from the four-chamber view was 19.5% (95% Confidence Interval 18.0-21.0%) and that derived from all three apical views was 22.5% (95% CI 20.6-24.7%), indicating that global longitudinal strain from the four-chamber view is slightly lower than global longitudinal strain from all three apical views. Neonatal strain values were close to strain values in older subjects found in previous meta-analyses. Further studies are recommended that examine strain rate, segmental strain values, strain derived from short axis views, and strain in the first few hours after birth.
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Aggarwal S, Agarwal P, Natarajan G. Echocardiographic prediction of severe pulmonary hypertension in neonates undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:1656-1662. [PMID: 31471580 DOI: 10.1038/s41372-019-0442-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/25/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Among neonates undergoing whole body cooling for hypoxic-ischemic encephalopathy (HIE), to compare ventricular function in the presence and absence of pulmonary hypertension (PPHN) needing inhaled nitric oxide (iNO)/ECMO. DESIGN This retrospective study included infants with HIE who underwent cooling. ECHO (<24 h age) measures, RV fractional area change (FAC), RV Tricuspid annular plane systolic excursion (TAPSE), myocardial performance indices (MPI), and the RV systolic to diastolic duration (S/D) ratio were evaluated. RESULTS The iNO/ECMO group (n = 26) had lower TAPSE and RV FAC and higher RV MPI and S/D, compared with controls (n = 39). Area under the curve was highest for RV S/D, with fair sensitivity (95% CI) [76.9 (56.3-91%)] and negative predictive value [78.6 (63.3-88.6%)] for subsequent iNO/ECMO at cutoff >1.45. CONCLUSIONS Infants with HIE undergoing cooling who progressed to iNO/ECMO for PPHN had RV dysfunction on early ECHO; S/D had the best predictive performance. RV S/D may be a useful early marker of PPHN in HIE.
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Affiliation(s)
- Sanjeev Aggarwal
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Prashant Agarwal
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
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Latham GJ, Yung D. Current understanding and perioperative management of pediatric pulmonary hypertension. Paediatr Anaesth 2019; 29:441-456. [PMID: 30414333 DOI: 10.1111/pan.13542] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/20/2018] [Accepted: 11/02/2018] [Indexed: 11/27/2022]
Abstract
Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortality in this group deserves recognition. Pulmonary hypertension due to left heart disease is another subset increasingly recognized as an important cause of pediatric pulmonary hypertension. One aspect of pediatric pulmonary hypertension is very clear: anesthetizing the child with pulmonary hypertension is associated with a significantly heightened risk of morbidity and mortality. It is therefore imperative that anesthesiologists who care for children with pulmonary hypertension have a firm understanding of the pathophysiology of the various forms of pediatric pulmonary hypertension, the impact of anesthesia and sedation in the setting of pulmonary hypertension, and anesthesiologists' role as perioperative experts from preoperative planning to postoperative disposition. This review summarizes the current understanding of pediatric pulmonary hypertension physiology, preoperative risk stratification, anesthetic risk, and intraoperative considerations relevant to the underlying pathophysiology of various forms of pediatric pulmonary hypertension.
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Affiliation(s)
- Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Delphine Yung
- Department of Pediatric Cardiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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Sanchez Mejia AA, Rodgers NJ. Evaluation and Monitoring of Pulmonary Hypertension in Neonates With Congenital Diaphragmatic Hernia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:11. [PMID: 30767157 DOI: 10.1007/s11936-019-0711-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This review aims to describe the assessment of pulmonary hypertension and ventricular function in neonates with congenital diaphragmatic hernia and the long-term follow-up of their pulmonary vascular disease. RECENT FINDINGS In 2015, the pediatric pulmonary hypertension guidelines from the American Heart Association and American Thoracic Society suggested class I level of evidence B guidelines for routine evaluation of patients with congenital diaphragmatic hernia, including longitudinal care in an interdisciplinary pulmonary hypertension program and following the recommendations offered for all children with pulmonary hypertension. Congenital diaphragmatic hernia causes compression of the lungs during critical stages of fetal development and results in lung hypoplasia. As a result, there is abnormal development of pulmonary vasculature that leads to post-natal pulmonary hypertension and increased afterload to the right ventricle. Left ventricular filling is affected by decreased pre-load and mechanical compression by abdominal content leading to decreased systemic perfusion. Persistent pulmonary hypertension after surgical repair of congenital diaphragmatic hernia is associated with increased mortality. Assessment and monitoring of pulmonary hypertension and ventricular function in this population of neonates is crucial to determine response to medical treatment, the need for extracorporeal membrane oxygenation, and the timing of surgical repair.
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Affiliation(s)
- Aura A Sanchez Mejia
- Department of Pediatrics, University of Minnesota, 2450 Riverside Ave, East Building, 5th Floor, Minneapolis, MN, 55454, USA.
| | - Nathan J Rodgers
- Department of Pediatrics, University of Minnesota, 2450 Riverside Ave, East Building, 5th Floor, Minneapolis, MN, 55454, USA
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Petroze RT, Puligandla PS. Preoperative cardiopulmonary evaluation in specific neonatal surgery. Semin Pediatr Surg 2019; 28:3-10. [PMID: 30824131 DOI: 10.1053/j.sempedsurg.2019.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Preoperative assessment of surgical neonates often relates to issues of prematurity, low birth weight, or associated malformations. This review explores the preoperative cardiopulmonary evaluation in specific newborn surgical populations, the role of echocardiography in congenital diaphragmatic hernia perioperative management, the impact of bronchopulmonary dysplasia in the ex-preterm surgical neonate and a brief discussion on the risk of general anesthesia and specific anesthetic considerations for any surgical neonate. Newborns with congenital anomalies requiring early general surgical intervention should have an assessment for congenital heart disease. In the asymptomatic neonate, a thorough physical exam may be sufficient preoperatively. Neonates born with esophageal atresia or anorectal malformations should have a full evaluation for VACTERL associations. Initial echocardiography in congenital diaphragmatic hernia is used to evaluate anatomy, but there is emerging evidence to suggest the use of echocardiography in the ongoing surveillance of CDH to influence the timing of surgical intervention. Bronchopulmonary dysplasia is present in up to 40% of ex-premature neonates and increases the risk of postoperative apneas and need for ventilatory support. However, all surgical neonates have an increased risk of post-operative apneas, and the need for surgical intervention should be balanced with the risk of general anesthesia.
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Affiliation(s)
- Robin T Petroze
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Pramod S Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Blvd, Room B04.2318, Montreal, QC, Canada.
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