1
|
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.
Collapse
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
| |
Collapse
|
2
|
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] [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.
Collapse
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.
| |
Collapse
|
3
|
Ibarra C, Bergh E, Tsao K, Johnson A. Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151436. [PMID: 39018717 DOI: 10.1016/j.sempedsurg.2024.151436] [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: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.
Collapse
Affiliation(s)
- Claudia Ibarra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eric Bergh
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States.
| | - Kuojen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| |
Collapse
|
4
|
Chen ZY, Tao J, Xu WL, Gao YY, Li WY, Liu Z, Zhou JY, Dai L. Epidemiology of congenital diaphragmatic hernia among 24 million Chinese births: a hospital-based surveillance study. World J Pediatr 2024; 20:712-722. [PMID: 38070097 PMCID: PMC11269495 DOI: 10.1007/s12519-023-00774-y] [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: 06/08/2023] [Accepted: 10/12/2023] [Indexed: 07/25/2024]
Abstract
BACKGROUND The prevalence of congenital diaphragmatic hernia (CDH) varies across countries, with limited information available on its epidemiology in China. Our study aimed to investigate the prevalence, time trends, and perinatal outcomes of CDH in China, as well as its associated malformations and potential associations with maternal and infant characteristics. METHODS This study included all birth and CDH cases from the Chinese Birth Defects Monitoring Network between 2007 and 2019, with CDH cases classified as either isolated or associated. We employed the joinpoint regression model to calculate the trends of prevalence and the annual percent change, with Poisson regression used for adjusted prevalence rate ratios. A P value ≤ 0.05 was considered statistically significant. RESULTS A total of 4397 CDH cases were identified among 24,158,029 births in the study period, yielding prevalence rates of 1.82, 1.13 and 0.69 per 10,000 for overall, isolated, and associated CDH, respectively. The prevalence of each type of CDH increased over time. The prevalence of overall CDH varied significantly by infant sex (male vs. female, 1.91/10,000 vs. 1.63/10,000), maternal residence (urban vs. rural, 2.13/10,000 vs. 1.45/10,000), maternal age (< 20 years, 1.31/10,000; 20-24 years, 1.63/10,000; 25-29 years, 1.80/10,000; 30-34 years, 1.87/10,000; ≥ 35 years, 2.22/10,000), and geographic region (central, 1.64/10,000; east, 2.45/10,000; west, 1.37/10,000). Cardiovascular anomalies were the most common malformations associated with CDH. Infants with associated CDH had a higher risk of premature birth and perinatal death than those with isolated CDH. CONCLUSION The increasing prevalence and high perinatal mortality rate of CDH highlight the need for further etiological, epidemiological, and clinical studies among the Chinese population. Video Abstract.
Collapse
Affiliation(s)
- Zhi-Yu Chen
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Jing Tao
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Wen-Li Xu
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Yu-Yang Gao
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Wen-Yan Li
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Zhen Liu
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Jia-Yuan Zhou
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China
| | - Li Dai
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, No. 17 Section 3 Renminnanlu, Chengdu 610041, China.
- The Joint Laboratory for Pulmonary Development and Related Diseases, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- NHC Key Laboratory of Chronobology, Sichuan University, Chengdu, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, China.
| |
Collapse
|
5
|
Biouss G, Antounians L, Aguet J, Kopcalic K, Fakhari N, Baranger J, Mertens L, Villemain O, Zani A. The brain of fetuses with congenital diaphragmatic hernia shows signs of hypoxic injury with loss of progenitor cells, neurons, and oligodendrocytes. Sci Rep 2024; 14:13680. [PMID: 38871804 DOI: 10.1038/s41598-024-64412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/08/2024] [Indexed: 06/15/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a birth defect characterized by incomplete closure of the diaphragm, herniation of abdominal organs into the chest, and compression of the lungs and the heart. Besides complications related to pulmonary hypoplasia, 1 in 4 survivors develop neurodevelopmental impairment, whose etiology remains unclear. Using a fetal rat model of CDH, we demonstrated that the compression exerted by herniated organs on the mediastinal structures results in decreased brain perfusion on ultrafast ultrasound, cerebral hypoxia with compensatory angiogenesis, mature neuron and oligodendrocyte loss, and activated microglia. In CDH fetuses, apoptosis was prominent in the subventricular and subgranular zones, areas that are key for neurogenesis. We validated these findings in the autopsy samples of four human fetuses with CDH compared to age- and sex-matched controls. This study reveals the molecular mechanisms and cellular changes that occur in the brain of fetuses with CDH and creates opportunities for therapeutic targets.
Collapse
Affiliation(s)
- George Biouss
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Julien Aguet
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, 263 McCaul Street, Toronto, ON, M5T 1W7, Canada
| | - Katarina Kopcalic
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Nikan Fakhari
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Jerome Baranger
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Luc Mertens
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Olivier Villemain
- Translation Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Surgery, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
6
|
Thater G, Angermann L, Virlan SV, Weiss C, Rafat N, Boettcher M, Elrod J, Bayer T, Nowak O, Schönberg SO, Weis M. Fetal MRI-Based Mediastinal Shift Angle (MSA) and Percentage Area of Left Ventricle (pALV) as Prognostic Parameters for Congenital Diaphragmatic Hernia. J Clin Med 2024; 13:268. [PMID: 38202274 PMCID: PMC10779621 DOI: 10.3390/jcm13010268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/23/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Fetal magnetic resonance imaging (MRI) is broadly used as a method for assessing prognosis in congenital diaphragmatic hernia (CDH). In addition to the extent of lung hypoplasia, determined by measuring the lung volume, cardiac impairment due to pulmonary hypertension and left cardiac hypoplasia is decisive for the prognosis. The percentage area of left ventricle (pALV) describes the percentage of the inner area of the left ventricle in relation to the total area, whereas the mediastinal shift angle (MSA) quantifies the extent of cardiac displacement. The prognostic value of pALV and MSA should be evaluated in terms of survival, the need for extracorporeal membrane oxygenation (ECMO) therapy, and the development of chronic lung disease (CLD). METHODS In a total of 122 fetal MRIs, the MSA and pALV were measured retrospectively and complete outcome parameters were determined regarding survival for all 122 subjects, regarding ECMO therapy in 109 cases and about the development of CLD in 78 cases. The prognostic value regarding the endpoints was evaluated using logistic regression and ROC analysis. RESULTS The MSA was significantly higher in children who received ECMO therapy (p = 0.0054), as well as in children who developed CLD (p = 0.0018). ROC analysis showed an AUC of 0.68 for ECMO requirement and 0.77 with respect to CLD development. The pALV showed a tendency towards higher levels in children who received ECMO therapy (p = 0.0824). The MSA and the pALV had no significant effect on survival (MSA: p = 0.4293, AUC = 0.56; pALV: p = 0.1134, AUC = 0.57). CONCLUSIONS The MSA determined in fetal MRI is a suitable prognostic parameter for ECMO requirement and CLD development in CDH patients and can possibly be used as a supplement to the established parameters.
Collapse
Affiliation(s)
- Greta Thater
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (G.T.); (S.-V.V.)
| | - Lara Angermann
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (G.T.); (S.-V.V.)
| | - Silviu-Viorel Virlan
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (G.T.); (S.-V.V.)
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
| | - Neysan Rafat
- Department of Neonatology and Neonatal Intensive Care Medicine, Hospital Stuttgart, Kriegsbergstraße 60, 70174 Stuttgart, Germany;
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (M.B.); (J.E.)
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (M.B.); (J.E.)
| | - Tom Bayer
- Department of Neonatology, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
| | - Oliver Nowak
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
| | - Stefan O. Schönberg
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (G.T.); (S.-V.V.)
| | - Meike Weis
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (G.T.); (S.-V.V.)
| |
Collapse
|
7
|
Johng S, Fraga MV, Patel N, Kipfmueller F, Bhattacharya A, Bhombal S. Unique Cardiopulmonary Interactions in Congenital Diaphragmatic Hernia: Physiology and Therapeutic Implications. Neoreviews 2023; 24:e720-e732. [PMID: 37907403 DOI: 10.1542/neo.24-11-e720] [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: 11/02/2023]
Abstract
Congenital diaphragmatic hernia (CDH) results in abdominal contents entering the thoracic cavity, affecting both cardiac and pulmonary development. Maldevelopment of the pulmonary vasculature occurs within both the ipsilateral lung and the contralateral lung. The resultant bilateral pulmonary hypoplasia and associated pulmonary hypertension are important components of the pathophysiology of this disease that affect outcomes. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies, pulmonary hypertension management, and the option of extracorporeal membrane oxygenation, overall CDH mortality remains between 25% and 30%. With increasing recognition that cardiac dysfunction plays a large role in morbidity and mortality in patients with CDH, it becomes imperative to understand the different clinical phenotypes, thus allowing for individual patient-directed therapies. Further research into therapeutic interventions that address the cardiopulmonary interactions in patients with CDH may lead to improved morbidity and mortality outcomes.
Collapse
Affiliation(s)
- Sandy Johng
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Maria V Fraga
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - 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 of Bonn, Bonn, Germany
| | | | - Shazia Bhombal
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
| |
Collapse
|
8
|
Pammi M, Kelagere Y, Koh S, Sisson A, Hagan J, Kailin J, Fernandes CJ. Prognostic value of echocardiographic parameters in congenital diaphragmatic hernia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2023; 108:631-637. [PMID: 37130729 DOI: 10.1136/archdischild-2022-325257] [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: 12/19/2022] [Accepted: 04/19/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Prognostication of mortality and decision to offer extracorporeal membrane oxygenation (ECMO) treatment in infants with congenital diaphragmatic hernia (CDH) can inform clinical management. OBJECTIVE To summarise the prognostic value of echocardiography in infants with CDH. METHODS Electronic databases Ovid MEDLINE, Embase, Scopus, CINAHL, the Cochrane Library and conference proceedings up to July 2022 were searched. Studies evaluating the prognostic performance of echocardiographic parameters in newborn infants were included. Risk of bias and applicability were assessed using the Quality Assessment of Prognostic Studies tool. We used a random-effect model for meta-analysis to compute mean differences (MDs) for continuous outcomes and relative risk (RR) for binary outcomes with 95% CIs. Our primary outcome was mortality; secondary outcomes were need for ECMO, duration of ventilation, length of stay, and need for oxygen and/or inhaled nitric oxide. RESULTS Twenty-six studies were included that were of acceptable methodological quality. Increased diameters of the right and left pulmonary arteries at birth (mm), MD 0.95 (95% CI 0.45 and 1.46) and MD 0.79 (95% CI 0.58 to 0.99), respectively) were associated with survival. Left ventricular (LV) dysfunction, RR 2.40, (95% CI 1.98 to 2.91), right ventricular (RV) dysfunction, RR 1.83 (95% CI 1.29 to 2.60) and severe pulmonary hypertension (PH), RR 1.69, (95% CI 1.53 to 1.86) were associated with mortality. Left and RV dysfunctions, RR 3.30 (95% CI 2.19 to 4.98) and RR 2.16 (95% CI 1.85 to 2.52), respectively, significantly predicted decision to offer ECMO treatment. Limitations are lack of consensus on what parameter is optimal and standardisation of echo assessments. CONCLUSIONS LV and RV dysfunctions, PH and pulmonary artery diameter are useful prognostic factors among patients with CDH.
Collapse
Affiliation(s)
- Mohan Pammi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Yashaswini Kelagere
- Department of Pediatrics, Saint Peters Hospital, New Brunswick, New Jersey, USA
| | - Sara Koh
- Rice University, Houston, Texas, USA
| | - Amy Sisson
- Texas Medical Center Library, Houston Academy of Medicine, Houston, Texas, USA
| | - Joseph Hagan
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Kailin
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | |
Collapse
|
9
|
Noh CY, Chock VY, Bhombal S, Danzer E, Patel N, Dahlen A, Harting MT, Lally KP, Ebanks AH, Van Meurs KP. Early nitric oxide is not associated with improved outcomes in congenital diaphragmatic hernia. Pediatr Res 2023; 93:1899-1906. [PMID: 36725908 DOI: 10.1038/s41390-023-02491-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is widely used for the management of infants with congenital diaphragmatic hernia (CDH); however, evidence of benefit is limited. METHODS This is a multicenter cohort study using data from the Congenital Diaphragmatic Hernia Study Group between 2015 and 2020. The impact of early iNO use in the first 3 days of life prior to ECLS use on mortality or ECLS use was explored using multivariate logistic regression models and subgroup analyses. RESULTS Of the 1777 infants, 863 (48.6%) infants received early iNO treatment. Infants receiving iNO had lower birth weight, larger defect size, more severe pulmonary hypertension, and abnormal ventricular size and function. After controlling for these factors, early iNO use was associated with increased mortality (aOR 2.06, 95% CI 1.05-4.03, P = 0.03) and increased ECLS use (aOR 3.44, 95% CI 2.11-5.60, P < 0.001). Subgroup analyses after stratification by echocardiographic characteristics and defect size revealed no subgroup with a reduction in mortality or ECLS use. CONCLUSIONS Use of iNO in the first 3 days of life prior to ECLS was not associated with a reduction in mortality or ECLS use in either the regression models or the subgroup analyses. The widespread use of iNO in this vulnerable population requires reconsideration. IMPACT Evidence to support widespread use of iNO for infants with congenital diaphragmatic hernia is limited. The use of iNO in the first 3 days of life was associated with significantly increased mortality and ECLS use. Stratification by echocardiographic characteristics and defect size did not reveal a subgroup that benefited from iNO. Even the subset of patients with R-to-L shunts at both ductal and atrial levels, a surrogate for elevated pulmonary arterial pressures in the absence of significantly decreased LV compliance, did not benefit from early iNO use. Early iNO therapy was of no benefit in the management of acute pulmonary hypertension in infants with congenital diaphragmatic hernia, supporting reconsideration of its use in this population.
Collapse
Affiliation(s)
- Caroline Y Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Enrico Danzer
- Division of Pediatric Surgery, Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil Patel
- Royal Hospital for Children Glasgow, Glasgow, UK
| | - Alex Dahlen
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA, 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, Houston, TX, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| |
Collapse
|
10
|
Toyoshima K, Saito T, Shimokaze T, Katsumata K, Ohmura J, Kimura S, Aoki H, Takahashi M, Shibasaki J, Kawataki M, Kim KS, Shinkai M, Ishikawa H, Saito N, Masutani S. Right to left ventricular volume ratio is associated with mortality in congenital diaphragmatic hernia. Pediatr Res 2023:10.1038/s41390-022-02430-z. [PMID: 36624284 DOI: 10.1038/s41390-022-02430-z] [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: 12/06/2021] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is associated with high neonatal mortality. We performed this study to test the hypothesis that left ventricular (LV) and right ventricular (RV) volumes assessed by three-dimensional echocardiography may be associated with mortality in CDH. METHODS This study was a single-center retrospective cohort study involving 35 infants with CDH. RV and LV end-diastolic volume (RVEDV and LVEDV, respectively) were measured by three-dimensional echocardiography and were corrected by birth body weight (BBW) on day 1. RVEDV/BBW, LVEDV/BBW, and LVEDV/RVEDV were compared between CDH survivors and non-survivors. Receiver-operating characteristic curve analysis was performed to assess the predictive ability for mortality of the echocardiographic parameters. RESULTS Comparing CDH non-survivors (n = 6) with survivors (n = 29), respectively, RVEDV/BBW was significantly larger (2.54 ± 0.33 vs 1.86 ± 0.35 ml/kg; P < 0.01), LVEDV/BBW was significantly smaller (0.86 ± 0.21 vs 1.22 ± 0.33 ml/kg; P < 0.001), and LVEDV/RVEDV was significantly lower (0.34 ± 0.06 vs 0.66 ± 0.18; P < 0.001). The area under the curve for LVEDV/RVEDV was the largest (0.98). CONCLUSIONS Three-dimensional echocardiographic volume imbalance between the RV and LV was remarkable in CDH non-survivors. The LVEDV/RVEDV ratio may be associated with mortality in CDH. IMPACT Mortality with congenital diaphragmatic hernia (CDH) is high, and evaluating left and right ventricular structures and functions may be helpful in assessing the prognosis. Three-dimensional (3D) echocardiography indicated that the left ventricular end-diastolic volume/right ventricular end-diastolic volume ratio within 24 h after birth was associated with mortality in CDH infants. The usefulness of this ratio should be validated in prospective multicenter studies involving larger numbers of patients.
Collapse
Affiliation(s)
- Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Tomoko Saito
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoyuki Shimokaze
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kaoru Katsumata
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Junya Ohmura
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Sasagu Kimura
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hirosato Aoki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Megumi Takahashi
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Ki-Sung Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hiroshi Ishikawa
- Department of Obstetrics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical University, Kawagoe, Japan
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
|
13
|
Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
Collapse
Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|