Right Ventricular Strain, Brain Natriuretic Peptide, and Mortality in Congenital Diaphragmatic Hernia

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.

The heart in congenital diaphragmatic hernia: Knowns, unknowns, and future priorities

“…In cohort studies early RV dysfunction is associated with prolonged duration of respiratory support, increased mortality and ECMO use (49,(59)(60)(61). In a recent large multi-center registry analysis of cardiac function in the first 48 h of life RV dysfunction was present in 34% of CDH cases either in isolation in combination with LV dysfunction, and was associated with increased mortality and ECMO use (62).…”

“…BNP has a short halflife complicating measurement, but in CDH has been shown to be associated with pulmonary hypertension, need for ECMO, predictive of adverse outcome at 1 month of age, Table 4 (84,85). Recently Avitabile et al also demonstrated that BNP was associated with impaired RV strain after CDH repair, though not in the pre-operative period (61).…”

“…As discussed above, severe LV dysfunction is a transient phenomenon and typically resolves in a matter of days. Nevertheless, ongoing right ventricular dysfunction after ECMO has been described, associated with persistent elevation of pulmonary artery pressure ( 61 ).…”

“…RV function may deteriorate within 72 h of surgical repair ( 49 ). In a recent cohort Avitabile et al observed that RV strain improved in the recovery phase after surgery, though over 50% of cases had ongoing reduction in RV strain ( 61 ). Chronic elevation of PVR, exacerbated by surgery, may contribute to this ongoing RV dysfunction.…”

Use of Prostaglandin E1 in the Management of Congenital Diaphragmatic Hernia–A Review

“…Echocardiographic studies of early RV function have demonstrated RV systolic and diastolic dysfunction, and evidence of interdependent impairment of LV function (47,48). Furthermore, early RV dysfunction pre-and post CDH repair have been shown to be associated with adverse outcomes, including increased mortality, ECLS use and length of hospitalization in survivors, in single center cohorts as well as large registry-based analyses (49)(50)(51).…”