237 - Fetal Echocardiography In Congenital Diaphragmatic Hernia and Outcomes – A Speckle-Tracking Echocardiography Study

Publication Number: 4233.237

Alexie Fonta Holder, Universite de Montreal Faculty of Medicine, Montréal, PQ, Canada; Camilo Lopez Ibarra, CHU Sainte-Justine, Université de Montréal, Montreal, PQ, Canada; Sam Amar, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Sariya Sahussarungsi, Thammasat University, Khlong Luang, Pathum Thani, Thailand; Phoenix Plessas-Azurduy, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Daniela Villegas Martinez, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Mona Beaunoyer, Universite de Montreal Faculty of Medicine, Montreal, PQ, Canada; Pramod Puligandla, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Marie-Josée Raboisson, Sainte Justine University Hospital Centre, Montreal, PQ, Canada; Tiscar Cavalle-Garrido, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Anie Lapointe, Universite de Montreal Faculty of Medicine, Montreal, PQ, Canada; Gabriel Altit, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada

Background: Congenital diaphragmatic hernia (CDH) is associated with a mortality rate of 25-45%. Traditionally, observed-to-expected lung-to-head ratio (o/e LHR) has been used to predict prognosis and identify candidates for early therapies. However, because CDH affects both the lungs and the heart, cardiac markers of fetal risk may improve prognostication and personalized care. Recently, the post-natal left-to-right ventricular base diameter ratio has been associated with prognosis.

Objective: Evaluate the association between prenatal cardiac markers derived from speckle-tracking echocardiography (STE) analysis and neonatal outcomes. The primary outcome was survival without death or the need for extracorporeal membrane oxygenation (ECMO).

Design/Methods: We conducted a retrospective, multicenter observational study of fetuses with prenatally diagnosed CDH and live birth between 2014 and 2024. Exclusion criteria were gestational age (GA) < 34 weeks, bilateral CDH, and major anomalies. Clinical and perinatal data were extracted from medical records. The first fetal echocardiogram (ECHO) was analyzed using TomTec from apical four-chamber views to assess ventricular dimensions and deformation using STE. Data extraction was blinded to perinatal outcomes.

Results: Of 65 fetuses retrieved with CDH, 48 were included; 9 died post-natally or required ECMO. The cohort was 56% male; 92% had left-sided CDH, 56% had liver herniation, 6% underwent FETO, and 4% required ECMO. Median GA at birth was 38 weeks, with a mean birth weight of 3186 grams. During hospitalization, 63% received inhaled nitric oxide (Table 1). After adjusting for GA at ECHO, no significant associations were found between ventricular STE parameters and outcomes. Among only left-sided cases (n=44), after adjustment for GA at ECHO, the left-to-right ventricular base diameter ratio at end-diastole (Figure 1; Table 2) was significantly associated with outcome (odds ratio 0.003; 95% CI 1×10⁻⁵-0.87, p=0.04), indicating that smaller relative left to right ventricular size was linked to higher risk of death or ECMO. Atrial strain was also evaluated and did not show any difference by adverse outcome.

Conclusion(s): In this cohort, left-to-right ventricular base diameter ratio in left-sided CDH was predictive of post-natal mortality or ECMO, suggesting that ventricular dimensions may serve as an additional prenatal prognostic marker in these fetuses.

Table 1: Clinical characteristics and demographics of cohort
Data are presented as mean (standard deviation) or median (interquartile range), depending on the distribution, as well as count (percentage).

Abbreviations: ECMO (Extracorporeal Membrane Oxygenation); FETO (Fetal Endoluminal Tracheal Occlusion); HFOV (High Frequency Oscillatory Ventilation); iNO (Inhaled Nitric Oxide exposure in the first week of life).

Table 2: Ventricular Deformations and Dimensions at Fetal Echocardiogram
Data are presented as mean (standard deviation) or median (interquartile range), depending on the distribution. *P-values were calculated using the Student's t-test for normally distributed variables and the Wilcoxon Mann-Whitney test for non-normally distributed variables. **Adjusted p-values were obtained through multiple logistic regression analysis, adjusting for gestational age at the time of fetal echocardiography.

Abbreviations: Echo (Fetal Echocardiography); ECMO (Extracorporeal Membrane Oxygenation); LV (Left Ventricle); RV (Right Ventricle).

Figure 1: Left-to-right ventricular base diameter ratio at end-diastole
The left-to-right ventricular base diameter ratio at end-diastole (d2/d1) was calculated from automated measurements obtained via speckle-tracking echocardiography (STE). These measurements were derived using the TomTEC Arena STE algorithm applied to the fetal apical four-chamber view.