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

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.

Could myocardial function be predictive of successful extubation in newborns and infants?

OBJECTIVE: To investigate the relationship between cardiac function and extubation readiness in infants using speckle tracking echocardiography. WORKING HYPOTHESIS: Cardiac function combined with established clinical parameters may better identify readiness for extubation. STUDY DESIGN: Pilot prospective observational study. PATIENT SELECTION: Mechanically ventilated infants were included. METHODOLOGY: Cardiac function was assessed by echocardiography immediately before extubation. Systolic and diastolic function in the left (LV) and right ventricles (RV) were assessed by measurement of longitudinal strain (LS), and circumferential strain (CS) in the LV only. Pulmonary artery pressures were assessed using the velocity of tricuspid regurgitation jet (TR), septal position, and end-systolic eccentricity index (EI ES). Cases who extubated successfully (Group 1) were compared to cases who required reintubation (Group 2). RESULTS: Twenty-five cases were included. LV CS and RV LS were significantly lower in those who required reintubation (Group 2) compared to those who were successfully extubated (Group 1) (LV CS, -21 (12)% vs. -33 (3)%, p = .001; RV LS -19 (2.7)% vs. -20 (2.5)%, p = .04). TR was absent in all cases. The septal shape was normal in 18 cases (72%), displaced to the left in 7 (28%) cases. No significant differences were found in LV EI ES between groups.

Point of care ultrasound in the paediatric acute care setting: Getting to the 'heart' of respiratory distress.

Point-of-care ultrasound (POCUS) is a growing interesting tool in the emergency setting. Its usefulness in diagnostic and therapeutic pathway of patients with respiratory distress in addition to clinical evaluation is well established in adult emergency medicine while paediatric specific data, although growing, remain limited. We report a case series of paediatric patients presenting with respiratory distress successfully diagnosed with cardiac dysfunction following POCUS evaluations. Lung POCUS, in combination with cardiac POCUS, is a very useful supplementary diagnostic tool to assess the breathless child and to rapidly identify life-threatening primary etiologies or secondary physiologies. Thus, fast echocardiography is a desirable aid for paediatric emergency physicians and should be supported in all paediatric emergency settings following an adequate training that is mandatory regarding image acquisition and data interpretation.