Congenital diaphragmatic hernia and associated cardiovascular malformations: type, frequency, and impact on management

Abstract

The co-occurrence of congenital diaphragmatic hernia (CDH) and cardiovascular malformations (CVMs) has important clinical, genetic, and developmental implications. Previous examinations of this topic often included patients with genetic syndromes. To correct this potential bias, we undertook an extensive review of the literature and obtained new data. The frequency of CVMs associated with isolated CDH was 11-15%. A careful analysis of CVMs indicates that atrial and ventricular septal defects, conotruncal defects, and left ventricular outflow tract obstructive defects were the most common type of CVMs, but proportional to the frequency of occurrence in the general population. The combination of CVM and CDH results in a poorer prognosis than would be expected with either malformation alone. However, the impact on survival from patients with a genetic syndrome has not been consistently evaluated. We encourage researchers to re-analyze existing series and recommend that future studies distinguish isolated CDH from that which is associated with other malformations, especially as part of genetic syndromes. Therapies should be tailored to maximize cardiac output and systemic oxygen delivery rather than systemic oxygen saturation alone. Although there is speculation about the frequency with which isolated left ventricular "hypoplasia" occurs in patients with CDH, we suggest it results from compression of a pre-load deficient left ventricle by the hypertensive right ventricle, and unlike true hypoplasia, is reversible. Irrespective of the type of severity of CVMs in patients with CDH, the degree of pulmonary hypoplasia and pulmonary vascular disease predicts outcome.

Figure 1–3

This series of four-chamber two-dimensional echocardiographic images compares the disproportion between right ventricle and left ventricle in congenital diaphragmatic hernia (Fig. 1A, B); total anomalous pulmonary venous drainage (Fig. 2A, B); and cerebral arteriovenous malformation (Fig. 3A, B) in systole (Fig. 1,2,3A) and diastole (Fig. 1,2,3B). The enlarged apex-forming right ventricle compresses the left ventricle. The left ventricle in these conditions differs from true HLHS because the aortic and mitral valves are morphologically normal, and when pulmonary hypertension resolves, the left ventricle assumes a normal shape and volume.