Mediastinal Shift Angle in Fetal MRI Is Associated With Prognosis, Severity, and Cardiac Underdevelopment in Left Congenital Diaphragmatic Hernia

Abstract

Objective:Fetal MRI has played an essential role in the evaluation and management of congenital diaphragmatic hernia (CDH). We aimed to investigate whether the mediastinal shift angle (MSA) value was associated with the prognosis and the severity of left CDH and explore the relationship between the MSA value and fetal and neonatal cardiac structures and functions.MethodsFrom January 2012 to December 2020, the fetal MSA values of left CDH in our institution were retrospectively measured. Other prenatal parameters and clinical outcomes of them are collected. We also measured the fetal and postnatal echocardiography parameters to analyze linear correlation with MSA values.ResultsA total of 94 patients with left CDH were included. MSA was significantly higher in the deceased group than in the survived group [((38.3 ± 4.7)° vs. 32.3 ± 5.3)°, p < 0.001]. The MSA value of the high-risk defect group [CDH Study Group (CDHSG) C/D type] was significantly higher than that of the low-risk defect group [CDHSG A/B type; (36.0 ± 4.9)° vs. (30.1 ± 4.8)°, p < 0.001]. The AUC for severity was 0.766 (95% CI, 0.661–0.851, p < 0.0001) and the best cut-off value for MSA was 30.7°. Higher MSA correlates with decreased fetal Z-score of left ventricle (LV) width, the diameter of the mitral valve (MV), peak velocity of MV and tricuspid valve (TV), and neonatal LV end-diastolic diameter (LVEDD) and velocity of tricuspid regurgitation (TR; p < 0.05).ConclusionA high MSA value can effectively predict high-risk defects and high mortality of left CDH. The higher the MSA value, the worse the neonatal conditions, the respiratory and cardiovascular prognosis. The MSA values could reflect the level of left heart underdevelopment, including decreased dimensions and diastolic dysfunction of the left ventricle.

Fetal MRI-Based Mediastinal Shift Angle (MSA) and Percentage Area of Left Ventricle (pALV) as Prognostic Parameters for Congenital Diaphragmatic Hernia

“…The mediastinal displacement angle (MSA) can be determined using MRI and quantifies the extent of cardiac displacement. Previous studies have considered the MSA regarding solely left-sided hernias and investigated its prognostic value in direct comparison with already established parameters such as the o/e LHR and o/e TFLV [ 10 , 11 , 12 ].…”

“…Only Wang et al (2022) and Savelli et al (2020) addressed direct outcome parameters such as survival or mortality and respiratory/cardiovascular prognosis [ 12 , 13 ]. According to Savelli et al (2020), the AUC for the predictive power of survival was 0.931 [ 13 ].…”

“…In addition to the extent of pulmonary hypoplasia, cardiac impairment due to pulmonary hypertension and left ventricular hypoplasia is crucial for prognosis. According to Wang et al (2022), the MSA value gives an indication of the extent of left heart hypoplasia [ 12 ]. Siebert et al (1984) already classified left heart hypoplasia as a relevant risk factor in the pathogenesis of heart failure in patients with left-sided CDH; recent studies by Patel et al (2019) and Prasad et al (2022) came to a comparable conclusion [ 7 , 8 , 9 ].…”

“…The mediastinal shift angle (MSA) can be determined by MRI and quantifies the extent of cardiac displacement. Previous studies have looked at the MSA in relation to left-sided hernias and have predominantly investigated its value as an MRI prognostic parameter in direct comparison with already established parameters such as the o/e LHR and o/e TFLV [ 10 , 11 , 12 ]. Only Wang et al (2022) and Savelli et al (2020) address direct outcome parameters such as survival and mortality, respectively, and respiratory-cardiovascular prognosis [ 12 , 13 ].…”

“…Previous studies have looked at the MSA in relation to left-sided hernias and have predominantly investigated its value as an MRI prognostic parameter in direct comparison with already established parameters such as the o/e LHR and o/e TFLV [ 10 , 11 , 12 ]. Only Wang et al (2022) and Savelli et al (2020) address direct outcome parameters such as survival and mortality, respectively, and respiratory-cardiovascular prognosis [ 12 , 13 ]. All studies ignored the rarer and smaller, but more frequently severely affected, subpopulation of right-sided hernias.…”