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Wu F, Chen Y, Zhang X, Li Y, Chen Z, Liu Z, Dai W, Yang C, Liu H. Relative Mediastinal Displacement Index (RMDI): A Prenatal MRI Indicator of Adverse Events in Fetuses With Isolated Left Congenital Diaphragmatic Hernia. J Magn Reson Imaging 2024. [PMID: 38440902 DOI: 10.1002/jmri.29329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO), has partly improved congenital diaphragmatic hernia (CDH) outcomes, yet the overall morbidity and mortality remain high. Existing prenatal indicators for CDH fetuses are operator-dependent, time-consuming, or less accurate, a new simple and accurate indicator to indicate adverse events in CDH patients is needed. PURPOSE To propose and assess the association of a new MRI parameter, the relative mediastinal displacement index (RMDI), with adverse events including in-hospital deaths or the need for ECMO in fetuses with isolated left CDH (iLCDH). STUDY TYPE Retrospective analysis. SUBJECTS One hundred thirty-nine fetuses were included in the iLCDH group (24 with adverse events and 115 without) and 257 fetuses were included in the control group from two centers in Guangzhou. FIELD STRENGTH/SEQUENCE 3.0 T, T2WI-TRUFI; 1.5 T, T2WI-FIESTA. ASSESSMENT Three operators independently measured the→ DL $$ \underset{\mathrm{DL}}{\to } $$ ,→ DR $$ \underset{\mathrm{DR}}{\to } $$ , and DH on the axial images. The calculation formula of the RMDI was (→ DL $$ \underset{\mathrm{DL}}{\to } $$ + → DR $$ \underset{\mathrm{DR}}{\to } $$ )/DH . STATISTICAL TESTS The independent sample t test, Mann-Whitney U test, Chi-square test, Chi-square test continuity correction, Fisher's test, linear regression analysis, logistic regression analysis, intraclass correlation coefficient, receiver operating characteristic curve analysis, and Delong test. A P value <0.05 was considered statistically significant. RESULTS The RMDI did not change with gestational age in the iLCDH group (with [P = 0.189] and without [P = 0.567] adverse events) and the control group (P = 0.876). There were significant differences in RMDI between the iLCDH group (0.89 [0.65, 1.00]) and the control group (-0.23 [-0.34, -0.16]). In the iLCDH group, RMDI was the only indicator left for indicating adverse events, and the best cutoff value was 1.105. Moreover, there was a significant difference in diagnostic accuracy between the RMDI (AUC = 0.900) and MSA (AUC = 0.820), LHR (AUC = 0.753), o/e LHR (AUC = 0.709), and o/e TFLV (AUC = 0.728), respectively. DATA CONCLUSION The RMDI is expected to be a simple and accurate tool for indicating adverse events in fetuses with iLCDH. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Fan Wu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | | | - Xin Zhang
- Guangzhou Medical University, Guangzhou, China
| | - Yuchao Li
- Guangzhou Medical University, Guangzhou, China
| | - Zhaoji Chen
- Guangzhou Medical University, Guangzhou, China
| | - Zhenqing Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Wangchun Dai
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Chaoxiang Yang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hongsheng Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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Moore SS, Keller RL, Altit G. Congenital Diaphragmatic Hernia: Pulmonary Hypertension and Pulmonary Vascular Disease. Clin Perinatol 2024; 51:151-170. [PMID: 38325939 DOI: 10.1016/j.clp.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
This review provides a comprehensive summary of the current understanding of pulmonary hypertension (PH) in congenital diaphragmatic hernia, outlining the underlying pathophysiologic mechanisms, methods for assessing PH severity, optimal management strategies, and prognostic implications.
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Affiliation(s)
- Shiran S Moore
- Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Weizamann 6, Tel-Aviv, Jaffa 6423906, Israel.
| | - Roberta L Keller
- Neonatology, UCSF Benioff Children's Hospital, 550 16th Street, #5517, San Francisco, CA 94158, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Gabriel Altit
- Neonatology, McGill University Health Centre, Montreal Children's Hospital, 1001 Décarie boulevard, Montreal, H4A Quebec; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Kipfmueller F, Leyens J, Pugnaloni F, Bo B, Grass T, Lemloh L, Schroeder L, Nitsch-Felsecker P, Berg C, Heydweiller A, Strizek B, Mueller A. Spontaneous breathing in selected neonates with very mild congenital diaphragmatic hernia. Pediatr Pulmonol 2024; 59:617-624. [PMID: 38018668 DOI: 10.1002/ppul.26791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/29/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
AIMS Current treatment guidelines recommend immediate postnatal intubation in all neonates with congenital diaphragmatic hernia (CDH). This study aimed to investigate the feasibility and outcomes of a spontaneous breathing approach (SBA) versus immediate intubation in neonates with prenatally diagnosed very mild CDH. METHODS A retrospective study was conducted comparing neonates with very mild CDH (left-sided, liver-down, observed-to-expected lung-to-head ratio ≥45%) undergoing SBA and matched controls receiving standard treatment. Data on early echocardiographic findings, respiratory support, length of hospital stay, and clinical outcomes were analyzed. RESULTS Of 151 CDH neonates, eight underwent SBA, while 31 received standard treatment. SBA was successful in six of eight patients. SBA patients had shorter length of stay (14 vs. 30 days, p = .005), mechanical ventilation (3.5 vs. 8.7 days, p = .011), and oxygen supplementation (3.2 vs. 9.3 days, p = .013) compared to matched controls. Echocardiographic evidence of pulmonary hypertension and cardiac dysfunction were significantly lower in SBA neonates after admission but similar before surgical repair. The SBA group tolerated enteral feeding earlier (day of life 7 vs. 16, p = .019). CONCLUSIONS SBA appears feasible and beneficial for prenatally diagnosed very mild CDH. It was associated with a shortened hospital stay supportive therapies. However, larger trials are needed to confirm these findings and determine optimal respiratory support.
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Affiliation(s)
- Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Judith Leyens
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Flaminia Pugnaloni
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Medical and Surgical Department of Fetus-Newborn-Infant, Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Bartolomeo Bo
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Tamara Grass
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Lotte Lemloh
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Patrizia Nitsch-Felsecker
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Heydweiller
- Department of General, Visceral, Thoracic and Vascular Surgery, Division of Pediatric Surgery, University of Bonn, Bonn, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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Afreen S, Kumar M, Nangia S. Lung Volume Head Ratio: A Potential Parameter for Prediction of Respiratory Distress in Newborn. Am J Perinatol 2023; 40:1461-1466. [PMID: 34544167 DOI: 10.1055/a-1649-2208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the role of fetal lung biometry profile including fetal lung volume head ratio (LVHR) in predicting the occurrence of respiratory distress (RD) in early preterm newborn. STUDY DESIGN Prospective analytical cohort study was done to evaluate the clinical value of fetal sonographic measures, such as the total lung area (TLA), total lung volume (TLV), TLA head ratio (TLHR), LVHR, in pregnant women between 30 to 34 weeks' gestation who were expected to deliver within the next 72 hours. The cases with RD were compared with controls who had normal outcome. RESULT A total of 30 (27.4%) out of 110 patients, who underwent early preterm delivery, with RD rest 80 (72.6%) were controls. The TLA was 694.1 ± 373.1 mm2 in cases whereas 1,149.0 ± 506 0.7 mm2 in controls with significant difference between the two groups (p < 0.001). Similarly the lung volume (p < 0.001) and the LVHR were significantly less (p < 0.001) in cases compared with controls. The TLV was a better parameter (sensitivity, 73.7% and specificity, 86.4%) compared with TLA (sensitivity, 68.4% and specificity, 81.5%). Among the lung head ratios, LVHR had the best sensitivity of 95.5%, specificity: 80.3%, positive predictive value (PPV): 58.3%, and negative predictive value (NPV): 97.0% at the cut-off of 46.5. CONCLUSION RD was observed in nearly one-third of the preterm infants born between 30 and 34 weeks of gestation and could be predicted accurately in over 9 out of 10 cases using the novel parameter TLVR. KEY POINTS · Preterm newborn.. · Fetal lung volume.. · Respiratory distress..
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Affiliation(s)
- Shama Afreen
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
| | - Manisha Kumar
- Division of Fetal Medicine, Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
| | - Shushma Nangia
- Department of Neonatology, Kalavati Saran Children's Hospital, New Delhi, India
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Avena-Zampieri CL, Hutter J, Rutherford M, Milan A, Hall M, Egloff A, Lloyd DFA, Nanda S, Greenough A, Story L. Assessment of the fetal lungs in utero. Am J Obstet Gynecol MFM 2022; 4:100693. [PMID: 35858660 PMCID: PMC9811184 DOI: 10.1016/j.ajogmf.2022.100693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Antenatal diagnosis of abnormal pulmonary development has improved significantly over recent years because of progress in imaging techniques. Two-dimensional ultrasound is the mainstay of investigation of pulmonary pathology during pregnancy, providing good prognostication in conditions such as congenital diaphragmatic hernia; however, it is less validated in other high-risk groups such as those with congenital pulmonary airway malformation or preterm premature rupture of membranes. Three-dimensional assessment of lung volume and size is now possible using ultrasound or magnetic resonance imaging; however, the use of these techniques is still limited because of unpredictable fetal motion, and such tools have also been inadequately validated in high-risk populations other than those with congenital diaphragmatic hernia. The advent of advanced, functional magnetic resonance imaging techniques such as diffusion and T2* imaging, and the development of postprocessing pipelines that facilitate motion correction, have enabled not only more accurate evaluation of pulmonary size, but also assessment of tissue microstructure and perfusion. In the future, fetal magnetic resonance imaging may have an increasing role in the prognostication of pulmonary abnormalities and in monitoring current and future antenatal therapies to enhance lung development. This review aims to examine the current imaging methods available for assessment of antenatal lung development and to outline possible future directions.
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Affiliation(s)
- Carla L Avena-Zampieri
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Anna Milan
- Neonatal Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Megan Hall
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Alexia Egloff
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - David F A Lloyd
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Surabhi Nanda
- Fetal Medicine Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health, King's College London, London, United Kingdom; Neonatal Unit, King's College Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, United Kingdom; National Institute for Health and Care Research Biomedical Research Centre, Guy's & St Thomas National Health Service Foundation Trust and King's College London, London, United Kingdom
| | - Lisa Story
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.
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Furman Y, Gavri-Beker A, Miller TE, Bilik R, Rosenblat O, Avnet H, Lipitz S, Yinon Y, Strauss T, Weisz B. Do Serial Sonographic Assessments of Fetuses with Isolated Congenital Diaphragmatic Hernia Help Us Predict Survival? Fetal Diagn Ther 2021; 48:421-429. [PMID: 34247165 DOI: 10.1159/000515693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to assess the ability of serial prenatal sonographic measurements, and specifically changes in the observed-to-expected lung-to-head ratio (O/E LHR) throughout gestation and to predict survival in congenital diaphragmatic hernia (CDH). METHODS Retrospective study of CDH fetuses evaluated prenatally and treated postnatally in a single tertiary center, 2008-2020. Sonographic evaluations included side of herniation, liver involvement, and O/E LHR. All data were calculated to assess ability to predict survival. RESULTS Overall, 94 fetuses were evaluated prenatally and delivered in our medical center. Among them, 75 had isolated CDH and 19 nonisolated. CDH was categorized as left (n = 76; 80.8%), right (n = 16; 17.0%), or bilateral (n = 2; 2.2%). Overall perinatal survival rate was 57% for all live-born infants, 68% in isolated CDH, and 40% in nonisolated (excluding 2 cases that underwent fetoscopic endoluminal tracheal occlusion and did not survive). The O/E LHR was lower in cases with perinatal death compared to survivors. In cases with multiple evaluations, the minimal O/E LHR was the most accurate predictor of survival and need for perinatal extracorporeal membrane oxygenation (ECMO) support. This remained significant when excluding twin pregnancies or when evaluating only isolated left CDH. In addition to disease severity, the side of herniation and liver position was associated with preoperative mortality. CONCLUSION O/E LHR is associated with perinatal survival. In cases with multiple evaluations, the minimal O/E LHR is the most accurate and significant predictor of perinatal mortality and need for ECMO support.
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Affiliation(s)
- Yael Furman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Gavri-Beker
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neonatology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tal Elkan Miller
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Ron Bilik
- Department of Pediatric Surgery, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Orgad Rosenblat
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Hagay Avnet
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Shlomo Lipitz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Yoav Yinon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tzipora Strauss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neonatology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Boaz Weisz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Weis M, Burhany S, Perez Ortiz A, Nowak O, Hetjens S, Zahn K, Schoenberg S, Schaible T, Rafat N. The Chest Radiographic Thoracic Area Can Serve as a Prediction Marker for Morbidity and Mortality in Infants With Congenital Diaphragmatic Hernia. Front Pediatr 2021; 9:740941. [PMID: 35004536 PMCID: PMC8733701 DOI: 10.3389/fped.2021.740941] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Valid postnatal prediction parameters for neonates with congenital diaphragmatic hernia (CDH) are lacking, but recently, the chest radiographic thoracic area (CRTA) was proposed to predict survival with high sensitivity. Here, we evaluated whether the CRTA correlated with morbidity and mortality in neonates with CDH and was able to predict these with higher sensitivity and specificity than prenatal observed-to-expected (O/E) lung-to-head ratio (LHR). Methods: In this retrospective cohort study, all neonates with CDH admitted to our institution between 2013 and 2019 were included. The CRTA was measured using the software Horos (V. 3.3.5) and compared with O/E LHR diagnosed by fetal ultrasonography in relation to outcome parameters including survival, extracorporeal membrane oxygenation (ECMO) support, and chronic lung disease (CLD). Results: In this study 255 neonates were included with a survival to discharge of 84%, ECMO support in 46%, and 56% developing a CLD. Multiple regression analysis demonstrated that the CRTA correlates significantly with survival (p = 0.001), ECMO support (p < 0.0001), and development of CLD (p = 0.0193). The CRTA displayed a higher prognostic validity for survival [area under the curve (AUC) = 0.822], ECMO support (AUC = 0.802), and developing a CLD (AUC = 0.855) compared with the O/E LHR. Conclusions: Our data suggest that the postnatal CRTA might be a better prognostic parameter for morbidity and mortality than the prenatal O/E LHR.
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Affiliation(s)
- Meike Weis
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sosan Burhany
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Alba Perez Ortiz
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Oliver Nowak
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Biomathematics and Medical Statistics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Katrin Zahn
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan Schoenberg
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Neysan Rafat
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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Prognostic factors of death in children during the first year of life due to congenital diaphragmatic hernia: analysis of a hospital cohort from 2005 to 2015. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Carmo RISD, Peixoto-Filho FM, Bueno A, Fonseca M, Junior SCDSG. Prognostic factors of death in children during the first year of life due to congenital diaphragmatic hernia: analysis of a hospital cohort from 2005 to 2015. J Pediatr (Rio J) 2020; 96:569-575. [PMID: 31029681 PMCID: PMC9432261 DOI: 10.1016/j.jped.2019.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/15/2019] [Accepted: 03/21/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe and analyze the prognosis of children during the first year of life with a diagnosis of congenital diaphragmatic hernia admitted between the years 2005 and 2015 in the Neonatal Intensive Care Unit. METHOD In a retrospective cohort, 129 children with a diagnosis of congenital diaphragmatic hernia were studied. The prognostic factors were analyzed, whereupon prenatal, delivery, and postnatal exposure variables were associated with death during the first year of life. The odds ratio and the confidence interval (95% CI) were calculated for all the studied variables, using the chi-squared test and Student's t-test. RESULTS The study included 129 children hospitalized from January of 2005 to December of 2015. Seventy-nine (61%) patients died, 50 survived, and 33 had other associated malformations. Among the prognostic factors, the following were significant and increased the chance of death: polyhydramnios (p=0.001), gestational age of the earliest diagnosis (p=0.004), associated congenital abnormalities (OR: 3.013, p=0.022), pO2 of the first gasometry (p=0.000), pCO2 of the first gasometry (p=0.000), presence of pulmonary hypoplasia (OR: 3.074, p=0.000), use of preoperative vasoactive drugs (OR: 2.881, p=0.000), and use of nitric oxide (OR: 1.739, p=0.000). The presence of only intestines in the hernia content was a protective factor (OR: 0.615, p=0.001). CONCLUSION The mortality in the first year of life in patients with congenital diaphragmatic hernia in this study was 61% in the years 2005-2015. Among the prognostic factors that demonstrated a significant effect, pulmonary hypoplasia had the greatest impact.
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Affiliation(s)
- Roberta Ivanira Silva do Carmo
- Fundação Oswaldo Cruz (Fiocruz), Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Departamento de Ensino, Rio de Janeiro, RJ, Brazil.
| | | | - Arnaldo Bueno
- Fundação Oswaldo Cruz (Fiocruz), Saúde da Criança e da Mulher, Rio de Janeiro, RJ, Brazil; Universidade Federal Fluminense (UFF), Departamento Materno Infantil, Niterói, RJ, Brazil
| | - Marlon Fonseca
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Fundação Oswaldo Cruz (Fiocruz), Instituto Fernandes Figueira (IFF), Departamento de Saúde da Mulher, Rio de Janeiro, RJ, Brazil
| | - Saint Clair Dos Santos Gomes Junior
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Fundação Oswaldo Cruz (Fiocruz), Instituto Fernandes Figueira (IFF), Unidade de Pesquisa Clínica, Rio de Janeiro, RJ, Brazil
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Mank A, Carrasco Carrasco C, Thio M, Clotet J, Pauws SC, DeKoninck P, Te Pas AB. Tidal volumes at birth as predictor for adverse outcome in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2020; 105:248-252. [PMID: 31256011 DOI: 10.1136/archdischild-2018-316504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the predictive value of tidal volume (Vt) of spontaneous breaths at birth in infants with congenital diaphragmatic hernia (CDH). DESIGN Prospective study. SETTING Tertiary neonatal intensive care unit. PATIENTS Thirty infants with antenatally diagnosed CDH born at Hospital Sant Joan de Déu in Barcelona from September 2013 to September 2015. INTERVENTIONS Spontaneous breaths and inflations given in the first 10 min after intubation at birth were recorded using respiratory function monitor. Only expired Vt of uninterrupted spontaneous breaths was included for analysis. Receiver operating characteristics (ROC) analysis was performed and the area under the curve (AUC) was estimated to assess the predictive accuracy of Vt. MAIN OUTCOME MEASURES Mortality before hospital discharge and chronic lung disease (CLD) at day 28 of life. RESULTS There were 1.233 uninterrupted spontaneous breaths measured, and the overall mean Vt was 2.8±2.1 mL/kg. A lower Vt was found in infants who died (n=14) compared with survivors (n=16) (1.7±1.6 vs 3.7±2.1 mL/kg; p=0.008). Vt was lower in infants who died during admission or had CLD (n=20) compared with survivors without CLD (n=10) (2.0±1.7 vs 4.3±2.2 mL/kg; p=0.004). ROC analysis showed that Vt ≤2.2 mL/kg predicted mortality with 79% sensitivity and 81% specificity (AUC=0.77, p=0.013). Vt ≤3.4 mL/kg was a good predictor of death or CLD (AUC=0.80, p=0.008) with 85% sensitivity and 70% specificity. CONCLUSION Vt of spontaneous breaths measured immediately after birth is associated with mortality and CLD. Vt seems to be a reliable predictor but is not an independent predictor after adjustment for observed/expected lung to head ratio and liver position.
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Affiliation(s)
- Arenda Mank
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Cristina Carrasco Carrasco
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Marta Thio
- Newborn Research, Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Jordi Clotet
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Steffen C Pauws
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Tilburg center for Cognition and Communication, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
| | - Philip DeKoninck
- Obstetrics, Erasmus MC, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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11
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Kim AG, Mon RA, Karmakar M, Kreutzman J, Ladino-Torres M, Treadwell MC, Mychaliska GB, Perrone EE. Calculating Observed-to-Expected Total Fetal Lung Volume in CDH Fetuses in Twin Gestation: Is There a Better Way? Fetal Diagn Ther 2019; 47:545-553. [PMID: 31865353 DOI: 10.1159/000504510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/31/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a potentially lethal birth defect, and identifying prenatal predictors of outcome is important. Observed-to-expected total fetal lung volume (o/e TFLV) has been shown to be a predictor of severity and useful in risk stratification but is variable due to different TFLV formulas. OBJECTIVES To calculate o/e TFLV for CDH patients part of a twin gestation using the unaffected sibling as an internal control and comparing these values to those calculated using published formulas for TFLV. METHODS Seven twin gestations with one fetus affected by CDH were identified between 2006 and 2017. The lung volume for each twin was calculated using magnetic resonance imaging (MRI), and o/e TFLV was calculated using the unaffected twin's TFLV. This percentage was then compared to the o/e TFLV calculated using published formulas. RESULTS Lung volumes in the unaffected twins were within normal ranges at the lower end of the spectrum. No single TFLV formula was found to correlate perfectly. Intraclass correlation coefficient estimate was most consistent for o/e TFLV calculated with the Meyers formula and supported by Bland-Altman plots. CONCLUSIONS O/e TFLV measured in CDH/non-CDH twin gestations using the unaffected sibling demonstrated agreement with o/e TFLV calculated using the Meyers formula. We urge the fetal community to standardize the method, use, and interpretation of fetal MRI in the prenatal evaluation of CDH.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo A Mon
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria Ladino-Torres
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Radiology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA, .,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA,
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12
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Madenci AL, Church JT, Gajarski RJ, Marchetti K, Klein EJ, Coughlin MA, Kreutzman J, Treadwell M, Ladino-Torres M, Mychaliska GB. Pulmonary Hypertension in Patients with Congenital Diaphragmatic Hernia: Does Lung Size Matter? Eur J Pediatr Surg 2018; 28:508-514. [PMID: 29036736 PMCID: PMC7183369 DOI: 10.1055/s-0037-1607291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE The relationship between pulmonary hypoplasia and pulmonary arterial hypertension (PHTN) in patients with congenital diaphragmatic hernia (CDH) remains ill-defined. We hypothesized that prenatal estimates of lung size would directly correlate with PHTN severity. METHODS Infants with isolated CDH (born 2004-2015) at a single institution were included. Estimates of lung size included observed-to-expected LHR (o:eLHR) and %-predicted lung volumes (PPLV = observed/predicted volumes). The primary outcome was severity of PHTN (grade 0-3) on echocardiography performed between day of life 3 and 30. RESULTS Among 62 patients included, there was 32% mortality and 65% ECMO utilization. PPLV (odds ratio [OR] = 0.94 per 1 grade in PHTN severity, 95% confidence interval [CI] = 0.89-0.98, p < 0.01) and o:eLHR (OR = 0.97, 95% CI = 0.94-0.99, p < 0.01) were significantly associated with PHTN grade. Among patients on ECMO, PPLV (OR = 0.92, 95% CI = 0.84-0.99, p = 0.03) and o:eLHR (OR = 0.95, 95% CI = 0.92-0.99, p = 0.01) were more strongly associated with PHTN grade. PPLV and o:eLHR were significantly associated with the use of inhaled nitric oxide (iNO) (OR = 0.90, 95% CI = 0.83-0.98, p = 0.01 and OR = 0.94, 95% CI = 0.91-0.98, p < 0.01, respectively) and epoprostenol (OR = 0.91, 95% CI = 0.84-0.99, p = 0.02 and OR = 0.93, 95% CI = 0.89-0.98, p < 0.01, respectively). CONCLUSION Among infants with isolated CDH, PPLV, and o:eLHR were significantly associated with PHTN severity, especially among patients requiring ECMO. Prenatal lung size may help predict postnatal PHTN and associated therapies.
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Affiliation(s)
- Arin L. Madenci
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Joseph T. Church
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | | | | | | | | | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI,Fetal Diagnosis and Treatment Center, Michigan Medicine, Ann Arbor, MI
| | - Marcie Treadwell
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI,Fetal Diagnosis and Treatment Center, Michigan Medicine, Ann Arbor, MI
| | - Maria Ladino-Torres
- Section of Pediatric Radiology, Department of Radiology, Michigan Medicine, Ann Arbor, MI,Fetal Diagnosis and Treatment Center, Michigan Medicine, Ann Arbor, MI
| | - George B. Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI,Fetal Diagnosis and Treatment Center, Michigan Medicine, Ann Arbor, MI
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13
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Majeed T, Koul A, Khan T, Hassan S. Bowel sounds in the chest: An uncommon presentation of adult hernia. Respir Med Case Rep 2018; 25:199-200. [PMID: 30228957 PMCID: PMC6140309 DOI: 10.1016/j.rmcr.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/27/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022] Open
Abstract
We report a case of a 65-year-old male, who presented with respiratory complaints of cough and breathlessness, managed initially as respiratory tract infection. However, the patient did not improve, and a thorough examination and imaging revealed herniation of a gut segment into the thorax. The patient was operated and respiratory symptoms improved dramatically.
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Affiliation(s)
- Tahir Majeed
- Internal Medicine, SKIMS Soura, India,Corresponding author.
| | - Ajaz Koul
- Internal Medicine, SKIMS Soura, India,Internal Medicine and Infectious diseases, SKIMS soura , India
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14
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Oh C, Youn JK, Han JW, Yang HB, Lee S, Seo JM, Ho IG, Kim SH, Cho YH, Shin SH, Kim HY, Jung SE. Predicting Survival of Congenital Diaphragmatic Hernia on the First Day of Life. World J Surg 2018; 43:282-290. [PMID: 30167768 DOI: 10.1007/s00268-018-4780-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to determine perinatal risk factors for 30-day mortality of congenital diaphragmatic hernia (CDH) patients and develop a prognostic index to predict 30-day mortality of CDH patients. Identifying risk factors that can prognosticate outcome is critical to obtain the best management practices for patients. METHODS A retrospective study was performed for patients who were diagnosed with CDH from November 2000 to August 2016. A total of 10 prenatal risk factors and 14 postnatal risk factors were analyzed. All postnatal variables were measured within 24 h after birth. RESULTS A total of 95 CDH patients were enrolled in this study, including 61 males and 34 females with mean gestational age of 38.86 ± 1.51 weeks. The overall 30-day survival rate was 63.2%. Multivariate analysis revealed that five factors (polyhydramnios, gestational age at diagnosis <25 weeks, observed-to-expected lung-to-head ratio ≤45, best oxygenation index in 24 h >11, and severity of tricuspid regurgitation ≥ mild) were independent predictors of 30-day mortality of CDH. Using these five factors, a perinatal prognostic index for 30-day mortality was developed. Four predictive models (poor, bad, good, and excellent) of the perinatal prognostic index were constructed, and external validation was performed. CONCLUSIONS Awareness of risk factors is very important for predicting prognosis and managing patients. Five independent perinatal risk factors were identified in this study. A perinatal prognostic index was developed for 30-day mortality for patients with CDH. This index may be used to help manage CDH patients.
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Affiliation(s)
- Chaeyoun Oh
- Department of Pediatric Surgery, Korea University College of Medicine, Seoul, Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University College of Medicine, Children's Hospital, 101, Daehang-ro, Yeongeon-dong, Jongro-Gu, Seoul, 03080, Korea
| | - Ji-Won Han
- Department of Pediatric Surgery, Seoul National University College of Medicine, Children's Hospital, 101, Daehang-ro, Yeongeon-dong, Jongro-Gu, Seoul, 03080, Korea
| | - Hee-Byum Yang
- Department of Pediatric Surgery, Seoul National University College of Medicine, Children's Hospital, 101, Daehang-ro, Yeongeon-dong, Jongro-Gu, Seoul, 03080, Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In Geol Ho
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Hong Kim
- Department of Pediatric Surgery, Pusan National University Children's Hospital, Yangsan, Korea
| | - Yong Hoon Cho
- Department of Pediatric Surgery, Pusan National University Children's Hospital, Yangsan, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University College of Medicine, Children's Hospital, 101, Daehang-ro, Yeongeon-dong, Jongro-Gu, Seoul, 03080, Korea.
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University College of Medicine, Children's Hospital, 101, Daehang-ro, Yeongeon-dong, Jongro-Gu, Seoul, 03080, Korea
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15
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Cruz-Lemini M, Valenzuela-Alcaraz B, Granados-Montiel J, Martínez JM, Crispi F, Gratacós E, Cruz-Martínez R. Characterizing cardiac dysfunction in fetuses with left congenital diaphragmatic hernia. Prenat Diagn 2018; 38:422-427. [PMID: 29572873 DOI: 10.1002/pd.5253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate cardiac function by conventional echocardiography and tissue Doppler imaging in fetuses with left congenital diaphragmatic hernia (CDH). METHODS Conventional echocardiography (myocardial performance index, ventricular filling velocities, and E/A ratios) and tissue Doppler imaging (annular myocardial peak velocities, E/E' and E'/A' ratios) in mitral, septal, and tricuspid annulus were evaluated in a cohort of 31 left-sided CDH fetuses and compared with 75 controls matched for gestational age 2:1. RESULTS In comparison to controls, CDH fetuses had prolonged isovolumetric time periods (isovolumetric contraction time 35 ms vs 28 ms, P < .001), with higher myocardial performance index (0.49 vs 0.42, P < .001) and tricuspid E/A ratios (0.77 vs 0.72, P = .033). Longitudinal function assessed by tissue Doppler showed signs of impaired relaxation (mitral lateral A' 8.0 vs 10.1 cm/s, P < .001 and an increased mitral lateral E'/A' ratio 0.93 vs 0.78, P < .001) in the CDH fetuses as compared with controls, with preserved systolic function. CONCLUSION Left CDH fetuses show echocardiographic signs of diastolic dysfunction, probably secondary to fetal heart compression, maintaining a preserved systolic function.
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Affiliation(s)
- Mónica Cruz-Lemini
- Fetal Medicine Mexico, Fetal Surgery Research Unit, Children and Women's Specialty Hospital; Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Juriquilla, Queretaro, Mexico.,BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Brenda Valenzuela-Alcaraz
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Julio Granados-Montiel
- Tissue Engineering, Cell Therapy and Regenerative Medicine Research Unit, Instituto Nacional de Rehabilitación, Mexico City, Mexico
| | - Josep M Martínez
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Fátima Crispi
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rogelio Cruz-Martínez
- Fetal Medicine Mexico, Fetal Surgery Research Unit, Children and Women's Specialty Hospital; Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Juriquilla, Queretaro, Mexico.,BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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16
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Yamoto M, Iwazaki T, Takeuchi K, Sano K, Fukumoto K, Takahashi T, Nomura A, Ooyama K, Sekioka A, Yamada Y, Urushihara N. The fetal lung-to-liver signal intensity ratio on magnetic resonance imaging as a predictor of outcomes from isolated congenital diaphragmatic hernia. Pediatr Surg Int 2018; 34:161-168. [PMID: 29018962 DOI: 10.1007/s00383-017-4184-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE We investigated the developmental changes in the unaffected contralateral lungs of patients with isolated left-sided congenital diaphragmatic hernia (CDH) using signal intensity ratios on prenatal magnetic resonance imaging (MRI) and determined whether these changes correlated with clinical outcomes. METHODS We performed 47 fetal MRI screens on 30 patients with isolated left-sided CDH. A cohort of 88 fetuses was selected as the control. We calculated the lung-to-liver signal intensity ratio (LLSIR) using region of interest analysis and compared LLSIR between the groups and between those in the CDH group with good and poor prognoses. RESULTS In the control group, LLSIR increased as pregnancy progressed [regression line = 2.232 + 0.135 × (GW-23), r = 0.669]. In the CDH group, especially in the poor prognosis group, LLSIR did not significantly increase as pregnancy progressed [regression line for good prognosis = 1.827 + 0.092 × (gestational week-23), r = 0.733; regression line for poor prognosis = 1.731 + 0.025 × (gestational week-23), r = 0.634]. CONCLUSION Fetal LLSIR on T2-weighted MRI is an accurate marker of fetal lung maturity that correlates with postnatal survival and can potentially be used as a prognostic parameter in CDH management.
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Affiliation(s)
- Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan.
| | - Teruo Iwazaki
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kasumi Takeuchi
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kyouhei Sano
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Toshiaki Takahashi
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kei Ooyama
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Akinori Sekioka
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Yutaka Yamada
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
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17
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Abstract
In congenital diaphragmatic hernia (CDH), herniation of the abdominal organs into the fetal chest causes pulmonary hypoplasia and pulmonary hypertension, the main causes of neonatal mortality. As antenatal ultrasound screening improves, the risk of postnatal death can now be better predicted, allowing for the identification of fetuses that might most benefit from a prenatal intervention. Fetoscopic tracheal occlusion is being evaluated in a large international randomized controlled trial. We present the antenatal imaging approaches that can help identify fetuses that might benefit from antenatal therapy, and review the evolution of fetal surgery for CDH to date.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Calgary, 1403 29 Street NW, Calgary, Alberta.
| | - Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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18
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Separate Evaluation of the Ipsilateral and Contralateral MR Fetal Lung Volume in Patients With Congenital Diaphragmatic Hernia. AJR Am J Roentgenol 2016; 207:415-23. [PMID: 27249543 DOI: 10.2214/ajr.15.15114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our study had two objectives. First, we separately evaluated observed-to-expected MR fetal lung volume (FLV) of lungs ipsilateral and contralateral to a congenital diaphragmatic hernia (CDH). Second, we compared the prognostic value of observed-to-expected MR FLV of the ipsilateral and contralateral lungs with that of observed-to-expected MR FLV of both lungs with respect to survival, need for extracorporeal membrane oxygenation (ECMO), and development of chronic lung disease (CLD). MATERIALS AND METHODS We evaluated observed-to-expected MR FLV of the lung ipsilateral to the diaphragmatic defect as well as in the contralateral lung in 107 fetuses with isolated CDH. ROC analysis and logistic regression analysis were performed to assess the prognostic value of the observed-to-expected MR FLV for association with outcome. RESULTS In all fetuses with CDH, values in the ipsilateral (mean observed-to-expected MR FLV ± SD, 9.4% ± 9.6%) and the contralateral lung (mean observed-to-expected MR FLV, 48.9% ± 18.5%; p < 0.0001) were significantly lower than values measured in healthy fetuses. Observed-to-expected MR FLV of both lungs and of the contralateral and ipsilateral lung revealed significant differences regarding survival (p < 0.0001, p < 0.0001, and p = 0.0170, respectively), need for ECMO (p < 0.0001, p < 0.0001, and p = 0.0051, respectively), and development of CLD (p = 0.0004, p = 0.0002, and p = 0.0460, respectively). Compared with the observed-to-expected MR FLV of both lungs, the observed-to-expected MR FLV of the contralateral lung showed a slightly higher prognostic accuracy regarding survival (AUC = 0.859 vs 0.825) and development of CLD (AUC = 0.734 vs 0.732) and a similar prognostic accuracy regarding need for ECMO (AUC = 0.805 vs 0.826). Observed-to-expected MR FLV of the ipsilateral lung did not show good prognostic value regarding survival (AUC = 0.617), need for ECMO (AUC = 0.673), and development of CLD (AUC = 0.636). These AUCs were significantly smaller than the AUCs resulting from the observed-to-expected MR FLV of both lungs (each p < 0.05) and considerably smaller than the AUCs of the observed-to-expected MR FLV of the contralateral lung (each p < 0.10). CONCLUSION Patients with CDH showed a substantially lower observed-to-expected MR FLV of both lungs compared with healthy fetuses. The observed-to-expected MR FLV of both lungs as well as of the lung contralateral to the CDH were reliable prenatal predictors of survival, need for ECMO, and development of CLD.
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19
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Partridge EA, Peranteau WH, Herkert L, Rintoul NE, Flake AW, Adzick NS, Hedrick HL. Rate of increase of lung-to-head ratio over the course of gestation is predictive of survival in left-sided congenital diaphragmatic hernia. J Pediatr Surg 2016; 51:703-5. [PMID: 27261559 DOI: 10.1016/j.jpedsurg.2016.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/07/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is associated with high postnatal mortality because of pulmonary hypoplasia. The prognostic utility of serial lung-to-head circumference measurements as a marker of lung growth has not been described. Our objective was to examine the relationship between the rate of interval increase of LHR and postnatal survival in left-sided CDH. METHODS We retrospectively reviewed charts of all left-sided CDH patients from January 2004 to July 2014. All ultrasound studies performed at our institution (n=473) were reviewed. Categorical and continuous data were analyzed by chi-square and Mann-Whitney t-test, respectively, and slope analysis was performed by linear regression analysis (p<0.05). RESULTS A total of 226 patients were studied, with 154 long-term survivors and 72 non-survivors. Established markers of CDH severity, including intrathoracic liver position and requirement for patch repair, were significantly increased in non-survivors (p<0.0001). The rate of LHR increase as measured by linear regression and slope analysis was significantly increased in long-term survivors (p=0.0175). CONCLUSIONS Our findings indicate that the interval increase in LHR levels over the course of gestation correlate with survival in left-sided CDH patients. Regular ultrasonographic re-evaluation of LHR throughout gestation following diagnosis of CDH may provide prognostic insight and help guide patient management.
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Affiliation(s)
- Emily A Partridge
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Lisa Herkert
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104.
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20
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King SK, Alfaraj M, Gaiteiro R, O'Brien K, Moraes T, Humpl T, Marcon M, Chiang M, Reyes J, Haliburton B, Ryan G, Cox P, Chiu PPL. Congenital diaphragmatic hernia: Observed/expected lung-to-head ratio as a predictor of long-term morbidity. J Pediatr Surg 2016; 51:699-702. [PMID: 26932249 DOI: 10.1016/j.jpedsurg.2016.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/07/2016] [Indexed: 02/06/2023]
Abstract
AIM The aim of this study was to investigate the association of observed/expected (O/E) lung-to-head ratio (LHR) with long-term morbidity for isolated fetal congenital diaphragmatic hernia (CDH) patients in a single institution. METHODS We performed a retrospective study of prenatally diagnosed CDH from 18 to 38weeks of gestation (01/2002-04/2010). Two cohorts of O/E LHR were defined (22.6-45%, 45.1-78.3%) based upon previous studies. Survivors with at least 1-year follow-up of prospectively collected long-term morbidity assessments were included. RESULTS O/E LHR was available in 43 survivors (median 40%, range 22.8-78.3%). Follow-up data were available in 41 survivors (M:F=24:17, left CDH=39/41). Median follow-up was 6.5years (1-11years). Height/weight trajectories were similar between the two cohorts, with the majority below the 50th centile. There were no differences between the two cohorts by age 3years for Bayley scales (developmental domains) and/or REEL-3 (language development). In addition, V/Q scans in the two cohorts demonstrated similar degrees of mismatch (mean delta V/Q=35.4 versus 31.3). CONCLUSIONS In fetuses with isolated CDH, a reduction in O/E LHR does not predict a worse outcome in long-term follow-up. There is no association between a lower O/E LHR and a reduction in REEL-3 or Bayley score nor V/Q mismatch.
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Affiliation(s)
- Sebastian K King
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Malikah Alfaraj
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rose Gaiteiro
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karel O'Brien
- Division of Neonatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Theo Moraes
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tilman Humpl
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Margaret Marcon
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Monping Chiang
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janette Reyes
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beth Haliburton
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter Cox
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Correlation of Observed-to-Expected MRI Fetal Lung Volume and Ultrasound Lung-to-Head Ratio at Different Gestational Times in Fetuses With Congenital Diaphragmatic Hernia. AJR Am J Roentgenol 2016; 206:856-66. [PMID: 27003054 DOI: 10.2214/ajr.15.15018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to compare the observed-to-expected MRI fetal lung volume and the observed-to-expected ultrasound lung-to-head ratio intraindividually for prediction of survival, the need for extracorporeal membrane oxygenation (ECMO) therapy, and the development of chronic lung disease (CLD) at different times of gestation (< 28, 28-32, and > 32 weeks) in fetuses with congenital diaphragmatic hernia (CDH), and to analyze the intraindividual correlation of observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio. MATERIALS AND METHODS Two hundred one fetuses were included in our study. Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio were calculated for 270 MRI and ultrasound examinations performed within 72 hours of each other. The prognostic accuracy of observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio was assessed by performing ROC analysis. Correlation was determined using linear regression analysis. RESULTS The results revealed statistically significant differences between the observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio for the prediction of survival, the need for ECMO therapy, and the development of CLD in fetuses with left-sided CDH (p ≤ 0.0444), with the highest prognostic accuracy for survival (AUC = 0.863). Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio correlated statistically significantly (p < 0.0001) for left-sided CDH with correlation coefficients (r) of 0.71, 0.71, and 0.56 for early, intermediate, and late times of gestation, respectively. The correlation was not statistically significant at any time for right-sided CDH (p ≥ 0.3947; r ≤ 0.26). CONCLUSION Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio are valuable prognostic parameters for prenatal prediction of survival, the need for ECMO therapy, and the development of CLD in fetuses with left-sided CDH at all times of gestation. Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio correlate statistically significantly for left-sided CDH, and the correlation is best before 32 weeks' gestation, but they do not correlate statistically significantly for right-sided CDH.
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Pruetz JD, Votava-Smith J, Miller DA. Clinical relevance of fetal hemodynamic monitoring: Perinatal implications. Semin Fetal Neonatal Med 2015; 20:217-24. [PMID: 25823939 DOI: 10.1016/j.siny.2015.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Comprehensive assessment of fetal wellbeing involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques form the foundation of antenatal diagnosis of structural anomalies, rhythm abnormalities and altered fetal circulation. Accurate and timely prenatal identification of the fetus at risk is critical for appropriate parental counseling, antenatal diagnostic testing, consideration for fetal intervention, perinatal planning, and coordination of postnatal care delivery. Fetal hemodynamic monitoring and serial assessment are vital to ensuring fetal wellbeing, particularly in the setting of complex congenital anomalies. A complete hemodynamic evaluation of the fetus gives important information on the likelihood of a smooth postnatal transition and contributes to ensuring the best possible outcome for the neonate.
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Affiliation(s)
- Jay D Pruetz
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Jodie Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David A Miller
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Kehl S, Becker L, Eckert S, Weiss C, Schaible T, Neff KW, Siemer J, Sütterlin M. Prediction of mortality and the need for neonatal extracorporeal membrane oxygenation therapy by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:981-988. [PMID: 23716519 DOI: 10.7863/ultra.32.6.981] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To compare different rotation angles for assessment of fetal lung volume by 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) regarding prediction of mortality and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernias. METHODS One hundred patients with fetal congenital diaphragmatic hernias between 22 and 39 weeks' gestation were examined by 3D sonography and MRI. Sonographic contralateral fetal lung volumes were assessed by the rotational technique (virtual organ computer-aided analysis) at 3 different rotation angles: 6°, 15°, and 30°. The MRI fetal lung volumes were calculated based on multiplanar T2-weighted MRI. To eliminate the influence of gestational age, the observed to expected contralateral fetal lung volume on sonography and the observed to expected fetal lung volume on MRI were calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed to expected contralateral fetal lung volume (sonography) and observed to expected fetal lung volume (MRI). RESULTS One hundred cases were assessed for survival and 89 for ECMO necessity (11 neonates were not eligible for ECMO). For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves (AUCs) showed very similar results for MRI and 3D sonography: observed to expected fetal lung volume by MRI, 0.819 (95% confidence interval, 0.730-0.909) and 0.835 (0.748-0.922), respectively; 6° sonography, 0.765 (0.647-0.883) and 0.820 (0.734-0.905); 15° sonography, 0.784 (0.672-0.896) and 0.811 (0.719-0.903); and 30° sonography, 0.732 (0.609-0.855) and 0.772 (0.671-0.872). Comparisons between the AUCs revealed no statistical differences. CONCLUSIONS We have shown the good prognostic value of 3D sonography in fetuses with congenital diaphragmatic hernias compared with MRI, particularly when using small rotation angles. Therefore, it can be an appropriate diagnostic tool when counseling patients for congenital diaphragmatic hernias.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynecology, Mannheim University Medical Center, Mannheim, Germany.
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Another dimension to survival: predicting outcomes with fetal MRI versus prenatal ultrasound in patients with congenital diaphragmatic hernia. J Pediatr Surg 2013; 48:1190-7. [PMID: 23845606 PMCID: PMC7183370 DOI: 10.1016/j.jpedsurg.2013.03.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 03/09/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency. METHODS We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30. RESULTS Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06). CONCLUSION When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.
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Bianchi E, Mancini P, De Vito S, Pompili E, Taurone S, Guerrisi I, Guerrisi A, D'Andrea V, Cantisani V, Artico M. Congenital asymptomatic diaphragmatic hernias in adults: a case series. J Med Case Rep 2013; 7:125. [PMID: 23668793 PMCID: PMC3668166 DOI: 10.1186/1752-1947-7-125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 03/05/2013] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Congenital diaphragmatic hernia is a major malformation occasionally found in newborns and babies. Congenital diaphragmatic hernia is defined by the presence of an orifice in the diaphragm, more often to the left and posterolateral, that permits the herniation of abdominal contents into the thorax. The aim of this case series is to provide information on the presentation, diagnosis and outcome of three patients with late-presenting congenital diaphragmatic hernias. The diagnosis of congenital diaphragmatic hernia is based on clinical investigation and is confirmed by plain X-ray films and computed tomography scans. CASE PRESENTATIONS In the present report three cases of asymptomatic abdominal viscera herniation within the thorax are described. The first case concerns herniation of some loops of the large intestine into the left hemi-thorax in a 75-year-old Caucasian Italian woman. The second case concerns a rare type of herniation in the right side of the thorax of the right kidney with a part of the liver parenchyma in a 57-year-old Caucasian Italian woman. The third case concerns herniation of the stomach and bowel into the left side of the chest with compression of the left lung in a 32-year-old Caucasian Italian man. This type of hernia may appear later in life, because of concomitant respiratory or gastrointestinal disease, or it may be an incidental finding in asymptomatic adults, such as in the three cases featured here. CONCLUSIONS Patients who present with late diaphragmatic hernias complain of a wide variety of symptoms, and diagnosis may be difficult. Additional investigation and research appear necessary to better explain the development and progression of this type of disease.
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Affiliation(s)
- Enrica Bianchi
- Department of Anatomical, Histological, Forensic and Locomotor System Sciences, V, A, Borelli 50, Rome, 00161, Italy.
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Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. J Pediatr Surg 2013; 48:488-95. [PMID: 23480901 DOI: 10.1016/j.jpedsurg.2012.09.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 08/18/2012] [Accepted: 09/10/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Publications aiming to prove the feasibility and safety of thoracoscopic CDH-repair in neonates grow in numbers. Some teams use selection criteria, but none have proven statistical evidence. The aim of this study is to detect risk factors for failure of thoracoscopic primary closure of CDH in neonates. METHODS In 8 centers performing minimal access surgery (MAS), complete prenatal, postnatal, and operative data were evaluated for a retrospective study concerning patients with thoracoscopic congenital diaphragmatic hernia (CDH) repair. Most of the selection criteria and risk factors mentioned in the literature were analyzed. Two groups were defined: Group A - neonates who tolerated thoracoscopic primary repair, and Group B - neonates who required conversion or presented with major complications after thoracoscopic repair. Univariate and multivariate logistic regressions were used to compare these two groups. RESULTS From 2006 to 2010, thoracoscopy was performed in 40 neonates: Group A consisting of 28 neonates, and Group B 9 patients. Three patients were excluded because of insufficient data or major associated malformations. Significant statistical differences were found in Group B for postnatal PaCO2 >60 mmHg, need of iNO during postnatal stabilization, intrathoracic position of the stomach, pulmonary hypertension signs on the postnatal cardiac ultrasound, and preoperative OI >3.0. On multivariate analysis, only an OI >3.0 was significantly associated with conversion or major post-operative complication of thoracoscopic primary repair. CONCLUSION CDH can be safely repaired in the neonatal period by thoracoscopy. The limiting factor for thoracoscopic CDH repair is PPHN. The best preoperative indicator for PPHN is OI. Prospective studies are nonetheless necessary to prove the effectiveness of using these risk factors as selection criteria to help design surgical management protocols for neonates presenting CDH.
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Affiliation(s)
- Cindy Gomes Ferreira
- Department of Pediatric Surgery of the University Hospitals, Strasbourg, France.
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Rodríguez MR, de Vega VM, Alonso RC, Arranz JC, Ten PM, Pedregosa JP. MR Imaging of Thoracic Abnormalities in the Fetus. Radiographics 2012; 32:E305-21. [DOI: 10.1148/rg.327125053] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Britto ISW, Tedesco GD, Herbst SRS, Bussamra LCS, de Andrade FM, Araujo Júnior E, Nardozza LMM, Ruano R, Moron AF, Aoki T. New anatomical landmarks to study the relationship between fetal lung area and thoracic circumference by three-dimensional ultrasonography. J Matern Fetal Neonatal Med 2012; 25:1927-32. [PMID: 22372878 DOI: 10.3109/14767058.2012.667176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the relation between total lung area (TLA) and thoracic circumference (TC) ratio by three-dimensional (3D) ultrasonography applying new anatomical landmarks as the fetal aorta and inferior angle of the scapula. METHODS A longitudinal prospective study was conducted with 56 uncomplicated pregnancies between 24 and 32 weeks of gestation. Polynomial regressions were used to evaluate the correlation between TC and gestational age (GA) as well as TC and estimated fetal weight (EFW). A simple linear regression was used to evaluate the correlation between TLA and Total thoracic area (TTA) and GA. The intraclass correlation coefficient (ICC) was used to assess the intra and interobserver variability. RESULTS 127 examinations were performed. TC values ranged from 150 to 174 mm (mean 166 mm) at 24 weeks and 215-248 mm (mean 231 mm) at 32 weeks. The TLA/TC ratio ranged from a mean of 0.64 at 24 weeks (range 0.56-0.70) to 0.90 at 32 weeks gestation (range 0.79-1.01). The intraobserver variability using the ICC was of 0.919 for TC; 0.916 for TTA; 0.860 for right lung area (RLA) and 0.910 for left lung area (LLA). Interobserver reproducibility was with an ICC of 0.970 for TC; 0.984 for RLA and 0.910 for LLA. CONCLUSIONS Measurement of fetal TC and the relationship between TLA and TC by 3D-ultrasonography applying new anatomical landmarks shows good reproducibility and allows a new assessment of thoracic and lung growth.
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Affiliation(s)
- Ingrid Schwach Werneck Britto
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo (FCMSCSP), São Paulo, SP, Brazil
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Abstract
Congenital Diaphragmatic Hernia (CDH) is defined by the presence of an orifice in the diaphragm, more often left and posterolateral that permits the herniation of abdominal contents into the thorax. The lungs are hypoplastic and have abnormal vessels that cause respiratory insufficiency and persistent pulmonary hypertension with high mortality. About one third of cases have cardiovascular malformations and lesser proportions have skeletal, neural, genitourinary, gastrointestinal or other defects. CDH can be a component of Pallister-Killian, Fryns, Ghersoni-Baruch, WAGR, Denys-Drash, Brachman-De Lange, Donnai-Barrow or Wolf-Hirschhorn syndromes. Some chromosomal anomalies involve CDH as well. The incidence is < 5 in 10,000 live-births. The etiology is unknown although clinical, genetic and experimental evidence points to disturbances in the retinoid-signaling pathway during organogenesis. Antenatal diagnosis is often made and this allows prenatal management (open correction of the hernia in the past and reversible fetoscopic tracheal obstruction nowadays) that may be indicated in cases with severe lung hypoplasia and grim prognosis. Treatment after birth requires all the refinements of critical care including extracorporeal membrane oxygenation prior to surgical correction. The best hospital series report 80% survival but it remains around 50% in population-based studies. Chronic respiratory tract disease, neurodevelopmental problems, neurosensorial hearing loss and gastroesophageal reflux are common problems in survivors. Much more research on several aspects of this severe condition is warranted.
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Ruano R, Takashi E, da Silva MM, Campos JADB, Tannuri U, Zugaib M. Prediction and probability of neonatal outcome in isolated congenital diaphragmatic hernia using multiple ultrasound parameters. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:42-49. [PMID: 21898639 DOI: 10.1002/uog.10095] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To evaluate the accuracy and probabilities of different fetal ultrasound parameters to predict neonatal outcome in isolated congenital diaphragmatic hernia (CDH). METHODS Between January 2004 and December 2010, we evaluated prospectively 108 fetuses with isolated CDH (82 left-sided and 26 right-sided). The following parameters were evaluated: gestational age at diagnosis, side of the diaphragmatic defect, presence of polyhydramnios, presence of liver herniated into the fetal thorax (liver-up), lung-to-head ratio (LHR) and observed/expected LHR (o/e-LHR), observed/expected contralateral and total fetal lung volume (o/e-ContFLV and o/e-TotFLV) ratios, ultrasonographic fetal lung volume/fetal weight ratio (US-FLW), observed/expected contralateral and main pulmonary artery diameter (o/e-ContPA and o/e-MPA) ratios and the contralateral vascularization index (Cont-VI). The outcomes were neonatal death and severe postnatal pulmonary arterial hypertension (PAH). RESULTS Neonatal mortality was 64.8% (70/108). Severe PAH was diagnosed in 68 (63.0%) cases, of which 63 died neonatally (92.6%) (P < 0.001). Gestational age at diagnosis, side of the defect and polyhydramnios were not associated with poor outcome (P > 0.05). LHR, o/e-LHR, liver-up, o/e-ContFLV, o/e-TotFLV, US-FLW, o/e-ContPA, o/e-MPA and Cont-VI were associated with both neonatal death and severe postnatal PAH (P < 0.001). Receiver-operating characteristics curves indicated that measuring total lung volumes (o/e-TotFLV and US-FLW) was more accurate than was considering only the contralateral lung sizes (LHR, o/e-LHR and o/e-ContFLV; P < 0.05), and Cont-VI was the most accurate ultrasound parameter to predict neonatal death and severe PAH (P < 0.001). CONCLUSIONS Evaluating total lung volumes is more accurate than is measuring only the contralateral lung size. Evaluating pulmonary vascularization (Cont-VI) is the most accurate predictor of neonatal outcome. Estimating the probability of survival and severe PAH allows classification of cases according to prognosis.
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MESH Headings
- Algorithms
- Balloon Occlusion/methods
- Female
- Fetal Diseases/diagnostic imaging
- Fetal Diseases/mortality
- Fetal Diseases/therapy
- Gestational Age
- Hernia, Diaphragmatic/diagnostic imaging
- Hernia, Diaphragmatic/embryology
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/therapy
- Hernias, Diaphragmatic, Congenital
- Humans
- Hypertension, Pulmonary/diagnostic imaging
- Infant, Newborn
- Lung/diagnostic imaging
- Lung/physiopathology
- Lung Volume Measurements
- Male
- Predictive Value of Tests
- Pregnancy
- Pregnancy Outcome
- Probability
- Prospective Studies
- ROC Curve
- Reproducibility of Results
- Survival Analysis
- Ultrasonography, Doppler/methods
- Ultrasonography, Prenatal/methods
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Universidade de São Paulo, São Paulo, Brazil.
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Aspelund G, Fisher JC, Simpson LL, Stolar CJH. Prenatal lung-head ratio: threshold to predict outcome for congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2011; 25:1011-6. [PMID: 21815746 DOI: 10.3109/14767058.2011.608442] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The literature suggests that lung-head ratio (LHR) and liver position may inconsistently predict outcome for congenital diaphragmatic hernia (CDH). We reviewed our inborn neonates with isolated left-sided CDH to determine whether these variables predicted survival and to estimate the optimal LHR threshold. METHODS Prenatal LHR and liver position were obtained from 2002 to 2009. The primary endpoint was survival. RESULTS LHR was greater in survivors after adjusting for gestational age (median 1.40 versus 0.81; p < 0.001). LHR demonstrated excellent diagnostic discrimination, with area under receiver operating characteristic (ROC) curve 0.93 (95% CI 0.86-0.99). LHR threshold of 1.0 was 83% sensitive and 91% specific in predicting survival. An optimal LHR threshold of 0.85 predicted survival with 95% sensitivity and 64% specificity, reducing false negatives (survivors with low LHR). LHR > 0.85 predicted survival after adjustment for gestational age (OR = 33.6, 95% CI = 5.4-209.5). Liver position did not predict survival. CONCLUSIONS Prenatal LHR >0.85 predicts survival for infants with isolated left-sided CDH without compromising discrimination of survivors from non-survivors. The diagnostic utility of LHR may be confounded by gestational age at measurement. Stringent LHR threshold may minimize false-negative attribution and improve utility of this measurement as predictor of survival.
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Affiliation(s)
- Gudrun Aspelund
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA.
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Alfaraj MA, Shah PS, Bohn D, Pantazi S, O'Brien K, Chiu PP, Gaiteiro R, Ryan G. Congenital diaphragmatic hernia: lung-to-head ratio and lung volume for prediction of outcome. Am J Obstet Gynecol 2011; 205:43.e1-8. [PMID: 21529758 DOI: 10.1016/j.ajog.2011.02.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 12/02/2010] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate observed/expected (O/E) lung-to-head ratio (LHR) by ultrasound (US) and total fetal lung volume (TFLV) by magnetic resonance imaging as neonatal outcome predictors in isolated fetal congenital diaphragmatic hernia (CDH). STUDY DESIGN We conducted a retrospective study of 72 fetuses with isolated CDH, in whom O/E LHR and TFLV were evaluated as survival predictors. RESULTS O/E LHR on US and O/E TFLV by magnetic resonance imaging were significantly lower in newborn infants with isolated CDH who died compared with survivors (30.3 ± 8.3 vs 44.2 ± 14.2; P < .0001 for O/E LHR; 21.9 ± 6.3 vs 41.5 ± 17.6; P = .001 for O/E TFLV). Area under receiver-operator characteristics curve for survival for O/E LHR was 0.80 (95% confidence interval, 0.70-0.90). On multivariate analysis, O/E LHR predicted survival, whereas hernia side and first neonatal pH did not. For each unit increase in O/E LHR, mortality odds decreased by 11% (95% confidence interval, 4-17%). CONCLUSION In fetuses with isolated CDH, O/E LHR (US) independently predicts survival and may predict severity, allowing management to be optimized.
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Diagnosis of Congenital Diaphragmatic Hernia. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/174_2010_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
Chronic lung disease (CLD), defined as chronic oxygen dependency, is a common outcome of neonatal intensive care. It occurs most frequently in infants born very prematurely, but also in infants born at term who had severe lung disease and those with abnormal antenatal lung growth due particularly to reduction in fetal breathing movements, amniotic fluid volume or intrathoracic space. There are, however, other causes and the importance of antenatal infection/inflammation regarding impairment of antenatal lung growth is increasingly recognised. Affected infants can suffer chronic respiratory morbidity including an excess of respiratory symptoms and lung function abnormalities even in adulthood. Antenatal interventions directed at improving lung growth are available, but require testing inappropriately designed trials with pulmonary function at follow-up as an outcome.
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Affiliation(s)
- Anne Greenough
- Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine, Denmark Hill, London, UK.
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Van Mieghem T, Gucciardo L, Doné E, Van Schoubroeck D, Graatsma EM, Visser GHA, Verhaeghe J, Deprest J. Left ventricular cardiac function in fetuses with congenital diaphragmatic hernia and the effect of fetal endoscopic tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:424-429. [PMID: 19753655 DOI: 10.1002/uog.7340] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The pre-existing compression of the left ventricle in congenital diaphragmatic hernia (CDH) could be aggravated by the amplified lung growth after fetoscopic endoluminal tracheal occlusion (FETO). Our aim was to document left ventricular (LV) size and function in fetuses with isolated left-sided CDH and to document the effect of FETO on the fetal heart. METHODS We determined cardiac axis, LV diameters, ejection fraction, shortening fraction, mitral E/A index and myocardial performance index (MPI) in 27 fetuses with isolated left-sided CDH, and compared these with values in a reference population (n = 117). In fetuses with severe CDH that subsequently underwent FETO and/or reversal of occlusion, additional measurements were obtained 24 h before and after each fetal intervention. We recorded fetal electrocardiograms non-invasively in six CDH fetuses and compared the duration of the QRS complex with data obtained from 12 controls. RESULTS LV end-diastolic diameter was 32% smaller in CDH fetuses than in controls (P < 0.0001) but LV function was comparable. QRS duration was no different between CDH and control fetuses. FETO did not affect cardiac size but reduced the MPI (P = 0.004). Reversal of FETO had no significant effect on cardiac size and function. CONCLUSIONS CDH fetuses have a smaller left ventricle than do healthy fetuses. There is no overall adverse impact of CDH and FETO on LV cardiac function.
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Affiliation(s)
- T Van Mieghem
- Division of Woman and Child, Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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Büsing KA, Kilian AK, Schaible T, Dinter DJ, Neff KW. MR lung volume in fetal congenital diaphragmatic hernia: logistic regression analysis--mortality and extracorporeal membrane oxygenation. Radiology 2008; 248:233-9. [PMID: 18566175 DOI: 10.1148/radiol.2481070934] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively assess the results of logistic regression analysis that were based on magnetic resonance (MR) image fetal lung volume (FLV) measurements to predict survival and the corresponding need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH) before and after 30 weeks gestation. MATERIALS AND METHODS Written informed consent was obtained and the study was approved by the local research ethics committee. FLV was measured on MR images in 95 fetuses (52 female neonates, 43 male neonates) with CDH between 22 and 39 weeks gestation by using multiplanar T2-weighted half-Fourier acquired single-shot turbo spin-echo MR imaging. On the basis of logistic regression analysis results, mortality and the need for ECMO therapy were calculated for fetuses before and after 30 weeks gestation. RESULTS Overall, higher FLV was associated with improved survival (P < .001) and decreasing probability of need for ECMO therapy (P = .008). Survival at discharge was 29.2% in neonates with an FLV of 5 mL, compared with 99.7% in neonates with an FLV of 25 mL. The corresponding need for ECMO therapy was 56.1% in fetuses with an FLV of 5 mL and 8.7% in fetuses with an FLV of 40 mL. Prognostic power was considerably lower before 30 weeks gestation. CONCLUSION Beyond 30 weeks gestation, logistic regression analysis that is based on MR FLV measurements is useful to estimate neonatal survival rates and ECMO requirements. Prior to 30 weeks gestation, the method is not reliable and the FLV measurement should be repeated, particularly in fetuses with small lung volumes, before a decision is made about therapeutic options.
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Affiliation(s)
- Karen A Büsing
- Department of Clinical Radiology, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany.
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Pasquali R, Potier A, Gorincour G. [Fetal lung imaging]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:587-602. [PMID: 18486517 DOI: 10.1016/j.gyobfe.2008.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 03/31/2008] [Indexed: 05/26/2023]
Abstract
Exponential improvements in imaging techniques over the last ten years, through patients' and physicians' wishes for less invasive fetal work-up, now allow us to better explore and understand fetal lung physiology during pregnancy. Diagnostic and prognostic consequences at stake are huge, especially for fetuses at risk of pulmonary hypoplasia. We will decline in three parts (normal lung, malformative lung and pulmonary hypoplasia), through a review of the literature and at the light of our experience, the potentialities and limitations of all imaging modalities (Ultrasound, Doppler, 3D, MRI). Then, we will dwell on future leads and the need for large-scale collaborative studies.
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Affiliation(s)
- R Pasquali
- Service de radiologie pédiatrique, hôpital de la Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
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Moreno-Alvarez O, Hernandez-Andrade E, Oros D, Jani J, Deprest J, Gratacos E. Association between intrapulmonary arterial Doppler parameters and degree of lung growth as measured by lung-to-head ratio in fetuses with congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:164-170. [PMID: 18196498 DOI: 10.1002/uog.5201] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To describe the association between the intrapulmonary circulation and the degree of lung growth in fetuses with congenital diaphragmatic hernia (CDH). METHODS Thirty-six fetuses with isolated left CDH at 22-29 weeks of gestation were studied. Four groups were defined according to lung-to-head ratio (LHR), expressed as the ratio of observed to expected LHR for gestational age (O/E LHR). Pulsatility index (PI), peak systolic velocity (PSV), peak early-diastolic reversed flow (PEDRF), end-diastolic velocity (EDV), acceleration time (AT), time averaged velocity (TAV) and the ratio AT to ejection time (AT/ET) were measured in all fetuses in the proximal arterial branch of both lungs. For analysis, Doppler values were converted to Z-scores. RESULTS It was possible to record all Doppler parameters from the contralateral lung of all CDH fetuses, and from the ipsilateral lung in 28 (77.7%). PEDRF significantly increased in relation to the decrease in O/E LHR in both lungs (contralateral: r = - 0.65, P = 0.01; ipsilateral: r = - 0.43, P = 0.02). PI increased significantly with the reduction in O/E LHR but only on the side contralateral to the hernia (r = - 0.55, P = 0.02). In the ipsilateral pulmonary artery, PI values showed a significant overall increase but no differences were observed among the O/E LHR groups. PSV, EDV and TAV were reduced in both lungs with respect to normal values, but no association was found with the O/E LHR. No changes in AT or AT/ET were observed in either lung. CONCLUSIONS PEDRF is quick and easy to calculate, and showed the strongest and most consistent correlation with O/E LHR. The association between PEDRF and LHR might be an additional parameter that could help to establish prognosis in fetuses with CDH.
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Affiliation(s)
- O Moreno-Alvarez
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomediques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
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Büsing KA, Kilian AK, Schaible T, Debus A, Weiss C, Neff KW. Reliability and Validity of MR Image Lung Volume Measurement in Fetuses with Congenital Diaphragmatic Hernia and in Vitro Lung Models. Radiology 2008; 246:553-61. [DOI: 10.1148/radiol.2462062166] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Breeze ACG, Gallagher FA, Lomas DJ, Smith GCS, Lees CC. Postmortem fetal organ volumetry using magnetic resonance imaging and comparison to organ weights at conventional autopsy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:187-193. [PMID: 18092338 DOI: 10.1002/uog.5199] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Following perinatal death, organ weights at autopsy may provide evidence of growth restriction and pulmonary hypoplasia. Whilst postmortem magnetic resonance imaging (MRI) may provide comparable information to autopsy about structural abnormalities, its ability to provide reproducible data about organ size has yet to be determined. We examined the feasibility of using postmortem MRI to provide estimates of organ size and weight. METHODS Twenty-five fetuses of gestational age from 16 to 40 weeks underwent postmortem MRI prior to autopsy. Fetal lung, brain and liver volume estimations were performed by two observers using the stereology technique on postmortem MRI slices. Fetal lung, brain and liver weights were recorded at autopsy. Organ volume estimates and autopsy organ weights were compared using regression analysis, and estimates of fetal organ densities made. Interobserver variability was assessed using a Bland-Altman plot. Receiver-operating characteristics curve (ROC) analysis compared MRI brain : liver volume ratios to autopsy brain : liver weight ratios. RESULTS A linear relationship between organ volume estimates and organ weight was observed. Estimated densities for the fetal brain, liver and lung were 1.08 g/cm(3), 1.15 g/cm(3) and 1.15 g/cm(3), respectively. Interobserver 5th and 95th percentile limits of agreement for fetal brain, liver and lung were - 5.4% to + 7.9%, - 11.8% to + 8.3% and - 14.3% to + 8.7%, respectively. For MRI organ volumes to detect a brain weight : liver weight ratio > or = 4, ROC analysis demonstrated an area under the curve of 0.61, with an optimal cut-off of 4.1. CONCLUSION Postmortem MRI organ volumetry can be used to estimate weights of major fetal organs. This may increase the information obtained from a minimally-invasive perinatal autopsy, particularly in the context of pulmonary hypoplasia and intrauterine growth restriction, where differential organ growth plays a major part in assessment of the underlying pathology.
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Affiliation(s)
- A C G Breeze
- Division of Maternal-Fetal Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Hata T, Kuno A, Dai SY, Inubashiri E, Hanaoka U, Kanenishi K, Yamashiro C, Tanaka H, Yanagihara T. Three-dimensional sonographic volume measurement of the fetal lung. J Obstet Gynaecol Res 2007; 33:793-8. [DOI: 10.1111/j.1447-0756.2007.00658.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jani JC, Peralta CFA, Ruano R, Benachi A, Done E, Nicolaides KH, Deprest JA. Comparison of fetal lung area to head circumference ratio with lung volume in the prediction of postnatal outcome in diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:850-854. [PMID: 17937452 DOI: 10.1002/uog.5167] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To compare prediction of postnatal survival in isolated diaphragmatic hernia by prenatal two-dimensional (2D) versus three-dimensional (3D) sonographic assessment of the contralateral lung. METHODS The lung area to head circumference ratio (LHR) of the contralateral lung was measured and expressed as a percentage of the normal mean for gestation (O/E) in 47 fetuses with isolated diaphragmatic hernia at 26 (range, 21-36) weeks of gestation. The lung area was measured by tracing the limits of the lungs (LHR trace) and by multiplying the longest diameter by its perpendicular (LHR diameters). The contralateral lung volume was measured by the Virtual Organ Computer-Aided anaLysis method and the O/E was calculated. Regression analysis was used to determine the significance of the LHRs and volume in the prediction of postnatal survival. RESULTS The survival rate was 59.6% (28 of 47). There were significant associations between O/E LHR trace and O/E LHR diameters, and between each O/E LHR and O/E volume, but multiple regression analysis demonstrated that significant prediction of survival was provided only by O/E LHR trace and intrathoracic herniation of the liver. CONCLUSIONS In diaphragmatic hernia prenatal prediction of postnatal outcome is better by 2D measurement of LHR trace than it is by 3D measurement of lung volume.
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Affiliation(s)
- J C Jani
- Unit of Prenatal and Gynecological Ultrasound and Fetal Therapy, Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium
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Jani J, Cannie M, Done E, Van Mieghem T, Van Schoubroeck D, Gucciardo L, Dymarkowski S, Deprest JA. Relationship between lung area at ultrasound examination and lung volume assessment with magnetic resonance imaging in isolated congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:855-860. [PMID: 17932997 DOI: 10.1002/uog.5168] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To prospectively examine the relationship between contralateral lung area measured by two-dimensional (2D) ultrasound examination and contralateral and total fetal lung volume (FLV) estimated by magnetic resonance imaging (MRI) in the assessment of fetuses with congenital diaphragmatic hernia (CDH). METHODS Sixty-six fetuses with isolated CDH were entered in this prospective study. Contralateral fetal lung area was measured by 2D ultrasonography using the longest axis method. Ipsilateral, contralateral and total FLV were measured using multiplanar axial T2-weighted MRI. Regression analysis was used to determine the significance of associations between contralateral lung area and contralateral and total FLV, and the predicted total FLV was subsequently calculated using the regression equation. Univariate regression analysis was used to investigate the effect on the proportionate difference between the predicted and the observed total FLV of gestational age, proportionate volume of ipsilateral vs. total FLV, side of CDH, intrathoracic herniation of the liver and intratracheal presence of a balloon. RESULTS The 66 fetuses underwent a total of 191 paired 2D ultrasound and MRI examinations at a median gestational age of 30 (range, 18-38) weeks. It was possible to visualize and measure the contralateral lung area by 2D ultrasound, as well as both the ipsilateral and contralateral lung volumes by MRI, in all instances. There was a significant association between contralateral lung area and contralateral lung volume (r = 0.86; P < 0.001) and with total FLV (r = 0.84; P < 0.001). Univariate regression analysis showed that the proportionate difference between the predicted and the observed total FLV was significantly associated with the proportionate volume of ipsilateral vs. total FLV but not with gestational age, side of CDH, intrathoracic herniation of the liver or intratracheal presence of the balloon. CONCLUSIONS In CDH, contralateral lung area measurement by 2D ultrasound correlates well with the total FLV estimated by MRI, irrespective of gestational age, liver herniation or side of herniation. Inconsistencies between the two measurements are attributable to the contribution of the ipsilateral lung to the total lung volume.
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Affiliation(s)
- J Jani
- Unit of Prenatal and Gynecological Ultrasound and Fetal Therapy, Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium
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Hedrick HL, Danzer E, Merchant AM, Bebbington MW, Zhao H, Flake AW, Johnson MP, Liechty KW, Howell LJ, Wilson RD, Adzick NS. Liver position and lung-to-head ratio for prediction of extracorporeal membrane oxygenation and survival in isolated left congenital diaphragmatic hernia. Am J Obstet Gynecol 2007; 197:422.e1-4. [PMID: 17904987 DOI: 10.1016/j.ajog.2007.07.001] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 05/08/2007] [Accepted: 07/01/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the ability of liver position and lung-to-head ratio to predict outcome in isolated left congenital diaphragmatic hernia. STUDY DESIGN We reviewed prenatal studies and postnatal outcomes of congenital diaphragmatic hernia between January 1996 and January 2006. RESULTS Eighty-nine patients received prenatal and postnatal care at 1 institution. In fetuses with liver up, extracorporeal membrane oxygenation was required in 39 of 49 fetuses (80%), compared with 10 of 40 fetuses (25%) for those with liver down (P < .0001). Overall survival rate was 45%, compared with 93% for those with liver down (P < .00005). Low lung-to-head ratio (<1.0) predicted increased incidence of extracorporeal membrane oxygenation (75%; P = .036) and lower survival (35%; P = .0003). However, when measured at <24 weeks of gestation, lung-to-head ratio was not predictive of outcome (extracorporeal membrane oxygenation, P = .108; survival, P = .150); liver position remained highly predictive (extracorporeal membrane oxygenation, P = .006; survival, P = .001). CONCLUSION Liver position is the best prenatal predictor of outcome in isolated left congenital diaphragmatic hernia. Lung-to-head ratio alone should not be used to counsel families regarding mid gestational management choices.
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Affiliation(s)
- Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Keller RL. Antenatal and postnatal lung and vascular anatomic and functional studies in congenital diaphragmatic hernia: implications for clinical management. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2007; 145C:184-200. [PMID: 17436304 DOI: 10.1002/ajmg.c.30130] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia is characterized by fetal and neonatal lung hypoplasia as well as vascular hypoplasia. Antenatal imaging studies have been performed that attempt to quantify the degree of hypoplasia and its impact on infant prognosis. Prenatal and perinatal growth of the lung and vasculature are interdependent and their continued coordinated growth is critical for survival after birth in this patient population. Lung protection strategies appear to improve survival in newborns with diaphragmatic hernia, but a subset of infants remain who demonstrate sufficiently severe lung hypoplasia that we are unable to provide support long-term after birth. Fetal intervention is a strategy designed to enhance fetal lung growth towards improving survival in this most severely affected group, though other therapies to enhance postnatal lung and vascular growth should be concurrently investigated. However, any of these interventions will require careful selection of those infants at risk for poor outcome and thorough follow up, since long-term morbidity is significant in children with diaphragmatic hernia.
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Jani J, Nicolaides KH, Keller RL, Benachi A, Peralta CFA, Favre R, Moreno O, Tibboel D, Lipitz S, Eggink A, Vaast P, Allegaert K, Harrison M, Deprest J. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:67-71. [PMID: 17587219 DOI: 10.1002/uog.4052] [Citation(s) in RCA: 364] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To assess the value of antenatally determined observed to expected fetal lung area to head circumference ratio (LHR) in the prediction of postnatal survival in isolated, congenital diaphragmatic hernia (CDH). METHODS Two groups of fetuses were examined. The first group included 650 normal fetuses at 12-32 weeks' gestation, and the data collected were used to establish a normal range of observed to expected LHR with gestational age. The second group included the data of a retrospective multicenter study of 354 fetuses with isolated CDH in which the LHR was measured on one occasion at 18-38 weeks' gestation. The patients were divided into those with left-sided CDH with and without intrathoracic herniation of the liver and right-sided CDH. Regression analysis was used to determine the significant predictors of postnatal survival. RESULTS In both the normal fetuses and those with CDH the LHR increased but the observed to expected LHR did not change significantly with gestational age. In normal fetuses the mean observed to expected LHR in the left lung was 100% (95% CI, 61-139%) and in the right lung it was 100% (95% CI, 67-133%). In fetuses with CDH the mean observed to expected LHR was 39% (range 7-79%). Regression analysis demonstrated that significant predictors of survival were the observed to expected LHR (odds ratio (OR) 1.09, 95% CI, 1.06-1.12), side of CDH (left side OR 11.14, 95% CI, 3.41-36.39) and gestational age at delivery (OR 1.18, 95% CI, 1.02-1.36). CONCLUSION In CDH, the LHR increases while observed to expected LHR is independent of gestational age. In fetuses with both left- and right-sided CDH, measurement of the observed to expected LHR provides a useful prediction of subsequent survival.
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Affiliation(s)
- J Jani
- Fetal Medicine and Treatment Units, University Hospital Gasthuisberg, Leuven, Belgium
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Abstract
Advances in prenatal ultrasound have revealed the poor natural history of fetal congenital diaphragmatic hernia (CDH) and its hidden mortality during gestation and immediately after birth. Attempts to improve this poor outcome led to the development of prenatal surgical intervention for severe CDH by Harrison and his colleagues at the University of California San Francisco. Prenatal surgical intervention for CDH has seen four phases: open fetal surgical repair, open surgical tracheal occlusion, endoscopic external tracheal occlusion, and endoscopic endoluminal tracheal occlusion. After extensive work in the laboratory, prenatal intervention has been applied in humans since 1984. With the most recent techniques, maternal risk is significantly reduced as is the incidence of preterm labor. In the meantime, the survival rate of fetuses with CDH without fetal intervention has improved mainly due to the minimization of iatrogenic lung injury by gentle ventilation, first described in 1985. However, the morbidity of the survivors with severe CDH remains high. Prenatal intervention for CDH will be justified if improvement in survival or morbidity can be demonstrated when compared to planned delivery and postnatal management with gentle ventilation strategy.
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Affiliation(s)
- Yoshihiro Kitano
- Division of General Surgery, Saitama Children's Medical Center, Saitama, Japan.
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