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Pasieczna M, Kuran-Ohde J, Grzyb A, Bokiniec R, Wójcik-Sęp A, Czajkowski K, Szymkiewicz-Dangel J. Value of fetal echocardiographic examination in pregnancies complicated by preterm premature rupture of membranes. J Perinat Med 2024; 52:538-545. [PMID: 38639637 DOI: 10.1515/jpm-2023-0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Cardiopulmonary and infectious complications are more common in preterm newborns after preterm premature rupture of membranes (pPROM). Fetal echocardiography may be helpful in predicting neonatal condition. Our aim was to assess the cardiovascular changes in fetuses from pregnancies complicated by pPROM and possible utility in predicting the intrauterine or neonatal infection, and neonatal heart failure (HF). METHODS It was a prospective study enrolling 46 women with singleton pregnancies complicated by pPROM between 18+0 and 33+6 weeks of gestation and followed until delivery. 46 women with uncomplicated pregnancies served as a control group. Fetal echocardiographic examinations with the assessment of cardiac structure and function (including pulmonary circulation) were performed in all patients. RESULTS Mean gestational age of pPROM patients was 26 weeks. Parameters suggesting impaired cardiac function in fetuses from pPROM were: higher right ventricle Tei index (0.48 vs. 0.42 p<0.001), lower blood flow velocity in Ao z-score (0.14 vs. 0.84 p=0.005), lower cardiovascular profile score (CVPS), higher rate of tricuspid regurgitation (18.2 % vs. 4.4 % p=0.04) and pericardial effusion (32.6 vs. 0 %). Intrauterine infection was diagnosed in 18 patients (39 %). 4 (8.7 %) newborns met the criteria of early onset sepsis (EOS). HF was diagnosed in 9 newborns. In fetal echocardiographic examination HF group had shorter mitral valve inflow time and higher left ventricle Tei index (0.58 vs. 0.49 p=0.007). CONCLUSIONS Worse cardiac function was observed in fetuses from pPROM compared to fetuses from uncomplicated pregnancies.
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Affiliation(s)
- Monika Pasieczna
- 2nd Department of Obstetrics and Gynecology, 37803 Medical University of Warsaw , Warsaw, Poland
| | - Joanna Kuran-Ohde
- 2nd Department of Obstetrics and Gynecology, 37803 Medical University of Warsaw , Warsaw, Poland
- Department of Perinatal Cardiology and Congenital Defects, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Agnieszka Grzyb
- Department of Perinatal Cardiology and Congenital Defects, Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Cardiology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Renata Bokiniec
- Department of Neonatology and Neonatal Intensive Care, 37803 Medical University of Warsaw , Warsaw, Poland
| | - Agata Wójcik-Sęp
- Department of Neonatology and Neonatal Intensive Care, 37803 Medical University of Warsaw , Warsaw, Poland
| | - Krzysztof Czajkowski
- 2nd Department of Obstetrics and Gynecology, 37803 Medical University of Warsaw , Warsaw, Poland
| | - Joanna Szymkiewicz-Dangel
- Department of Perinatal Cardiology and Congenital Defects, Centre of Postgraduate Medical Education, Warsaw, Poland
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Park SH, Kim JY, Seol KH, Roh JH, Lee HN, Kim SH, Jeong J, Namgoong JM, Lee BS, Jung E. Pulmonary Artery Measurements as Postnatal Prognostic Tool in Right Congenital Diaphragmatic Hernia. J Pediatr Surg 2024; 59:1077-1082. [PMID: 38168548 DOI: 10.1016/j.jpedsurg.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is a rare and often fatal congenital anomaly, primarily attributed to lung hypoplasia, which is associated with small branch pulmonary artery (PA). This study investigated whether postnatal PA measurements obtained through echocardiography are associated with mortality or the extracorporeal membrane oxygenation (ECMO) requirement in neonates with RCDH. METHODS A retrospective study was conducted on neonates with RCDH born between 2008 and 2022. Echocardiography was performed on the day of birth. The diameter of the main PA (MPA) was measured at the maximal dimension, and the diameters of the left PA (LPA) and right PA (RPA) were measured at the bifurcation. The primary outcome was mortality or ECMO requirement. Parameters, including the LPA:MPA ratio, RPA:MPA ratio, Nakata index, McGoon ratio, and ejection fraction (EF), were analyzed and compared with the observed-to-expected lung-to-head ratio (o/e LHR), initial blood gas, and defect size as predictive values. RESULTS Among 39 neonates with RCDH, 25 (64.1 %) survived without ECMO. The non-survivor or ECMO group exhibited lower o/e LHR, reduced EF, smaller LPA and RPA diameters, and larger MPA diameter than survivors. Lower LPA:MPA ratio, Nakata index, McGoon ratio, and higher initial PaCO2 were associated with adverse outcomes. Notably, the LPA:MPA ratio showed the highest predictive capability (area under the curve, 0.983; p < 0.001). CONCLUSION The LPA:MPA ratio is a promising postnatal predictor of mortality or ECMO requirement in neonates with RCDH. Additionally, Nakata index, McGoon ratio, and initial PaCO2 are significantly correlated with outcomes. LEVEL OF EVIDENCE This is a level III. TYPE OF STUDY Prognostic study.
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Affiliation(s)
- Sung Hyeon Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Yoo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keon Hee Seol
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joo Hyung Roh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha Na Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiyoon Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Yang MJ, Ellsworth TS, Woodward PJ, Kennedy AM, Fenton SJ, Russell KW, Byrne JLB, Yost CC, Yoder BA. Comparison of current to past outcomes in congenital diaphragmatic hernia using mri observed-to-expected total fetal lung volume. J Perinatol 2024:10.1038/s41372-024-02008-z. [PMID: 38796522 DOI: 10.1038/s41372-024-02008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/23/2023] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Fetal Centers use imaging studies to predict congenital diaphragmatic hernia (CDH) prognosis and the need for fetal therapy. Given improving CDH survival, we hypothesized that current fetal imaging severity predictions no longer reflect true outcomes and fail to justify the risks of fetal therapy. METHODS We analyzed our single-center contemporary data in a left-sided CDH cohort (n = 58) by prognostic criteria determined by MRI observed-to-expected total fetal lung volumes: severe <25%, moderate 25-35%, and mild >35%. We compared contemporary survival to prior studies and the TOTAL trials. RESULTS Contemporary survival was significantly higher than past studies for all prognostic classifications (mild 100% vs 80-94%, moderate 95% vs 59-75%, severe 79% vs 13-25%; P < 0.01), and to either control or fetal therapy arms of the TOTAL trials. CONCLUSIONS Current fetal imaging criteria are overly pessimistic and may lead to unwarranted fetal intervention. Fetal therapies remain experimental. Future studies will require updated prognostic criteria.
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Affiliation(s)
- Michelle J Yang
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA.
| | - Tanner S Ellsworth
- Divisions of General Pediatrics, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Paula J Woodward
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Anne M Kennedy
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Katie W Russell
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Janice L B Byrne
- Divisions of Maternal-Fetal Medicine, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Christian C Yost
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
- Divisions of Molecular Medicine Program, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
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Dütemeyer V, Cannie MM, Schaible T, Weis M, Persico N, Borzani I, Badr DA, Jani JC. Timing of magnetic resonance imaging in pregnancy for outcome prediction in congenital diaphragmatic hernia. Arch Gynecol Obstet 2024:10.1007/s00404-024-07545-8. [PMID: 38782762 DOI: 10.1007/s00404-024-07545-8] [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: 03/17/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE To evaluate the impact of the timing of MRI on the prediction of survival and morbidity in patients with CDH, and whether serial measurements have a beneficial value. METHODS This retrospective cohort study was conducted in two perinatal centers, in Germany and Italy. It included 354 patients with isolated CDH having at least one fetal MRI. The severity was assessed with the observed-to-expected total fetal lung volume (o/e TFLV) measured by two experienced double-blinded operators. The cohort was divided into three groups according to the gestational age (GA) at which the MRI was performed (< 27, 27-32, and > 32 weeks' gestation [WG]). The accuracy for the prediction of survival at discharge and morbidity was analyzed with receiver operating characteristic (ROC) curves. Multiple logistic regression analyses and propensity score matching examined the population for balance. The effect of repeated MRI was evaluated in ninety-seven cases. RESULTS There were no significant differences in the prediction of survival when the o/e TFLV was measured before 27, between 27 and 32, and after 32 WG (area under the curve [AUC]: 0.77, 0.79, and 0.77, respectively). After adjustment for confounding factors, it was seen, that GA at MRI was not associated with survival at discharge, but the risk of mortality was higher with an intrathoracic liver position (adjusted odds ratio [aOR]: 0.30, 95% confidence interval [95%CI] 0.12-0.78), lower GA at birth (aOR 1.48, 95%CI 1.24-1.78) and lower o/e TFLV (aOR 1.13, 95%CI 1.06-1.20). ROC curves showed comparable prediction accuracy for the different timepoints in pregnancy for pulmonary hypertension, the need of extracorporeal membrane oxygenation, and feeding aids. Serial measurements revealed no difference in change rate of the o/e TFLV according to survival. CONCLUSION The timing of MRI does not affect the prediction of survival rate or morbidity as the o/e TFLV does not change during pregnancy. Clinicians could choose any gestational age starting mid second trimester for the assessment of severity and counseling.
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Affiliation(s)
- Vivien Dütemeyer
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
- Present Address: Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Thomas Schaible
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Meike Weis
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Nicola Persico
- Fetal Medicine and Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium.
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Dimmer A, Meehan M, Beauseigle S, Koclas L, Paquette K, Michel Macias C, Moore SS, Sant'Anna A, Shapiro A, Simoneau J, Villegas Martinez D, Altit G, Puligandla P. Disease severity impacts perceived quality of life in congenital diaphragmatic hernia: a prospective observational study. Arch Dis Child 2024; 109:510-514. [PMID: 38589198 DOI: 10.1136/archdischild-2024-326906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND While research indicates comparable quality of life (QOL) in congenital diaphragmatic hernia (CDH) and healthy populations, the effect of CDH severity on patients' health perceptions remains unexplored. We aimed to assess QOL perception in CDH, hypothesising a decline correlated with increased disease severity. METHODS In this prospective observational study, we analysed patients with CDH aged 5 years and above participating in a longitudinal outpatient programme. We excluded bilateral CDH, genetic/syndromic conditions, prematurity and late diagnosis. Participants self-administered the age-adapted Pediatric Quality of Life Inventory (PedsQL) survey, covering four domains (physical, emotional, social, school). After enrolment, data were collected blind to severity status (larger defects denoting significant/'severe' disease). Repeated measurements were managed using a random mixed-effects model. RESULTS Of 34 participants (50% males) who completed the PedsQL, 10 provided measurements at two visits. Eight required a patch (type C), while 26 had primary repairs (type A=8; type B=18). Age at first evaluation was comparable across groups (no patch: median 11 (7-16), patch: 13 (8-15) years, p=0.78). Severe CDH correlated significantly with lower PedsQL scores (adjusted β: -18%, 95% CI -28%; -7%, adjusted for age at visit and sex). Lower scores specifically occurred in walking, exercising, social and academic functioning. CONCLUSION Severe CDH significantly lowers QOL. This finding is crucial for resource allocation in long-term CDH health surveillance and advocates for regular inclusion of patient experiences in quality improvement efforts.
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Affiliation(s)
- Alexandra Dimmer
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Madison Meehan
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Sabrina Beauseigle
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Louise Koclas
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Katryn Paquette
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Carolina Michel Macias
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Shiran S Moore
- Division of Neonatology, Dana-Dwek Children's Hospital, Tel Aviv, Israel
| | - Ana Sant'Anna
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Adam Shapiro
- Division of Respiratory Medicine, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Jessica Simoneau
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Daniela Villegas Martinez
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Pramod Puligandla
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
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Dirickx M, Vermeulen F, Boon M, Debeer A, Proesmans M. Multiple breath washout measurements in school aged patients with congenital diaphragmatic hernia. Pediatr Pulmonol 2024; 59:1493-1497. [PMID: 38289110 DOI: 10.1002/ppul.26888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 04/30/2024]
Affiliation(s)
- Marlies Dirickx
- Department of General Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, Heilig Hart Ziekenhuis Lier, Lier, Belgium
| | - Francois Vermeulen
- Pediatric Pulmonology, Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - Mieke Boon
- Pediatric Pulmonology, Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - Anne Debeer
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven
- Academic Department of Development and Regeneration, KU Leuven, Belgium
| | - Marijke Proesmans
- Pediatric Pulmonology, Department of Pediatrics, University of Leuven, Leuven, Belgium
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Rosales JP, Flores MEY. Ultrasonographic measurement of mediastinal shift angle for the prediction of postnatal survival in fetuses with isolated left congenital diaphragmatic hernia. Int J Gynaecol Obstet 2024; 165:474-479. [PMID: 38189145 DOI: 10.1002/ijgo.15348] [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] [Received: 09/13/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The main objective of the study was to determine if ultrasonographic measurement of mediastinal shift angle (MSA) can predict postnatal survival in fetuses with isolated left congenital diaphragmatic hernia (CDH). This relatively new technique may be used to enhance antenatal prediction of survival in fetuses with CDH. METHODS A retrospective cross-sectional study was conducted at the Philippine Children's Medical Center involving 16 cases with prenatally diagnosed isolated left CDH and 60 controls with normal fetuses. The cases with prenatally diagnosed isolated left CDH were allocated into two groups: Group A (survivors) and group B (non-survivors). For all fetuses (study and control groups), MSA was determined independently by two operators. The diagnostic capacity of MSA was assessed using the receiver operating characteristic curve. RESULTS The mean MSA for the control group was 17.18°. Among CDH cases, the mean MSA was 33.04° and 37.57° for survivors and non-survivors, respectively. Results showed that MSA significantly predicted the probability of neonatal survival status (OR = 0.46, P = 0.021). The best cutoff score of MSA based on the receiver operating characteristic curve was 33.80° with 87.50% sensitivity and specificity. CONCLUSION MSA has the potential to enhance antenatal prediction of survival in fetuses with CDH and may serve as a guide in prenatal counseling and evaluation of the need for in-utero treatment or postnatal procedures.
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Affiliation(s)
- Jacel P Rosales
- Section of Perinatology, Philippine Children's Medical Center, Quezon City, Philippines
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Vaughn AE, Lyttle BD, Louiselle AE, Cooper E, Niemiec SM, Phillips R, Hilton SA, Kinsella JP, Gien J, Derderian SC, Liechty KW. Muscle Flap Technique Safe for On-ECMO Congenital Diaphragmatic Hernia Repair. J Pediatr Surg 2024; 59:962-968. [PMID: 38160185 DOI: 10.1016/j.jpedsurg.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Prosthetic patches (patch) and muscle flaps (flap) are techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extra-corporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared to patch due to the hemostatic advantage of native tissue. METHODS A single-center retrospective comparative study of patients who underwent on-ECMO CDH repair between 2008 and 2022 was performed. RESULTS Fifty-two patients met inclusion criteria: 18 patch (34.6%) and 34 flap (65.4%). There was no difference in CDH severity between groups. On univariate analysis, reoperation for surgical bleeding was lower following flap repair compared to patch (23.5% vs 55.6%, respectively; p = 0.045), 48-h postoperative blood product transfusion was lower after flap repair (132 mL/kg vs 273.5 mL/kg patch; p = 0.006), and two-year survival was increased in the flap repair group compared to patch (53.1% vs 17.7%, respectively; p = 0.036). On multivariate analysis adjusting for CDH side, day on ECMO repaired, and day of life CDH repaired, flap repair was significantly associated with lower five-day postoperative packed red blood cell transfusion amount, improved survival to hospital discharge, and improved two-year survival. CONCLUSIONS Our experience suggests that the muscle flap technique for on-ECMO CDH repair is associated with reduced bleeding complications compared to prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. These results support the flap repair technique as a favored method for on-ECMO CDH repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alyssa E Vaughn
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States.
| | - Bailey D Lyttle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Amanda E Louiselle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Emily Cooper
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Stephen M Niemiec
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Ryan Phillips
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Sarah A Hilton
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - S Christopher Derderian
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Kenneth W Liechty
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Division of Pediatric Surgery, Department of Surgery, University of Arizona Tucson College of Medicine and Banner Children's Hospital at Diamond Children's Medical Center, Tucson, AZ, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
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Conte L, Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Persico N, Griggio A, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. Congenital diaphragmatic hernia: automatic lung and liver MRI segmentation with nnU-Net, reproducibility of pyradiomics features, and a machine learning application for the classification of liver herniation. Eur J Pediatr 2024; 183:2285-2300. [PMID: 38416256 PMCID: PMC11035462 DOI: 10.1007/s00431-024-05476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
Prenatal assessment of lung size and liver position is essential to stratify congenital diaphragmatic hernia (CDH) fetuses in risk categories, guiding counseling, and patient management. Manual segmentation on fetal MRI provides a quantitative estimation of total lung volume and liver herniation. However, it is time-consuming and operator-dependent. In this study, we utilized a publicly available deep learning (DL) segmentation system (nnU-Net) to automatically contour CDH-affected fetal lungs and liver on MRI sections. Concordance between automatic and manual segmentation was assessed by calculating the Jaccard coefficient. Pyradiomics standard features were then extracted from both manually and automatically segmented regions. The reproducibility of features between the two groups was evaluated through the Wilcoxon rank-sum test and intraclass correlation coefficients (ICCs). We finally tested the reliability of the automatic-segmentation approach by building a ML classifier system for the prediction of liver herniation based on support vector machines (SVM) and trained on shape features computed both in the manual and nnU-Net-segmented organs. We compared the area under the classifier receiver operating characteristic curve (AUC) in the two cases. Pyradiomics features calculated in the manual ROIs were partly reproducible by the same features calculated in nnU-Net segmented ROIs and, when used in the ML procedure, to predict liver herniation (both AUC around 0.85). Conclusion: Our results suggest that automatic MRI segmentation is feasible, with good reproducibility of pyradiomics features, and that a ML system for liver herniation prediction offers good reliability. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04609163?term=NCT04609163&draw=2&rank=1 ; Clinical Trial Identification no. NCT04609163. What is Known: • Magnetic resonance imaging (MRI) is crucial for prenatal congenital diaphragmatic hernia (CDH) assessment. It enables the quantification of the total lung volume and the extent of liver herniation, which are essential for stratifying the severity of CDH, guiding counseling, and patient management. • The manual segmentation of MRI scans is a time-consuming process that is heavily reliant upon the skill set of the operator. What is New: • MRI lung and liver automatic segmentation using the deep learning nnU-Net system is feasible, with good Jaccard coefficient values and satisfactory reproducibility of pyradiomics features compared to manual results. • A feasible ML system for predicting liver herniation could improve prenatal assessments and CDH patient management.
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Affiliation(s)
- Luana Conte
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy.
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy.
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- ASST Fatebenefratelli Sacco, Ospedale Macedonio Melloni, Milan, Italy
| | - Giuseppe Como
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università Degli Studi Di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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10
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Tsukamoto J, Miyazaki O, Saito Y, Irahara S, Okamoto R, Miyasaka M, Tsutsumi Y, Itoh Y, Sago H, Kanamori Y, Mikami M, Hayashida Y, Aoki T, Nosaka S. Assessment of mediastinal shift angles in congenital pulmonary airway malformation: a new fetal magnetic resonance imaging indicator of congenital lung disease. Pediatr Radiol 2024; 54:715-724. [PMID: 38285191 DOI: 10.1007/s00247-024-05852-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND The mediastinal shift angle is a new fetal magnetic resonance imaging (MRI) index that is reportedly correlated with postnatal survival in fetuses with congenital diaphragmatic hernia. However, its correlation in patients with congenital pulmonary airway malformation (CPAM) has not been assessed. OBJECTIVE This study aimed to establish a normal range for the right/left mediastinal shift angles, to evaluate the mediastinal shift angle in fetuses with CPAM, to compare the mediastinal shift angle with the CPAM volume ratio, and to evaluate the predictive value of the mediastinal shift angle measurements. MATERIALS AND METHODS To establish the normal range, we measured the mediastinal shift angle bilaterally in 124 fetuses without any lung abnormality (the control group). Subsequently, the mediastinal shift angle was measured in 32 fetuses pathologically diagnosed with CPAM. Moreover, the mediastinal shift angle and CPAM volume ratio were compared using fetal MRI. RESULTS The mean values for the right/left mediastinal shift angles were 18.6°/26.3° and 39.2°/35.9° for control fetuses and fetuses with CPAM, respectively. The mediastinal shift angle and the CPAM volume ratio showed a positive statistical correlation. The area under the curve demonstrated high discriminatory accuracy for the mediastinal shift angle (0.76). CONCLUSION The mediastinal shift angle has potential to replace the CPAM volume ratio for evaluating the severity of CPAM in fetal MRI.
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Affiliation(s)
- Jun Tsukamoto
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan.
- Department of Radiology, University of Occupational and Environmental Health School of Medicine, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, 807-8555, Japan.
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuki Saito
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Saho Irahara
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Okamoto
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Miyasaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiyuki Tsutsumi
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Itoh
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yutaka Kanamori
- Division of Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- Department of Data Science, Clinical Research Center, Biostatistics Unit, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiko Hayashida
- Department of Radiology, University of Occupational and Environmental Health School of Medicine, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Takatoshi Aoki
- Department of Radiology, University of Occupational and Environmental Health School of Medicine, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
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11
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Thater G, Appelhaus S, Schoenberg SO, Weis M. [Congenital diaphragmatic hernia : Imaging-from diagnosis to aftercare]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:366-372. [PMID: 38587632 DOI: 10.1007/s00117-024-01289-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
STANDARD RADIOLOGICAL METHODS Fetal: Ultrasound and magnetic resonance imaging (MRI); postnatal: conventional X‑ray diagnostics, computed tomography (CT) and MRI. METHODICAL INNOVATIONS MRI-based lung ventilation and perfusion measurement. PRACTICAL RECOMMENDATIONS Lifelong follow-up care should be provided, in which radiology is part of the treatment team.
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Affiliation(s)
- G Thater
- Klinik für Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - S Appelhaus
- Klinik für Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - S O Schoenberg
- Klinik für Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - M Weis
- Klinik für Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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12
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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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13
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Gehle DB, Meyer LC, Jancelewicz T. The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000752. [PMID: 38645885 PMCID: PMC11029407 DOI: 10.1136/wjps-2023-000752] [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: 12/05/2023] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.
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Affiliation(s)
- Daniel B Gehle
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Logan C Meyer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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14
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Cordier AG, Badr DA, Basurto D, Russo F, Deprest J, Orain E, Eixarch E, Otano J, Gratacos E, Moraes De Luna Freire Vargas A, Peralta CFA, Jani JC, Benachi A. Effect of cannula insertion site during fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia on preterm prelabor rupture of membranes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:529-535. [PMID: 38051135 DOI: 10.1002/uog.27548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE To assess whether the cannula insertion site on the maternal abdomen during fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) was associated with preterm prelabor rupture of membranes (PPROM) before balloon removal. METHODS This was a multicenter retrospective study of consecutive pregnancies with isolated left- or right-sided CDH that underwent FETO in four centers between January 2009 and January 2021. The site for balloon insertion was categorized as above or below the umbilicus. One propensity score was analyzed in both groups to calculate an average treatment effect (ATE) by inverse probability of treatment weighting. Logistic regression and Cox proportional hazard regression including the ATE weights were performed to examine the effect size of entry point on the frequency and timing of PPROM before balloon removal. RESULTS A total of 294 patients were included. The mean ± SD gestational age at PPROM was 33.45 ± 2.01 weeks and the mean rate of PPROM before balloon removal was 25.9% (76/294). Gestational age at FETO was later in the below-umbilicus group (mean ± SD, 29.47 ± 1.29 weeks vs 29.00 ± 1.25 weeks; P = 0.002) and the duration of FETO was longer in the above-umbilicus group (median, 14.49 min (interquartile range (IQR), 8.00-21.00 min) vs 11.00 min (IQR, 7.00-14.49 min); P = 0.002). After balancing for possible confounding factors, trocar entry point below the umbilicus did not increase the risk of PPROM before balloon removal (adjusted odds ratio, 1.56 (95% CI, 0.89-2.74); P = 0.120) and had no effect on the timing of PPROM before balloon removal (adjusted hazard ratio, 1.56 (95% CI, 0.95-2.55); P = 0.080). CONCLUSION There was no evidence that uterine entry site for FETO was correlated with the risk of PPROM before balloon removal. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A-G Cordier
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
- Centre de Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Sorbonne Université, APHP, Tenon Hospital, Paris, France
| | - D A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - D Basurto
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - F Russo
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - J Deprest
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - E Orain
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
| | - E Eixarch
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - J Otano
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - E Gratacos
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - A Moraes De Luna Freire Vargas
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
- Fetal Medicine Unit, The Heart Hospital, São Paulo, Brazil
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil
| | - C F A Peralta
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
- Fetal Medicine Unit, The Heart Hospital, São Paulo, Brazil
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil
| | - J C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Benachi
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
- Centre de Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
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15
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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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16
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Ding W, Gu Y, Wang H, Wu H, Zhang X, Zhang R, Wang H, Huang L, Lv J, Xia B, Zhong W, He Q, Hou L. Prenatal MRI assessment of mediastinal shift angle as a feasible and effective risk stratification tool in isolated right-sided congenital diaphragmatic hernia. Eur Radiol 2024; 34:1524-1533. [PMID: 37644150 DOI: 10.1007/s00330-023-10178-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/21/2023] [Accepted: 07/07/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVES To develop a mediastinal shift angle (MSA) measurement method applicable to right-sided congenital diaphragmatic hernia (RCDH) in fetal MRI and to validate the predictive value of MSA in RCDH. METHODS Twenty-seven fetuses with isolated RCDH and 53 controls were included in our study. MSA was measured on MRI axial image at the level of four-chamber view of the fetal heart. The angle between the sagittal midline landmark line and the left boundary landmark line touching tangentially the lateral wall of the left ventricle was used to quantify MSA for RCDH. Appropriate statistical analyses were performed to determine whether MSA can be regarded as a valid predictive tool for postnatal outcomes. Furthermore, predictive performance of MSA was compared with that of lung area to head circumference ratio (LHR), observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected TFLV (O/E TFLV). RESULTS MSA was significantly higher in the RCDH group than in the control group. MSA, LHR, O/E LHR, TFLV, and O/E TFLV were all correlated with postnatal survival, pulmonary hypertension (PH), and extracorporeal membrane oxygenation (ECMO) therapy (p < 0.05). Value of the AUC demonstrated good predictive performance of MSA for postnatal survival (0.901, 95%CI: (0.781-1.000)), PH (0.828, 95%CI: (0.661-0.994)), and ECMO therapy (0.813, 95%CI: (0.645-0.980)), which was similar to O/E TFLV but slightly better than TFLV, O/E LHR, and LHR. CONCLUSIONS We developed a measurement method of MSA for RCDH for the first time and demonstrated that MSA could be used to predict postnatal survival, PH, and ECMO therapy in RCDH. CLINICAL RELEVANCE STATEMENT Newly developed MRI assessment method of fetal MSA in RCDH offers a simple and effective risk stratification tool for patients with RCDH. KEY POINTS • We developed a measurement method of mediastinal shift angle for right-sided congenital diaphragmatic hernia for the first time and demonstrated its feasibility and reproducibility. • Mediastinal shift angle can predict more prognostic information other than survival in right-sided congenital diaphragmatic hernia with good performance. • Mediastinal shift angle can be used as a simple and effective risk stratification tool in right-sided congenital diaphragmatic hernia to improve planning of postnatal management.
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Affiliation(s)
- Wen Ding
- Department of Fetal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuanyuan Gu
- Department of Fetal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Haiyu Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Wu
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiaochun Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Rui Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Hongying Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Li Huang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Junjian Lv
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Bo Xia
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Qiuming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Longlong Hou
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
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17
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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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18
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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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19
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Dütemeyer V, Schaible T, Badr DA, Cordier AG, Weis M, Perez-Ortiz A, Carriere D, Cannie MM, Vuckovic A, Persico N, Cavallaro G, Benachi A, Jani JC. Fetoscopic endoluminal tracheal occlusion vs expectant management for fetuses with severe left-sided congenital diaphragmatic hernia. Am J Obstet Gynecol MFM 2024; 6:101248. [PMID: 38070678 DOI: 10.1016/j.ajogmf.2023.101248] [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] [Received: 09/27/2023] [Revised: 11/14/2023] [Accepted: 12/02/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The treatment of fetuses with a congenital diaphragmatic hernia is challenging, but there is evidence that fetoscopic endoluminal tracheal occlusion has a benefit over expectant care. In addition, standardization and expertism have a great impact on survival and are probably crucial in centers that rely on expectant management with extracorporeal membrane oxygenation after birth. OBJECTIVE This study aimed to examine the survival and morbidity rates of fetuses with a severe isolated left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion vs expectant management in high-volume centers. STUDY DESIGN This was a multicenter, retrospective study that included all consecutive fetuses with severe isolated left-sided congenital diaphragmatic hernia who were expectantly managed in a German center or who underwent fetoscopic endoluminal tracheal occlusion in 3 other European centers (Belgium, France, and Italy). Severe congenital diaphragmatic hernia was defined as having an observed to expected total fetal lung volume ≤35% with intrathoracic position of the liver diagnosed with magnetic resonance imaging. All magnetic resonance images were centralized, and lung volumes were measured by 2 experienced operators who were blinded to the pre- and postnatal data. Multiple logistic regression analyses were performed to examine the effect of the management strategy in the 2 groups on the short- and long-term outcomes. RESULTS A total of 147 patients who were managed expectantly and 47 patients who underwent fetoscopic endoluminal tracheal occlusion were analyzed. Fetuses who were managed expectantly had lower observed to expected total fetal lung volumes (20.6%±7.5% vs 23.7%±6.8%; P=.013), higher gestational age at delivery (median weeks of gestation, 37.4; interquartile range, 36.6-38.00 vs 35.1; interquartile range, 33.1-37.2; P<.001), and more frequent use of extracorporeal membrane oxygenation (55.8% vs 4.3%; P<.001) than the fetuses who underwent fetoscopic endoluminal tracheal occlusion. The survival rates at discharge and at 2 years of age in the expectant management group were higher than the survival rates of the fetoscopic endoluminal tracheal occlusion group (74.3% vs 44.7%; P=.001 and 72.8% vs 42.5%; P=.001, respectively). After adjustment for maternal age, gestational age at birth, observed to expected total fetal lung volume, and birth weight Z-score, the odds ratios were 4.65 (95% confidence interval, 1.9-11.9; P=.001) and 4.37 (95% confidence interval, 1.8-11.0; P=.001), respectively. CONCLUSION Fetuses with a severe isolated left-sided congenital diaphragmatic hernia had a higher survival rate when treated in an experienced center in Germany with antenatal expectant management and frequent use of extracorporeal membrane oxygenation during the postnatal period than fetuses who were treated with fetoscopic endoluminal tracheal occlusion in 3 centers in Belgium, France, and Italy.
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Affiliation(s)
- Vivien Dütemeyer
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (Drs Dütemeyer)
| | - Thomas Schaible
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani)
| | - Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Meike Weis
- Department of Radiology, Universitätsklinikum Mannheim, Mannheim, Germany (Dr Weis)
| | - Alba Perez-Ortiz
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Diane Carriere
- Service de Réanimation Pédiatrique, Hôpital Bicêtre- AP-HP, Université Paris Saclay, Le Kremlin Bicêtre, France (Dr Carriere)
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Dr Cannie)
| | - Aline Vuckovic
- Neonatal Intensive Care Unit, Queen Fabiola Children's Hospital-ULB, Brussels, Belgium (Dr Vuckovic)
| | - Nicola Persico
- Fetal Medicine and Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Persico); Department of Clinical Science and Community Health, University of Milan, Milan, Italy (Dr Persico)
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Cavallaro)
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani).
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20
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Huntley ES, Hernandez-Andrade E, Papanna R, Bergh E, Espinoza J, Soto E, Lopez SM, Harting MT, Johnson A. Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2024; 51:191-202. [PMID: 38194948 DOI: 10.1159/000536171] [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] [Received: 05/16/2023] [Accepted: 01/03/2024] [Indexed: 01/11/2024]
Abstract
INTRODUCTION The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH). METHODS CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated. RESULTS Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02). CONCLUSION Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eric Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Maternal Fetal Medicine, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Suzanne M Lopez
- Department of Pediatrics, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
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21
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Teunissen NM, Daniels H, Schnater JM, de Blaauw I, Wijnen RMH. Prevalence and early surgical outcome of congenital diaphragmatic hernia in the Netherlands: a population-based cohort study from the European Pediatric Surgical Audit. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326311. [PMID: 38195217 DOI: 10.1136/archdischild-2023-326311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a rare birth defect with substantial mortality. This study aims to generate a population-based overview of CDH care and outcomes in the Netherlands. Moreover, it assesses interhospital variations between the two Dutch CDH expert centres. METHODS This study uses data from the Dutch branch of the European Pediatric Surgical Audit, a prospective clinical audit for congenital anomalies. Data of all patients with CDH treated between 2014 and 2021 were included for epidemiological analysis. For comparative analyses, patients presenting after the neonatal period or not treated in the two CDH expert centres were excluded. Identified interhospital variations were assessed using regression analysis. RESULTS In the study period, 283 children with CDH were born, resulting in a national prevalence rate of 2.06/10 000 live births. The patient population, treatment and outcomes at 1 year were comparable between the hospitals, except for length of hospital stay. Regression analysis identified the treating hospital as the strongest significant predictor thereof. Other factors associated with longer length of stay include the presence of other malformations, intrathoracic liver position on prenatal ultrasound, extracorporeal membrane oxygenation treatment, patch repair, complicated postoperative course and discharge to home rather than to another care facility. CONCLUSION Outcomes of CDH care throughout the Netherlands are comparable. However, the length of stay differed between the two hospitals, also when adjusting for other covariates. Further qualitative analysis to explain this interhospital variation is indicated. Our findings underscore the potential of clinical auditing as a quality measurement tool in rare conditions.
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Affiliation(s)
- Nadine Maria Teunissen
- Department of Paediatric Surgery, Erasmus Medical Center, Rotterdam, Netherlands
- Dutch Institute for Clinical Auditing, Leiden, Netherlands
| | - Horst Daniels
- Division of Paediatric Surgery, Department of Surgery, Radboudumc, Nijmegen, Netherlands
| | - J Marco Schnater
- Department of Paediatric Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ivo de Blaauw
- Division of Paediatric Surgery, Department of Surgery, Radboudumc, Nijmegen, Netherlands
| | - René M H Wijnen
- Department of Paediatric Surgery, Erasmus Medical Center, Rotterdam, Netherlands
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22
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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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23
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Johng S, Fraga MV, Patel N, Kipfmueller F, Bhattacharya A, Bhombal S. Unique Cardiopulmonary Interactions in Congenital Diaphragmatic Hernia: Physiology and Therapeutic Implications. Neoreviews 2023; 24:e720-e732. [PMID: 37907403 DOI: 10.1542/neo.24-11-e720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Congenital diaphragmatic hernia (CDH) results in abdominal contents entering the thoracic cavity, affecting both cardiac and pulmonary development. Maldevelopment of the pulmonary vasculature occurs within both the ipsilateral lung and the contralateral lung. The resultant bilateral pulmonary hypoplasia and associated pulmonary hypertension are important components of the pathophysiology of this disease that affect outcomes. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies, pulmonary hypertension management, and the option of extracorporeal membrane oxygenation, overall CDH mortality remains between 25% and 30%. With increasing recognition that cardiac dysfunction plays a large role in morbidity and mortality in patients with CDH, it becomes imperative to understand the different clinical phenotypes, thus allowing for individual patient-directed therapies. Further research into therapeutic interventions that address the cardiopulmonary interactions in patients with CDH may lead to improved morbidity and mortality outcomes.
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Affiliation(s)
- Sandy Johng
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Maria V Fraga
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Shazia Bhombal
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
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24
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Herranz Barbero A, Iglesias-Platas I, Prat-Ortells J, Clotet Caba J, Moreno Hernando J, Castañón García-Alix M, Pertierra Cortada Á. Transpyloric Tube Placement Shortens Time to Full Feeding in Left Congenital Diaphragmatic Hernia. J Pediatr Surg 2023; 58:2098-2104. [PMID: 37507336 DOI: 10.1016/j.jpedsurg.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Nutritional complications have an impact in both short- and long-term morbidity of patients with congenital diaphragmatic hernia (CDH). We aimed to compare time to full enteral tube feeding depending on route -gastric (GT) or transpyloric (TPT)- in newborns with left CDH (L-CDH). METHODS Retrospective cohort study of L-CDH patients admitted to a referral tertiary care NICU between January 2007 and December 2014. Lethal chromosomal abnormalities and death before initiation of enteral nutrition were exclusion criteria. RESULTS 37 patients were fed through GT, 46 by TPT. TPT children took 11.0 (6.8) days to reach full enteral tube feeding and spent 16.6 (8.1) days on parenteral nutrition vs 16.8 (14.7) days (p = 0.041) and 22.7 (13.5) days (p = 0.020) of GT patients. TPT children had 3.9 (2.4) days of fasting due to GI issues and 20% had episodes of decreased rates of enteral nutrition for extra-GI complications vs 11.4 (11.1) days (p = 0.028) and 49% (p = 0.006). According to the best fitting model (R2 0.383, p < 0.001), the TPT-group achieved full enteral feeding 8.4 days earlier than the GT-group (95% CI -14.76 to - 2.02 days), after adjustment by severity of illness during the first days, o/e LHR_liver and class of diaphragmatic defect. There were no differences in growth outcomes and length of stay between survivors of GT and TPT groups. CONCLUSION TPT shortens time to full enteral nutrition, especially in the most severe L-CDH patients. We propose that placement of a TPT at the end of the surgical repair procedure should be considered, especially in higher-risk patients. LEVEL OF EVIDENCE Treatment study, Level III. Retrospective comparative, case-control study.
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Affiliation(s)
- Ana Herranz Barbero
- Neonatology Department, Hospital Clínic, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain.
| | - Isabel Iglesias-Platas
- Neonatology Department, Hospital Sant Joan de Deu, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Jordi Prat-Ortells
- Pediatrics Surgery Department, Hospital Sant Joan de Deu, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Jordi Clotet Caba
- Neonatology Department, Hospital Sant Joan de Deu, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Julio Moreno Hernando
- Neonatology Department, Hospital Sant Joan de Deu, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Montserrat Castañón García-Alix
- Pediatrics Surgery Department, Hospital Sant Joan de Deu, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - África Pertierra Cortada
- Neonatology Department, Hospital Sant Joan de Deu, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, Pg. Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
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Idelson A, Tenenbaum-Gavish K, Danon D, Duvdevani NR, Bromiker R, Klinger G, Orbach-Zinger S, Almog A, Sharabi-Nov A, Meiri H, Nicolaides KH, Wiznitzer A, Gielchinsky Y. Fetal surgery using fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: a single-center experience. Arch Gynecol Obstet 2023:10.1007/s00404-023-07215-1. [PMID: 37789206 DOI: 10.1007/s00404-023-07215-1] [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: 07/29/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE To provide a comprehensive report of the experience gained in the prenatal treatment of congenital diaphragmatic hernia (CDH) using fetoscopic endoluminal tracheal occlusion (FETO) following its implementation at a newly established specialized fetal medicine center. METHODS Mothers of fetuses with severe CDH were offered prenatal treatment by FETO. RESULTS Between 2018 and 2021, 16 cases of severe CDH underwent FETO. The median gestational age (GA) at balloon insertion was 28.4 weeks (IQR 27.8-28.6). The median GA at delivery was 37 weeks (IQR 34.4-37.8). The survival rate was 8/16 cases (50%). None of the survivors required home oxygen therapy at 6 months of age. Comparison between the survivors and deceased showed that survivors had balloon insertion 1 week earlier (27.8 vs. 28.4 weeks, p = 0.007), a higher amniotic fluid level change between pre- to post-FETO (3.4 vs 1.3, p = 0.024), a higher O/E LHR change between pre- to post-FETO (50.8 vs. 37.5, p = 0.047), and a GA at delivery that was 2 weeks later (37.6 vs. 35.4 weeks, p = 0.032). CONCLUSIONS The survival rate at 6 months of age in cases of severe CDH treated with FETO in our center was 50%. Our new fetal medicine center matches the performance of other leading international centers.
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Affiliation(s)
- Ana Idelson
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel
| | - Kinneret Tenenbaum-Gavish
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Danon
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir-Ram Duvdevani
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel
| | - Ruben Bromiker
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neonatal Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Gil Klinger
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neonatal Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Sharon Orbach-Zinger
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Anesthesia, Rabin Medical Center, Petah Tikva, Israel
| | - Anastasia Almog
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Adi Sharabi-Nov
- Department of Statistics, Ziv Medical Center and The Galil University, Tel Hai, Safed, Israel
| | | | - Kypros H Nicolaides
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Arnon Wiznitzer
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yuval Gielchinsky
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center 39, Jabotinski Street, 4941492, Petah Tikva, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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26
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Park SH, Kim MJ, Lee HN, Lee JM, Kim SH, Jeong J, Lee BS, Jung E. Early echocardiographic pulmonary artery measurements as prognostic indicators in left congenital diaphragmatic hernia. BMC Pediatr 2023; 23:499. [PMID: 37784067 PMCID: PMC10544371 DOI: 10.1186/s12887-023-04308-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/13/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND To predict whether the left pulmonary artery (LPA) to the main pulmonary artery (MPA) ratio measured by echocardiography in left congenital diaphragmatic hernia (CDH) was related to death or need for extracorporeal membrane oxygenation (ECMO). METHODS This retrospective study analyzed neonates with left CDH born between 2018 and 2022 in a single tertiary medical institution. Echocardiography was performed immediately after birth. The diameter of the LPA was measured at the bifurcation, and the diameter of the MPA was measured at the maximal dimension during the systolic phase. The Nakata index, McGoon ratio, and ejection fraction (EF) were analyzed and compared with the LPA: MPA ratio as predictive values. RESULTS Seventy-two neonates with left CDH were included, 19 (26.4%) died or needed ECMO, and 53 (73.6%) survived without ECMO. The lower observed/expected lung-to-head ratio, lower EF, lower LPA: MPA ratio, lower RPA: MPA ratio, lower Nakata index, and lower McGoon ratio were associated with death or need for ECMO. By multivariate analysis, lower LPA: MPA ratio, RPA: MPA ratio, and Nakata index were independent postnatal risk factors for death or need for ECMO. Among the measurements, the LPA: MPA ratio had the highest area under the curve (0.957) with a sensitivity of 84.2% and specificity of 96.3% at a cut-off value of 31.2%. CONCLUSION In patients with left CDH, the LPA: MPA ratio measured by echocardiography could be used as an independent postnatal predictor of death or need for ECMO.
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Affiliation(s)
- Sung Hyeon Park
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Mi Jin Kim
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ha Na Lee
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Min Lee
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Soo Hyun Kim
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jiyoon Jeong
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Byong Sop Lee
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Euiseok Jung
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Horn-Oudshoorn EJJ, Russo FM, Deprest JA, Kipfmueller F, Geipel A, Schaible T, Rafat N, Cordier AG, Benachi A, Abbasi N, Chiu PPL, de Boode WP, Sikkel E, Peters NCJ, Hansen BE, Reiss IKM, DeKoninck PLJ. Survival in very preterm infants with congenital diaphragmatic hernia and association with prenatal imaging markers: A retrospective cohort study. BJOG 2023; 130:1403-1411. [PMID: 37069727 DOI: 10.1111/1471-0528.17497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To describe the outcomes of preterm born infants with congenital diaphragmatic hernia (CDH; ≤32.0 weeks of gestation) and the associations between prenatal imaging markers and survival. DESIGN Retrospective cohort study. SETTING Multicentre study in large referral centres. POPULATION Infants with an isolated unilateral CDH, live born at 32.0 weeks or less of gestation, between January 2009 and January 2020. METHODS Neonatal outcomes were evaluated for infants that were expectantly managed during pregnancy and infants that underwent fetoscopic endoluminal tracheal occlusion (FETO) therapy, separately. We evaluated the association between prenatal imaging markers and survival to discharge. Prenatal imaging markers included observed to expected lung-to-head ratio (o/e LHR), side of the defect, liver position, stomach position grade, and observed to expected total fetal lung volume (o/e TFLV). MAIN OUTCOME MEASURE Survival to discharge. RESULTS We included 53 infants born at 30+4 (interquartile range 29+1 -31+2 ) weeks. Survival in fetuses expectantly managed during pregnancy was 48% (13/27) in left-sided CDH and 33% (2/6) in right-sided CDH. Survival in fetuses that underwent FETO therapy was 50% (6/12) in left-sided CDH and 25% (2/8) in right-sided CDH. The o/e LHR at baseline was positively associated with survival in cases expectantly managed during pregnancy (odds ratio [OR] 1.20, 95% CI 1.07-1.42, p < 0.01), but not in cases that received FETO therapy (OR 1.01, 95% CI 0.88-1.15, p = 0.87). Stomach position grade (p = 0.03) and o/e TFLV were associated with survival (p = 0.02); liver position was not (p = 0.13). CONCLUSIONS In infants with CDH born at or before 32 weeks of gestation, prenatal imaging markers of disease severity were associated with postnatal survival.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Jan A Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Critical Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Schaible
- Department of Neonatology, University Hospital Mannheim, Mannheim, Germany
| | - Neysan Rafat
- Department of Neonatology, University Hospital Mannheim, Mannheim, Germany
| | - Anne-Gael Cordier
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, University Paris-Saclay, Clamart, France
| | - Alexandra Benachi
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, University Paris-Saclay, Clamart, France
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Esther Sikkel
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Nina C J Peters
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Rana A, Sharma KA, Kumar V, Chaudhary P, Thukral A, Agarwala S, Dadhwal V. Perinatal Outcome in Congenital Diaphragmatic Hernia (CDH): A Single-Center Experience. J Obstet Gynaecol India 2023; 73:37-42. [PMID: 37916008 PMCID: PMC10616035 DOI: 10.1007/s13224-023-01796-2] [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: 03/27/2023] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To study the perinatal outcome in fetuses diagnosed with congenital diaphragmatic hernia (CDH). Methods Thirty-two pregnant women with antenatal diagnosis of CDH in fetus, who delivered between 2018 and 2021, were included in the study. Postnatally eventration of diaphragm was diagnosed in 3 neonates and were excluded. Results The median gestational age at diagnosis was 23 weeks (IQR: 216-261 weeks). The mean O/E LHR was 34.88 ± 9.03%, and the O/E LHR was significantly lower in fetuses who did not survive (40.81 ± 4.25 vs 31.26 ± 9.33; p = 0.0037). On ROC analysis, at a cutoff of ≤ 32.93, O/E LHR had a specificity of 100% with a sensitivity of 72.22% in predicting mortality. Cases with liver herniation were not significantly different between survivors versus non-survivors. The overall survival rate was 37.93%, and the leading cause of death was severe persistent pulmonary hypertension. Conclusion O/E LHR can predict mortality in neonates with antenatal diagnosis of CDH. The presence of pulmonary hypertension was the leading cause of death in these neonates.
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Affiliation(s)
- Anubhuti Rana
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - K. Aparna Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Kumar
- Division of Neonatology, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Chaudhary
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Anu Thukral
- Division of Neonatology, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vatsla Dadhwal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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29
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Chimenea A, Domínguez-Moreno M, Barrera-Talavera M, García-Díaz L, Antiñolo G. Maternal and Neonatal Outcomes After Ex-Utero Intrapartum Treatment for Congenital Diaphragmatic Hernia: A Case Series. Eur J Pediatr Surg 2023. [PMID: 37473779 DOI: 10.1055/a-2133-8380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition. MATERIAL AND METHODS We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery. RESULTS A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful. CONCLUSIONS In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.
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Affiliation(s)
- Angel Chimenea
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | - Marta Domínguez-Moreno
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - María Barrera-Talavera
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain
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30
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Teillet B, Manœuvrier F, Rougraff C, Besengez C, Bernard L, Wojtanowski A, Ghesquieres L, Storme L, Mur S, Sharma D, Le Duc K. Intact cord resuscitation in newborns with congenital diaphragmatic hernia: insights from a lamb model. Front Pediatr 2023; 11:1236556. [PMID: 37744447 PMCID: PMC10516551 DOI: 10.3389/fped.2023.1236556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) is a rare condition characterized by pulmonary hypoplasia, vascular dystrophy, and pulmonary hypertension at birth. Validation of the lamb model as an accurate representation of human CDH is essential to translating research findings into clinical practice and understanding disease mechanisms. This article emphasizes the importance of validating the lamb model to study CDH pathogenesis and develop innovative therapeutics. Material and methods At 78 days of gestation, the fetal lamb's left forelimb was exposed through a midline laparotomy and hysterotomy, and a supra diaphragmatic thoracotomy was performed to allow the digestive organs to ascend into the thoracic cavity. At 138 ± 3 days of gestation, lambs were delivered via a cesarean section; then, with umbilical cord intact during 1 hour, the lambs were mechanically ventilated with gentle ventilation in a pressure-controlled mode for 2 h. Results CDH lambs exhibited a lower left lung-to-body weight ratio of 5.3 (2.03), p < 0.05, and right lung-to-body weight ratio of 8.2 (3.1), p < 0.05. They reached lower Vt/kg (tidal volume per kg) during the course of the resuscitation period with 1.2 (0.7) ml/kg at 10 min and 3 (1.65) ml/kg at 60 min (p < 0.05). Compliance of the respiratory system was lower in CDH lambs with 0.5 (0.3) ml/cmH2O at 60 min (p < 0.05) and 0.9 (0.26) ml/cmH2O at 120 min (p < 0.05). Differences between pre- and postductal SpO2 were higher with 15.1% (21.4%) at 20 min and 6.7% (14.5%) at 80 min (p < 0.05). CDH lambs had lower differences between inspired and expired oxygen fractions with 4.55% (6.84%) at 20 min and 6.72% (8.57%) at 60 min (p < 0.05). CDH lamb had lower left ventricle [2.73 (0.5) g/kg, p < 0.05] and lower right ventricle [0.69 (0.8), p < 0.05] to left ventricle ratio. Discussion CDH lambs had significantly lower tidal volume than control lambs due to lower compliance of the respiratory system and higher airway resistance. These respiratory changes are characteristic of CDH infants and are associated with higher mortality rates. CDH lambs also exhibited pulmonary hypertension, pulmonary hypoplasia, and left ventricle hypoplasia, consistent with observations in human newborns. To conclude, our lamb model successfully provides a reliable representation of CDH and can be used to study its pathophysiology and potential interventions.
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Affiliation(s)
- Baptiste Teillet
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Florian Manœuvrier
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatry, Centre Hospitalier Universitaire d’Amiens, Lille, France
| | - Céline Rougraff
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Capucine Besengez
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laure Bernard
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Wojtanowski
- INSERM CIC-IT 1403, Maison Régionale de la Recherche Clinique, CHRU de, Lille, France
| | - Louise Ghesquieres
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Obstetrics, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laurent Storme
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sébastien Mur
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Dyuti Sharma
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Kévin Le Duc
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
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Wallace MW, Niec JA, Mirza MB, Achey MA, Oros J, Danko ME, Hilmes MA, Hatch LD, Morris EA, Lovvorn HN. Enteric tube position on preoperative radiographs predicts clinical outcomes in neonatal congenital diaphragmatic hernia with and without prenatal diagnosis. J Perinatol 2023; 43:1131-1138. [PMID: 37391509 DOI: 10.1038/s41372-023-01712-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE Congenital Diaphragmatic Hernia (CDH) is diagnosed prenatally in ~60% of cases. Prenatal measures typically guide management and prognostication. Simple postnatal prognosticators are needed when prenatal diagnosis is lacking. We hypothesized that preoperative orogastric tube (OGT) tip position relative to the contralateral diaphragm correlates with defect severity, resource utilization, and clinical outcomes regardless of diagnostic status. STUDY DESIGN 150 neonates with left-posterolateral CDH were analyzed. Impact of intrathoracic and intraabdominal preoperative tip position on clinical outcomes was compared. RESULTS Ninety-nine neonates were prenatally diagnosed. Overall, intrathoracic position significantly correlated with larger diaphragmatic defects, advanced postnatal pulmonary support requirements (HFOV, pulmonary vasodilators, and ECMO), operative complexity, longer hospitalization, and poorer survival to discharge. These observations persisted when analyzing only cases lacking prenatal diagnosis. CONCLUSIONS Preoperative OGT tip position predicts defect severity, resource utilization, and outcomes in CDH. This observation enhances postnatal prognostication and care planning for neonates without a prenatal diagnosis.
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Affiliation(s)
| | - Jan A Niec
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Muhammad B Mirza
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith A Achey
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph Oros
- Department of Radiology, Children's Hospital at Erlanger, Chattanooga, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa A Hilmes
- Division of Pediatric Radiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - L Dupree Hatch
- Division of Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Morris
- Division of Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Weller K, Edel GG, Steegers EAP, Reiss IKM, DeKoninck PLJ, Rottier RJ, Eggink AJ, Peters NCJ. Prenatal assessment of pulmonary vasculature development in fetuses with congenital diaphragmatic hernia: A literature review. Prenat Diagn 2023; 43:1296-1309. [PMID: 37539818 DOI: 10.1002/pd.6412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/17/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
Pathophysiological studies have shown that pulmonary vascular development is impaired in fetuses with a congenital diaphragmatic hernia (CDH), leading to a simplified vascular tree and increased vascular resistance. Multiple studies have described prenatal ultrasound parameters for the assessment of the pulmonary vasculature, but none of these parameters are used in daily clinical practice. We provide a comprehensive review of the literature published between January 1990 and February 2022 describing these parameters, and aim to explain the clinical relevance of these parameters from what is known from pathophysiological studies. Prenatal detection of a smaller diameter of the contralateral (i.e. contralateral to the diaphragmatic defect) first branch of the pulmonary artery (PA), higher pulsatility indices (PI), higher peak early diastolic reverse flow values, and a lower vascularization index seem of added value for the prediction of survival and, to a lesser extent, morbidity. Integration within the routine evaluation is complicated by the lack of uniformity of the methods used. To address the main components of the pathophysiological changes, we recommend future prenatal studies in CDH with a focus on PI values, PA diameters and pulmonary vascular branching.
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Affiliation(s)
- Katinka Weller
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gabriëla G Edel
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robbert J Rottier
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Sferra SR, Guo M, Gonzalez Salazar AJ, Penikis AB, Engwall-Gill AJ, Ebanks A, Harting MT, Collaco JM, Kunisaki SM. Sex-Specific Differences in Congenital Diaphragmatic Hernia Mortality. J Pediatr 2023; 259:113481. [PMID: 37196780 DOI: 10.1016/j.jpeds.2023.113481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To compare disease severity and mortality differences between female and male patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN We queried the CDH Study Group (CDHSG) database for CDH neonates managed between 2007 and 2018. Female and males were compared in statistical analyses using t tests, χ² tests, and Cox regression, as appropriate (P ≤ .05). RESULTS There were 7288 CDH patients, of which 3048 (41.8%) were female. Females weighed less on average at birth than males (2.84 kg vs 2.97 kg, P < .001) despite comparable gestational age. Females had similar rates of extracorporeal life support (ECLS) utilization (27.8% vs 27.3%, P = .65). Although both cohorts had equivalent defect size and rates of patch repair, female patients had increased rates of intrathoracic liver herniation (49.2% vs 45.9%, P = .01) and pulmonary hypertension (PH) (86.6% vs 81.1%, P < .001). Females had lower survival rates at 30-days (77.3% vs 80.1%, P = .003) and overall lower survival to discharge (70.2% vs 74.2%, P < .001). Subgroup analysis revealed that increased mortality was significant among those who underwent repair but were never supported on ECLS (P = .005). On Cox regression analysis, female sex was independently associated with mortality (adjusted hazard ratio 1.32, P = .02). CONCLUSION After controlling for the established prenatal and postnatal predictors of mortality, female sex remains independently associated with a higher risk of mortality in CDH. Further study into the underlying causes for sex-specific disparities in CDH outcomes is warranted.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andres J Gonzalez Salazar
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abigail J Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashley Ebanks
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Ding W, Wu H. A novel congenital diaphragmatic hernia prediction model for Chinese subjects: A multicenter cohort investigation. Heliyon 2023; 9:e17275. [PMID: 37456039 PMCID: PMC10344702 DOI: 10.1016/j.heliyon.2023.e17275] [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: 11/15/2022] [Revised: 05/28/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose of the study Brindle et al. (2014) and the Congenital Diaphragmatic Hernia Study Group constructed a simplified clinical prediction rule (Brindle score) to stratify infants with congenital diaphragmatic hernia based on disease severity. We aimed to develop a predictive model applicable to Chinese patients with congenital diaphragmatic hernia and externally validate whether the Brindle score is applicable to the Chinese population. Patients and the methods Multiple imputations supplemented the missing data. A least absolute shrinkage and selection operator regression was used to screen the factors influencing adverse outcomes. Internal validation was performed by bootstrap resampling. The C-index, area under the receiver operating characteristic curve, and the Hosmer-Lemeshow test evaluated the predictive power. Results A nomogram named "CCDH score" (Chinese Congenital Diaphragmatic Hernia score), including pulmonary hypertension, low 5-min Apgar score (<7), chromosomal anomaly, major cardiac anomalies (MCAs), observed-to-expected lung-to-head ratio, and the percentage of liver herniation, was constructed. The CCDH score revealed good calibration and discriminative abilities, with a C-index of 0.941. In the training and external validation cohorts, the area under the receiver operating characteristic curve of the Brindle score were 0.820 and 0.881, respectively. The Brindle score has fair predictive power in the Chinese population, but the newly established CCDH score seems more suitable for Chinese patients with congenital diaphragmatic hernia. Conclusion The CCDH score is the first predictive model constructed based on the characteristics of the Chinese population and can accurately predict the survival outcomes of patients with congenital diaphragmatic hernia.
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Affiliation(s)
- Wen Ding
- Department of Fetal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Huiying Wu
- Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, 510623, China
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Sourouni M, Haisch L, Oelmeier K, Möllers M, Willy D, Sondern K, Köster H, Steinhard J, Sandkötter J, Klockenbusch W, Schmitz R, Potratz J. Observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT): assessment and evaluation as predictive factor for acute postnatal outcome-a single center study. Front Pediatr 2023; 11:1145907. [PMID: 37404558 PMCID: PMC10317208 DOI: 10.3389/fped.2023.1145907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/06/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction To assess the observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT) and to explore its value as a potential predictive factor for postnatal outcome. Methods A retrospective single-center study was conducted on pregnancies complicated by CAKUT between 2007 and 2018. The lung-to-head ratio (LHR) was calculated for each fetus by two independent observers. Correlations between O/E LHR and various perinatal outcome factors were assessed with Spearman's rank correlation. Furthermore, nominal logistic regression was performed to assess O/E LHR as predictive factor for respiratory distress in newborn. Results Of 64 pregnancies complicated by CAKUT, 23 were terminated. In the 41 cases of continuation of pregnancy, newborn presenting respiratory distress with need for respiratory support in the delivery room showed earlier gestational age at onset of amniotic fluid abnormalities and at birth. Although median O/E LHR and median single deepest pocket (SDP) of amniotic fluid were significantly smaller in newborn that did develop respiratory distress with need of respiratory support in the delivery room, neither O/E LHR nor SDP were accurate predictors for the development of respiratory distress. Conclusions Our data show that O/E LHR alone cannot serve as a predictive marker for fetal outcome in pregnancies complicated by CAKUT, though it might still be a helpful parameter together with detailed renal ultrasound evaluation, onset of amniotic fluid abnormality and SDP, particularly in its extreme values.
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Affiliation(s)
- M. Sourouni
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
- Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - L. Haisch
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
| | - K. Oelmeier
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - M. Möllers
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - D. Willy
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - K. Sondern
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - H. Köster
- Gynaecologist’s Office of Dr. Natalia Ulrich, Berlin, Germany
| | - J. Steinhard
- Department of Fetal Cardiology, University Hospital of the Ruhr University Bochum, Bad Oeynhausen, Germany
| | - J. Sandkötter
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
| | - W. Klockenbusch
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - R. Schmitz
- Department of Obstetrics and Gynecology, University Hospital Muenster, Muenster, Germany
| | - J. Potratz
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
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Huntley ES, Hernandez-Andrade E, Fishel Bartal M, Papanna R, Bergh EP, Lopez S, Soto E, Harting MT, Johnson A. Does Prediction of Neonatal Mortality by the Observed/Expected Lung-To-Head Ratio Change during Pregnancy in Fetuses with Left Congenital Diaphragmatic Hernia? Fetal Diagn Ther 2023; 50:438-445. [PMID: 37285832 DOI: 10.1159/000531406] [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: 12/02/2022] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate prediction of neonatal mortality in fetuses with isolated left congenital diaphragmatic hernia (CDH) when the observed/expected lung-to-head ratio (O/E LHR) was estimated at two different gestational time points during pregnancy. METHODS Forty-four (44) fetuses with isolated left CDH were included. O/E LHR was estimated at the time of referral (first scan) and before delivery (last scan). The main outcome was neonatal death due to respiratory complications. RESULTS There were 10/44 (22.7%) perinatal deaths. The areas under (AU) the ROC curves were: first scan, 0.76, best O/E LHR cut-off 35.5% with 76% sensitivity and 70% specificity; last scan, AU-ROC 0.79, best O/E LHR cut-off 35.2%, with 79.0% sensitivity and 80% specificity. Considering an O/E LHR cut-off ≤35% to define high-risk fetuses at any examination, prediction for perinatal mortality showed: 80% sensitivity, 73.5% specificity, 47.1% positive and 92.6% negative predictive values, and 3.02 (95% CI 1.59-5.73) positive and 0.27 (95% CI 0.08-0.96) negative likelihood ratios. Prediction was similar in the two evaluations as 16/21 (76.2%) of fetuses considered at risk had an O/E LHR ≤35% in the two examinations; in the remaining 5 cases, two were identified only in the first and three only in the last scan. CONCLUSION The O/E LHR is a good predictor of perinatal death in fetuses with left isolated CDH. Approximately 80% of fetuses at risk of perinatal death can be identified with an O/E LHR ≤35%, and 90% of them will have similar O/E LHR values at the first and at the last ultrasound examinations prior to delivery. In general, 88.6% of all CDH fetuses have a similar severity classification based on the O/E LHR at the first diagnostic ultrasound or at the ultrasound examination prior to delivery.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Michal Fishel Bartal
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Eric P Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Suzanne Lopez
- Department of Pediatrics Neonatology services, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
- Department of Pediatrics Neonatology services, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
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Chen Y, Xu R, Xie X, Wang T, Yang Z, Chen J. Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:667-681. [PMID: 36704940 DOI: 10.1002/uog.26164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE It is debated whether fetal endoscopic tracheal occlusion (FETO) is beneficial to fetuses with congenital diaphragmatic hernia (CDH) and whether FETO has different effects in moderate and severe CDH. We conducted a systematic review and meta-analysis including the latest evidence to assess the overall effects of FETO on clinical outcomes of CDH. METHODS We searched PubMed, EMBASE, The Cochrane Library, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang Database to retrieve eligible studies published before 8 September 2022. No language or study design restrictions were applied. Studies were included if CDH fetuses underwent FETO surgery and were compared with a cohort that underwent expectant management, with at least one outcome reported. The primary outcomes were mortality at 1, 6 and 12 months after birth, rates of pulmonary hypertension, use of extracorporeal membrane oxygenation (ECMO) and prematurity. Meta-analysis was conducted to obtain pooled odds ratios (ORs) and mean differences. The quality of included studies and pooled evidence was also assessed. RESULTS A total of 1187 CDH fetuses from 20 studies were included in the quantitative synthesis. FETO significantly reduced 1-month (OR, 0.56 (95% CI, 0.34-0.93); P = 0.02, number needed to treat (NNT) = 7.67) and 6-month (OR, 0.34 (95% CI, 0.18-0.65); P = 0.0009, NNT = 5.26) CDH mortality (moderate/low quality of evidence). Subgroup analysis suggested that the effects of FETO on the rates of pulmonary hypertension and ECMO usage were significant in severe CDH (low/moderate quality of evidence) but not in moderate CDH (low/very low quality of evidence). FETO was also associated with an increased risk of preterm prelabor rupture of membranes before 37 weeks' gestation (OR, 4.94 (95% CI, 2.25-10.88); P < 0.0001, number needed to harm (NNH) = 3.13) and preterm birth before 37 weeks (OR, 5.24 (95% CI, 3.33-8.23); P < 0.00001, NNH = 2.79) (high/moderate quality of evidence). However, FETO was not associated with severe complications, such as preterm birth before 32 weeks, placental abruption or chorioamnionitis (very low/low quality of evidence). CONCLUSIONS FETO is associated with a reduction in mortality, rate of pulmonary hypertension and ECMO usage in severe CDH, while it reduces only the risk of mortality in moderate CDH. Although FETO increases the risk of late prematurity, it does not result in extreme prematurity. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y Chen
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy and Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - R Xu
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy and Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - X Xie
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy and Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - T Wang
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy and Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Z Yang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - J Chen
- Division of Pulmonary Diseases, State Key Laboratory of Biotherapy and Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
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Nam CPBM, Campos CV, Leal GN, Tannuri U, Ceccon MEJR, Carvalho WBD. Post-natal prognostic factors in CDH: experience of 11 years in a referral center in Brazil. Clinics (Sao Paulo) 2023; 78:100217. [PMID: 37247561 DOI: 10.1016/j.clinsp.2023.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE To describe post-natal risk factors associated with death in Newborns (NB) with Congenital Diaphragmatic Hernia (CDH) in a Brazilian reference center. METHODS In this retrospective cohort study, post-natal clinical factors of all NB diagnosed with CDH were reviewed in an 11-year period (2007‒2018). The primary outcome was death. Secondary outcomes included clinical features, prognostic indexes, type of mechanical ventilation, complications during hospitalization and surgical repair. RESULTS After applying the exclusion criteria, the authors analyzed 137 charts. Overall mortality was 59% (81/137), and the highest rates were observed for low-birth-weight NB (87%), syndromic phenotype (92%), and those with major malformations (100%). Prognostic indexes such as Apgar, SNAPPE-II and 24hOI (best oxygenation index in 24 hours) were all associated with poor evolution. In a multivariate analysis, only birth weight and 24hOI were statistically significant risk factors for mortality, with a reduction in mortality risk of 17.1% (OR = 0.829, 95% IC 0.72‒0.955, p = 0.009) for each additional 100g at birth and an increase by 26.5% (OR = 1.265, 95% IC 1.113‒1.436, p = 0.0003) for each unitary increase at the 24hOI. CONCLUSION Prognostic indexes are an important tool for predicting outcomes and improving resource allocation. Post-natal risk factors may be more suitable for settings where antenatal diagnosis is not universal. Classical risk factors, such as prematurity, low birth weight, higher need for supportive care, and poorer prognostic indexes were associated with mortality in our CDH population.
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Affiliation(s)
- Camila Pinho Brasileiro Martins Nam
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Carolina Vieira Campos
- Pediatric Cardiology Department, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gabriela Nunes Leal
- Echocardiography Laboratory of Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Esther Jurfest Rivero Ceccon
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Pugnaloni F, Capolupo I, Patel N, Giliberti P, Dotta A, Bagolan P, Kipfmueller F. Role of microRNAs in Congenital Diaphragmatic Hernia-Associated Pulmonary Hypertension. Int J Mol Sci 2023; 24:ijms24076656. [PMID: 37047629 PMCID: PMC10095389 DOI: 10.3390/ijms24076656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Epigenetic regulators such as microRNAs (miRNAs) have a key role in modulating several gene expression pathways and have a role both in lung development and function. One of the main pathogenetic determinants in patients with congenital diaphragmatic hernia (CDH) is pulmonary hypertension (PH), which is directly related to smaller lung size and pulmonary microarchitecture alterations. The aim of this review is to highlight the importance of miRNAs in CDH-related PH and to summarize the results covering this topic in animal and human CDH studies. The focus on epigenetic modulators of CDH-PH offers the opportunity to develop innovative diagnostic tools and novel treatment modalities, and provides a great potential to increase researchers’ understanding of the pathophysiology of CDH.
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Affiliation(s)
- Flaminia Pugnaloni
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Neil Patel
- Department of Neonatology, The Royal Hospital for Children, Glasgow G51 4TF, UK
| | - Paola Giliberti
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, Instituti di Ricovero e Cura a Carattere Scietifico (IRCCS), 00165 Rome, Italy
| | - Pietro Bagolan
- Area of Fetal, Neonatal and Cardiological Sciences Children’s Hospital Bambino Gesù-Research Institute, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00165 Rome, Italy
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany
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Ding W, Gu Y, Wu H, Wang H, Zhang X, Wang H, Huang L, Zhang R, He Q, Zhong W, Lv J, Xia B, Zhang G, Mei S. Mediastinal shift angle (MSA) measurement with MRI: a simple and effective tool for prenatal risk stratification in fetuses with congenital diaphragmatic hernia. Eur Radiol 2023; 33:1668-1676. [PMID: 36180644 DOI: 10.1007/s00330-022-09142-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/21/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the predictive value of mediastinal shift angle (MSA) in congenital diaphragmatic hernia (CDH). METHODS A retrospective analysis was performed on 87 fetuses with prenatally diagnosed left-sided CDH (LCDH) and 88 controls. MSA was measured on magnetic resonance imaging (MRI). Lung area to head circumference ratio (LHR), ratio of the observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected total fetal lung volume (O/E TFLV) were also measured. Correlation of MSA with pulmonary hypertension (PH), extracorporeal membrane oxygenation (ECMO) use, duration of hospitalization and survival in neonates with CDH was analyzed. Performance of MSA in prediction of postnatal outcomes was compared with LHR, O/E LHR, TFLV, and O/E TFLV. RESULTS There were significant differences in MSA values not only between the CDH group and the control group but also in CDH patients with different survival outcomes. MSA was inversely correlated with O/E LHR, O/E TFLV, and TFLV. MSA, LHR, O/E LHR, TFLV, and O/E TFLV could all be used to predict survival of CDH patients. In addition, the receiver operating characteristic (ROC) curve showed that the test performance of MSA was similar to that of TFLV, O/E TFLV, and O/E LHR, but superior to that of LHR. MSA was also correlated with PH, need for ECMO support, and duration of hospitalization. CONCLUSION MRI measurement of MSA can provide various prognostic information for prenatally diagnosed LCDH, in addition to postnatal survival. The test performance of MSA is similar to TFLV, O/E TFLV, and O/E LHR. KEY POINTS • Mediastinal shift angle (MSA) can be measured quickly and reproducibly on MRI images. • MSA could provide more prognostic information other than postnatal survival for LCDH with good test performance. • MSA should be incorporated into prenatal risk stratification for LCDH to improve planning of postnatal management.
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Affiliation(s)
- Wen Ding
- Guangzhou Medical University, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yuanyuan Gu
- Department of Fetal Medicine, Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Huiying Wu
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Haiyu Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiaochun Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Hongying Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Li Huang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Rui Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Qiuming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Junjian Lv
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Bo Xia
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Guanglan Zhang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Shanshan Mei
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou, China
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Niemiec SM, Louiselle AE, Phillips R, Gien J, Zaretsky MV, Derderian SC, Liechty KW, Meyers ML. Third-trimester percentage predicted lung volume and percentage liver herniation as prognostic indicators in congenital diaphragmatic hernia. Pediatr Radiol 2023; 53:479-486. [PMID: 36289070 DOI: 10.1007/s00247-022-05538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/13/2022] [Accepted: 10/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Over the last two decades, fetal imaging has greatly improved, and new prenatal imaging measurements have been developed to characterize congenital diaphragmatic hernia (CDH) severity. OBJECTIVE To determine the best prenatal imaging predictor of postnatal CDH outcomes, including use of extracorporeal membrane oxygenation (ECMO) and in-hospital mortality, with particular attention to the percentage of liver herniation (%LH) as a predictor. Additionally, we sought to guide best practices across hospital systems including improved models of prenatal risk assessment. MATERIALS AND METHODS We conducted a retrospective review of infants with left CDH who were prenatally diagnosed. We analyzed prenatal imaging measurements including observed-to-expected (O/E) lung-to-head ratio (LHR) on US, percentage predicted lung volume (PPLV) on MRI, and O/E total fetal lung volume (TFLV) and %LH on MRI. We compared prenatal imaging characteristics for infants with (1) in-hospital postnatal mortality and (2) use of ECMO. Then we performed multivariate logistic regression to determine independent predictors of postnatal outcomes. RESULTS We included 63 infants with a median gestation of 34 weeks at the time of prenatal MRI. Low O/E LHR (31.2 vs. 50, P < 0.0001), PPLV (14.7 vs. 22.6, P < 0.0001) and O/E TLFV (24.6 vs. 38.3, P < 0.0001) and high %LH (15.1 vs. 2.1, P = 0.0006) were associated with worse postnatal outcomes; however, only PPLV was predictive of survival and need for ECMO on multivariable analysis. PPLV survival to discharge model showed an area under the curve (AUC) of 0.93 (95% confidence interval [CI]: 0.86, 0.99), P < 0.0001; and an odds ratio of 68.7 (95% CI: 6.5-2,302), P = 0.003. PPLV need for ECMO model showed AUC = 0.87 (95% CI: 0.78, 0.96), P < 0.0001; and odds ratio = 20.1 (95% CI: 3.1-226.3), P = 0.011. CONCLUSION Low O/E LHR, PPLV and O/E TFLV and high %LH in the third trimester are associated with worse postnatal outcomes. PPLV most strongly predicted outcome using a logistic regression model. Percentage of liver herniation was not an independent predictor of outcomes.
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Affiliation(s)
- Stephen M Niemiec
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amanda E Louiselle
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason Gien
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Pediatrics Section of Neonatology, Children's Hospital of Colorado, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Michael V Zaretsky
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Sarkis C Derderian
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Kenneth W Liechty
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Mariana L Meyers
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA. .,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA. .,Department of Radiology, Division of Pediatric Radiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Harting MT, Munson D, Linebarger J, Hirshberg E, Gow KW, Malek MM, Robbins AJ, Turnbull J. Ethical Considerations in Critically Ill Neonatal and Pediatric Patients. J Pediatr Surg 2023; 58:1059-1073. [PMID: 36948932 DOI: 10.1016/j.jpedsurg.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/19/2023]
Abstract
The care of critically ill neonates and pediatric patients can be particularly emotionally and ethically challenging. Emerging evidence suggests that we can improve the patient, family, and care team experience in the critical care setting through a better understanding and application of ethical frameworks and communication strategies. We conducted a multidisciplinary panel session at the American Academy of Pediatrics National Conference and Exhibition in the fall of 2022 wherein we explored a myriad of ethical and communication considerations in this unique patient population, with congenital diaphragmatic hernia (CDH) as the congenital anomaly/disease framework. In this review, we will cover state of the art topics in ethics, communication, and palliative care including basic terminology, communication strategies such as trauma-informed communication, establishing/evolving goals of care, futility, medically inappropriate treatment, ethical frameworks, parental discretion, establishing milestones, internal/external intentions, and re-direction of care. These topics will be helpful to many specialties who are involved in the care of critically ill neonates and children including maternal fetal medicine, pediatrics, neonatology, pediatric critical care, palliative care, and pediatric surgery, along with the pediatric surgical subspecialties. We use a theoretical CDH case as an example and include the live audience responses from the interactive session. This primer provides overarching educational principles, as well as practical communication concepts, that can cultivate compassionate multidisciplinary teams, equipped to optimize family-centered, evidence-based compassionate communication and care.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - David Munson
- Department of Pediatrics, Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Linebarger
- Department of Pediatrics, University of Missouri - Kansas City and Children's Mercy Hospital, Kansas City, MO, USA
| | - Ellie Hirshberg
- Department of Pediatrics, University of Utah School of Medicine and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Kenneth W Gow
- Department of Surgery, Division of Pediatric Surgery, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Marcus M Malek
- Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Family Medicine and Community Health, Division of Palliative Care, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jessica Turnbull
- Department of Pediatrics and the Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Olutoye OO, Mehl SC, Moturu A, Pettit RW, Coleman RD, Vogel AM, Lee TC, Keswani SG, King A. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res 2023; 282:168-173. [PMID: 36306587 PMCID: PMC11132729 DOI: 10.1016/j.jss.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. METHODS A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. RESULTS Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. CONCLUSIONS Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Anoosha Moturu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ryan D Coleman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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Scottoline B, Jordan BK, Parkhotyuk K, Schilling D, McEvoy CT. Perioperative Improvement in Pulmonary Function in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2023; 253:173-180.e2. [PMID: 36181873 DOI: 10.1016/j.jpeds.2022.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/26/2022] [Accepted: 09/23/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to compare serial changes in pulmonary function in contemporary infants with congenital diaphragmatic hernia managed with a gentle ventilation approach. STUDY DESIGN Observational cohort, single-center study of infants ≥350/7 weeks gestation at delivery with congenital diaphragmatic hernia. Functional residual capacity (FRC), passive respiratory compliance, and passive respiratory resistance were measured presurgical and postsurgical repair and within 2 weeks of discharge. A 1-way analysis of variance for repeated measures was used to evaluate the change in FRC, passive respiratory compliance, and passive respiratory resistance over these repeated measures. RESULTS Twenty-eight infants were included in the analysis with a mean gestational age of 38.3 weeks and birth weight of 3139 g. We found a significant increase in FRC across the 3 time points (mean in mL/kg [SD]: 10.9 [3.6] to 18.5 [5.2] to 24.2 [4.4]; P < .0001). There was also a significant increase in passive respiratory compliance and decrease in passive respiratory resistance. In contrast to a previous report, there were survivors in the current cohort with a preoperative FRC of <9 mL/kg. The mean FRC measured at discharge was in the range considered within normal limits. Sixteen infants had prenatal measurements of the lung-to-head ratio, but there was no relationship between the lung-to-head ratio and preoperative or postoperative FRC measurements. CONCLUSIONS Infants with congenital diaphragmatic hernia demonstrate significant increases in FRC and improvements in respiratory mechanics measured preoperatively and postoperatively and at discharge. We speculate these improvements are due to the surgical resolution of the mechanical obstruction to lung recruitment and that after achieving preoperative stability, repair should not be delayed given these demonstrable postoperative improvements.
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Affiliation(s)
- Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR.
| | - Brian K Jordan
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Kseniya Parkhotyuk
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Diane Schilling
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Cindy T McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Toyoshima K, Saito T, Shimokaze T, Katsumata K, Ohmura J, Kimura S, Aoki H, Takahashi M, Shibasaki J, Kawataki M, Kim KS, Shinkai M, Ishikawa H, Saito N, Masutani S. Right to left ventricular volume ratio is associated with mortality in congenital diaphragmatic hernia. Pediatr Res 2023:10.1038/s41390-022-02430-z. [PMID: 36624284 DOI: 10.1038/s41390-022-02430-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is associated with high neonatal mortality. We performed this study to test the hypothesis that left ventricular (LV) and right ventricular (RV) volumes assessed by three-dimensional echocardiography may be associated with mortality in CDH. METHODS This study was a single-center retrospective cohort study involving 35 infants with CDH. RV and LV end-diastolic volume (RVEDV and LVEDV, respectively) were measured by three-dimensional echocardiography and were corrected by birth body weight (BBW) on day 1. RVEDV/BBW, LVEDV/BBW, and LVEDV/RVEDV were compared between CDH survivors and non-survivors. Receiver-operating characteristic curve analysis was performed to assess the predictive ability for mortality of the echocardiographic parameters. RESULTS Comparing CDH non-survivors (n = 6) with survivors (n = 29), respectively, RVEDV/BBW was significantly larger (2.54 ± 0.33 vs 1.86 ± 0.35 ml/kg; P < 0.01), LVEDV/BBW was significantly smaller (0.86 ± 0.21 vs 1.22 ± 0.33 ml/kg; P < 0.001), and LVEDV/RVEDV was significantly lower (0.34 ± 0.06 vs 0.66 ± 0.18; P < 0.001). The area under the curve for LVEDV/RVEDV was the largest (0.98). CONCLUSIONS Three-dimensional echocardiographic volume imbalance between the RV and LV was remarkable in CDH non-survivors. The LVEDV/RVEDV ratio may be associated with mortality in CDH. IMPACT Mortality with congenital diaphragmatic hernia (CDH) is high, and evaluating left and right ventricular structures and functions may be helpful in assessing the prognosis. Three-dimensional (3D) echocardiography indicated that the left ventricular end-diastolic volume/right ventricular end-diastolic volume ratio within 24 h after birth was associated with mortality in CDH infants. The usefulness of this ratio should be validated in prospective multicenter studies involving larger numbers of patients.
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Affiliation(s)
- Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Tomoko Saito
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoyuki Shimokaze
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kaoru Katsumata
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Junya Ohmura
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Sasagu Kimura
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hirosato Aoki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Megumi Takahashi
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Ki-Sung Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hiroshi Ishikawa
- Department of Obstetrics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical University, Kawagoe, Japan
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Dassios T. Critical functional lung volumes in neonatal intensive care: evidence and clinical applications. Pediatr Res 2023:10.1038/s41390-022-02450-9. [PMID: 36624281 DOI: 10.1038/s41390-022-02450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/08/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
Respiratory disease is common in premature and sick newborn infants and can often necessitate the initiation of intensive care. Newborn infants often suffer from conditions that are associated with decreased lung volumes that occur as a result of abnormal or incomplete lung development. Such conditions are prematurity and respiratory distress syndrome, preterm premature rupture of membranes and the ensuing pulmonary hypoplasia and congenital lung anomalies such as congenital diaphragmatic hernia. These diseases have a structural component manifesting with lower lung volumes and a functional component that can present with increased oxygen and ventilatory requirements. The corresponding decreased functional lung volume is possibly responsible for some unfavourable pulmonary outcomes. Some infants are unable to wean off invasive respiratory support and, in extreme cases, unable to sustain independent breathing that can lead to long-term invasive ventilation or subsequent death. The aim of this review is to summarise the available evidence behind the concept of a critical functional lung volume in neonatal intensive care and describe the clinical implications that arise from decreased functional lung volumes in the main high-risk populations of newborn infants. IMPACT: Newborn infants suffer from diseases such as respiratory distress syndrome, pulmonary hypoplasia and congenital diaphragmatic hernia that are associated with a decrease in the total lung volume and impaired lung function. Critically decreased functional lung volumes during neonatal care are associated with failure to wean off invasive respiratory support, increased mortality and possibly longer-term respiratory complications.
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Affiliation(s)
- Theodore Dassios
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK. .,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Yoneda K, Amari S, Mikami M, Uchida K, Yokoi A, Okawada M, Furukawa T, Toyoshima K, Inamura N, Okazaki T, Yamoto M, Masumoto K, Terui K, Okuyama H, Hayakawa M, Taguchi T, Usui N, Isayama T. Development of mortality prediction models for infants with isolated, left-sided congenital diaphragmatic hernia before and after birth. Pediatr Pulmonol 2023; 58:152-160. [PMID: 36174997 DOI: 10.1002/ppul.26172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/29/2022] [Accepted: 09/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mortality prediction of congenital diaphragmatic hernia (CDH) is essential for developing treatment strategies, including fetal therapy. Several researchers have reported prognostic factors for this rare but life-threatening condition; however, the optimal combination of prognostic factors remains to be elucidated. OBJECTIVES This study aimed to develop the most discriminative prenatal and postnatal models to predict the mortality of infants with an isolated left-sided CDH. METHODS This multi-institutional retrospective cohort study included infants with CDH born at 15 tertiary hospitals of the Japanese CDH Study Group between 2011 and 2016. We developed multivariable logistic models with every possible combination of predictors and identified models with the highest cross-validated area under the receiver operating characteristic curve (AUC) for prenatal and postnatal predictions. RESULTS Among 302 eligible infants, 44 died before discharge. The prenatal mortality prediction model was based on the observed/expected lung area to head circumference ratio (O/E LHR), liver herniation, and stomach herniation (AUC, 0.830). The postnatal mortality prediction model was based on O/E LHR, liver herniation, and the lowest oxygenation index (AUC, 0.944). CONCLUSION Our models can facilitate the prenatal and postnatal mortality prediction of infants with isolated left-sided CDH.
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Affiliation(s)
- Kota Yoneda
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Shoichiro Amari
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Masashi Mikami
- Division of Biostatistics, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University, Faculty of Medicine, Osaka-Sayama, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Fukuoka College of Health Sciences, Fukuoka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
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O'Connor E, Tamura R, Hannon T, Harigopal S, Jaffray B. Congenital diaphragmatic hernia survival in an English regional ECMO center. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000506. [PMID: 37143688 PMCID: PMC10152044 DOI: 10.1136/wjps-2022-000506] [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: 10/05/2022] [Accepted: 03/22/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) remains a cause of neonatal death. Our aims are to describe contemporary rates of survival and the variables associated with this outcome, contrasting these with our study of two decades earlier and recent reports. Materials and methods A retrospective review of all infants diagnosed in a regional center between January 2000 and December 2020 was performed. The outcome of interest was survival. Possible explanatory variables included side of defect, use of complex ventilatory or hemodynamic strategies (inhaled nitric oxide (iNO), high-frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and Prostin), presence of antenatal diagnosis, associated anomalies, birth weight, and gestation. Temporal changes were studied by measuring outcomes in each of four consecutive 63-month periods. Results A total of 225 cases were diagnosed. Survival was 60% (134 of 225). Postnatal survival was 68% (134 of 198 liveborn), and postrepair survival was 84% (134 of 159 who survived to repair). Diagnosis was made antenatally in 66% of cases. Variables associated with mortality were the need for complex ventilatory strategies (iNO, HFOV, Prostin, and ECMO), antenatal diagnosis, right-sided defects, use of patch repair, associated anomalies, birth weight, and gestation. Survival has improved from our report of a prior decade and did not vary during the study period. Postnatal survival has improved despite fewer terminations. On multivariate analysis, the need for complex ventilation was the strongest predictor of death (OR=50, 95% CI 13 to 224, p<0.0001), and associated anomalies ceased to be predictive. Conclusions Survival has improved from our earlier report, despite reduced numbers of terminations. This may be related to increased use of complex ventilatory strategies.
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Affiliation(s)
- Elizabeth O'Connor
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
| | - Ryo Tamura
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
| | - Therese Hannon
- Fetal medicine and obstetrics, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne & Wear, UK
| | - Sundeep Harigopal
- Neonatal medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne & Wear, UK
| | - Bruce Jaffray
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
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50
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Horn-Oudshoorn EJJ, Peters NCJ, Franx A, Eggink AJ, Cochius-den Otter SCM, Reiss IKM, DeKoninck PLJ. Termination of pregnancy after a prenatal diagnosis of congenital diaphragmatic hernia: Factors influencing the parental decision process. Prenat Diagn 2023; 43:95-101. [PMID: 36443507 PMCID: PMC10107614 DOI: 10.1002/pd.6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). STUDY DESIGN Single-centre retrospective cohort includes all prenatally detected CDH cases born between January 2009 and December 2021. Parental factors, such as parity, and fetal characteristics, such as disease severity, were collected. Descriptive statistics were used to present the data. Differences between terminated and continued pregnancies were analysed. RESULTS The study population consisted of 278 prenatally detected CDH cases of which 80% detected <24 weeks of gestation. The TOP rate was 28% in cases that were detected <24 weeks of gestation. Twenty continued pregnancies resulted in either intrauterine fetal demise (n = 6), preterm birth <24 weeks (n = 2), or comfort care after birth (n = 12). The survival rate was 70% in the remaining 195 live born cases. Factors associated with the decision for TOP were additional fetal genetic or anatomical abnormalities (p < 0.0001) and expected severity of pulmonary hypoplasia in left-sided CDH (p = 0.0456). CONCLUSION The decision to terminate a pregnancy complicated by fetal CDH depends on the severity of pulmonary hypoplasia and the presence of additional abnormalities. This emphasises the importance of early referral to expertise centres for detailed evaluation and multidisciplinary counselling.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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