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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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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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3
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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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4
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Wild KT, Rintoul NE, Ades AM, Gebb JS, Moldenhauer JS, Mathew L, Flohr S, Bostwick A, Reynolds T, Ruiz RL, Javia LR, Nelson O, Peranteau WH, Partridge EA, Adzick NS, Hedrick HL. The Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia Treated with Fetoscopic Endoluminal Tracheal Occlusion: Beyond the Balloon. Fetal Diagn Ther 2024; 51:184-190. [PMID: 38198774 DOI: 10.1159/000536209] [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: 10/20/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Randomized controlled trials found that fetoscopic endoluminal tracheal occlusion (FETO) resulted in increased fetal lung volume and improved survival for infants with isolated, severe left-sided congenital diaphragmatic hernia (CDH). The delivery room resuscitation of these infants is particularly unique, and the specific delivery room events are largely unknown. The objective of this study was to compare the delivery room resuscitation of infants treated with FETO to standard of care (SOC) and describe lessons learned. METHODS Retrospective single-center cohort study of infants treated with FETO compared to infants who met FETO criteria during the same period but who received SOC. RESULTS FETO infants were more likely to be born prematurely with 8/12 infants born <35 weeks gestational age compared to 3/35 SOC infants. There were 5 infants who required emergent balloon removal (2 ex utero intrapartum treatment and 3 tracheoscopic removal on placental bypass with delayed cord clamping) and 7 with prenatal balloon removal. Surfactant was administered in 6/12 FETO (50%) infants compared to 2/35 (6%) in the SOC group. Extracorporeal membrane oxygenation use was lower at 25% and survival was higher at 92% compared to 60% and 71% in the SOC infants, respectively. CONCLUSION The delivery room resuscitation of infants treated with FETO requires thoughtful preparation with an experienced multidisciplinary team. Given increased survival, FETO should be offered to infants with severe isolated left-sided CDH, but only in high-volume centers with the experience and capability of removing the balloon, emergently if needed. The neonatal clinical team must be skilled in managing the unique postnatal physiology inherent to FETO where effective interdisciplinary teamwork is essential. Empiric and immediate surfactant administration should be considered in all FETO infants to lavage thick airway secretions, particularly those delivered <48 h after balloon removal.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Juliana S Gebb
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sabrina Flohr
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anna Bostwick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryan L Ruiz
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Luv R Javia
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Emily A Partridge
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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5
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Orlinsky R, Land S, Flohr S, Rintoul N, Goldshore M, Hedrick HL. Birth Admission Length-of-Stay and Hospital Readmission in Children With Congenital Diaphragmatic Hernia. J Pediatr Surg 2023; 58:2368-2374. [PMID: 37659921 DOI: 10.1016/j.jpedsurg.2023.08.002] [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: 02/22/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND The objective of this study was to identify factors associated with prolonged birth admission length of stay (LOS) and to evaluate the association between these characteristics and readmission in the year following discharge for children with congenital diaphragmatic hernia (CDH). METHODS This was a single-center retrospective cohort study of children with isolated CDH born in the Special Delivery Unit and admitted to the Newborn/Infant Intensive Care Unit at Children's Hospital of Philadelphia from April 2008 to August 2019. Birth admission hospitalization was categorized into 3 groups (≤35, 36-75, and >76 days) based on the data distribution. Participant factors included gestational age (days), side of CDH (right/left), liver position (up/down), CDH repair technique (open/minimally invasive), exposure to extracorporeal membrane oxygenation, lung-to-head circumference ratio, and feeding tube at discharge. Chi-squared, t-tests and analysis of variance were used to examine bivariable associations between participant characteristics, birth admission LOS and readmission in the year following initial hospital discharge. Multivariable logistic regression was used to evaluate factors associated with readmission. RESULTS Children hospitalized ≥76 days at birth had 4.33 (95% CI: 1.2, 15.2) higher odds of readmission than those admitted for ≤35 days. Children with a non-operative feeding tube at discharge had 4.12 (895% CI: 1.6, 10.5) higher odds of readmission when compared to those with no feeding tube at discharge. CONCLUSIONS Longer birth hospitalization and non-operative feeding tube are associated with increased readmissions in the year after discharge. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rachel Orlinsky
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA; University of Maryland Medical Center, Baltimore, MD, USA
| | - Sierra Land
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA.
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, PA, USA
| | - Matthew Goldshore
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
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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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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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8
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Wild KT, Mathew L, Hedrick HL, Rintoul NE, Ades A, Soorikian L, Matthews K, Posencheg MA, Kesler E, Van Hoose KT, Panitch HB, Flibotte J, Foglia EE. Respiratory function after birth in infants with congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2023; 108:535-539. [PMID: 36400455 DOI: 10.1136/archdischild-2022-324415] [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: 05/12/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To characterise the transitional pulmonary physiology of infants with congenital diaphragmatic hernia (CDH) using measures of expiratory tidal volume (TV) and end-tidal carbon dioxide (ETCO2). DESIGN Prospective single-centre observational study. SETTING Quaternary neonatal intensive care unit. PATIENTS Infants with an antenatal diagnosis of CDH born at the Children's Hospital of Philadelphia. INTERVENTIONS TV and ETCO2 were simultaneously recorded using a respiratory function monitor (RFM) during invasive positive pressure ventilation immediately after birth. MAIN OUTCOME MEASURES TV per birth weight and ETCO2 values were summarised for each minute after birth. Subgroups of interest were defined by liver position (thoracic vs abdominal) and extracorporeal membrane oxygenation (ECMO) treatment. RESULTS RFM data were available for 50 infants from intubation until a median (IQR) of 9 (7-14) min after birth. TV and ETCO2 values increased for the first 10 min after birth, but intersubject values were heterogeneous. TVs were overall lower and ETCO2 values higher in infants with an intrathoracic liver and infants who were ultimately treated with ECMO. On hospital discharge, survival was 88% (n=43) and 34% (n=17) of infants were treated with ECMO. CONCLUSION Respiratory function immediately after birth is heterogeneous for infants with CDH. Lung aeration, as evidenced by expired TV and ETCO2, appears to be ongoing throughout the first 10 min after birth during invasive positive pressure ventilation. Close attention to expired TV and ETCO2 levels by 10 min after birth may provide an opportunity to optimise and individualise ventilatory support for this high-risk population.
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Affiliation(s)
- K Taylor Wild
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leane Soorikian
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Kelle Matthews
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Michael A Posencheg
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erin Kesler
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - K Taylor Van Hoose
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard B Panitch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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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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10
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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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11
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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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12
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Postnatal Imaging for Prediction of Outcome in Patients with Left-sided Congenital Diaphragmatic Hernia. J Pediatr 2022; 251:89-97.e3. [PMID: 35944713 DOI: 10.1016/j.jpeds.2022.07.037] [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: 03/28/2022] [Revised: 06/17/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate associations between postnatal imaging features and outcome of left-sided congenital diaphragmatic hernia, as defined by overall survival and a requirement for extracorporeal membrane oxygenation (ECMO). STUDY DESIGN Newborns diagnosed prenatally with left-sided congenital diaphragmatic hernia between January 2013 and September 2021 were studied retrospectively. The esophageal deviation index was newly defined as the largest diameter from the midline to deviated gastric tube divided by the largest transverse diameter of the thoracic cavity on the radiograph. Regression analyses were performed to identify postnatal imaging features associated with overall survival and a requirement for ECMO. The predictive power (ie, area under the curve [AUC] of a time-dependent receiver operating characteristic curve) of prenatal, postnatal, and intraoperative findings for predicting survival were calculated. RESULTS Ninety-seven patients (54 males; mean gestational age, 38.3 ± 1.9 weeks; mean birth weight, 2956.5 ± 540.0 g) were analyzed. The esophageal deviation index (adjusted hazard ratio [HR], moderate [≥0.19 to <0.24], 6.427 [P = .029]; severe [≥0.24], 33.007 [P < .001]) and right pneumothorax (adjusted HR, 8.763; P = .002) were associated with overall survival and with a requirement for ECMO. Liver herniation on postnatal ultrasound also was associated with overall survival (P < .001) and need for ECMO (P = .001). In addition, the AUC for prediction of 1-year survival from postnatal ultrasound was comparable with that of prenatally or intraoperatively detected liver herniation (0.93; 95% CI, 0.88-0.97). CONCLUSIONS The esophageal deviation index, right pneumothorax, and liver herniation observed by postnatal imaging have prognostic value in patients with left-sided congenital diaphragmatic hernia.
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13
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Masahata K, Yamoto M, Umeda S, Nagata K, Terui K, Fujii M, Shiraishi M, Hayakawa M, Amari S, Masumoto K, Okazaki T, Inamura N, Toyoshima K, Koike Y, Furukawa T, Yazaki Y, Yokoi A, Endo M, Tazuke Y, Okuyama H, Usui N. Prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1745-1757. [PMID: 36102982 DOI: 10.1007/s00383-022-05232-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] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to evaluate prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia (CDH). METHODS A systematic literature search was performed to identify relevant observational studies that evaluated the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e-LHR), observed-to-expected total fetal lung volume (o/e-TFLV), lung-to-thorax transverse area ratio (L/T ratio), intrathoracic herniation of the liver and the stomach, and side of diaphragmatic hernia, using a threshold for the prediction of mortality in fetuses with CDH. Study quality was assessed using the QUADAS-2 tool. Hierarchical summary receiver operating characteristic curves were constructed. RESULTS A total of 50 articles were included in this meta-analysis. The QUADAS-2 tool identified a high risk of bias in more than one domain scored in all parameters. Among those parameters, the diagnostic odds ratio of mortality with o/e-LHR < 25%, o/e-TFLV < 25%, and L/T ratio < 0.08 were 11.98 [95% confidence interval (CI) 4.65-30.89], 11.14 (95% CI 5.19-23.89), and 10.28 (95% CI 3.38-31.31), respectively. The predictive values for mortality were similar between the presence of liver herniation and retrocardiac fetal stomach position. CONCLUSIONS This systematic review suggests that o/e-LHR, o/e-TFLV, and L/T ratio are equally good predictors of neonatal mortality in fetuses with isolated CDH.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Fujii
- Department of Health Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Katsuaki Toyoshima
- Departments of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Yokoi
- Departments of Pediatric Surgery, Kobe Children's Medical Center, Kobe, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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14
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Management of the CDH patient on ECLS. Semin Fetal Neonatal Med 2022; 27:101407. [PMID: 36411199 DOI: 10.1016/j.siny.2022.101407] [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: 11/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.
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15
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Danzer E, Rintoul NE, van Meurs KP, Deprest J. Prenatal management of congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101406. [PMID: 36456433 DOI: 10.1016/j.siny.2022.101406] [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: 11/18/2022]
Abstract
Recently, two randomized controlled, prospective trials, the Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trials, reported the outcomes on fetal endoluminal tracheal occlusion (FETO) for isolated left congenital diaphragmatic hernia (CDH). FETO significantly improved outcomes for severe hypoplasia. The effect in moderate cases, where the balloon was inserted later in pregnancy, did not reach significance. In a pooled analysis investigating the effect of the heterogeneity of the treatment effect by the time point of occlusion and severity, the difference may be explained by a difference in the duration of occlusion. Nevertheless, FETO carries a significant risk of preterm birth. The primary objective of this review is to provide an overview of the rationale for fetal intervention in CDH and the results of the randomized trials. The secondary objective is to discuss the technical aspects of FETO. Finally, recent developments of potential alternative fetal approaches will be highlighted.
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Affiliation(s)
- Enrico Danzer
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA; Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
| | - Natalie E Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment and Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krisa P van Meurs
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium; Institute of Women's Health, University College London Hospitals, London, United Kingdom
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16
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Image-based prenatal predictors of postnatal survival, extracorporeal life support, and defect size in right congenital diaphragmatic hernia. J Perinatol 2022; 42:1202-1209. [PMID: 35922665 DOI: 10.1038/s41372-022-01470-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the association between prenatal ultrasound (US) and magnetic resonance imaging (MRI) characteristics in right congenital diaphragmatic hernia (RCDH) with postnatal outcome. STUDY DESIGN CDH Study Group data were reviewed for all RCDH infants (n = 156) born between 2015 and 2019. Prenatal US and MRI lung size measurements were correlated with survival, extracorporeal life support (ECLS), and defect size. RESULT Overall survival was 64.1%. ECLS was required in 40.4%. US and MRI-based prenatal assessment of pulmonary hypoplasia does not predict survival. Prenatal measurement of lung size using either US or MRI correlates with ECLS use. Only MRI-based measures of lung size are associated with defect size. CONCLUSION Image-based prenatal predictors of survival, ECLS, and defect size are of limited value in RCDH. Extrapolation of prenatal survival and morbidity indicators from left to right-sided CDH is not appropriate. There is an urgent need to develop RCDH prenatal prediction models.
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17
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Avena-Zampieri CL, Hutter J, Rutherford M, Milan A, Hall M, Egloff A, Lloyd DFA, Nanda S, Greenough A, Story L. Assessment of the fetal lungs in utero. Am J Obstet Gynecol MFM 2022; 4:100693. [PMID: 35858660 PMCID: PMC9811184 DOI: 10.1016/j.ajogmf.2022.100693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Antenatal diagnosis of abnormal pulmonary development has improved significantly over recent years because of progress in imaging techniques. Two-dimensional ultrasound is the mainstay of investigation of pulmonary pathology during pregnancy, providing good prognostication in conditions such as congenital diaphragmatic hernia; however, it is less validated in other high-risk groups such as those with congenital pulmonary airway malformation or preterm premature rupture of membranes. Three-dimensional assessment of lung volume and size is now possible using ultrasound or magnetic resonance imaging; however, the use of these techniques is still limited because of unpredictable fetal motion, and such tools have also been inadequately validated in high-risk populations other than those with congenital diaphragmatic hernia. The advent of advanced, functional magnetic resonance imaging techniques such as diffusion and T2* imaging, and the development of postprocessing pipelines that facilitate motion correction, have enabled not only more accurate evaluation of pulmonary size, but also assessment of tissue microstructure and perfusion. In the future, fetal magnetic resonance imaging may have an increasing role in the prognostication of pulmonary abnormalities and in monitoring current and future antenatal therapies to enhance lung development. This review aims to examine the current imaging methods available for assessment of antenatal lung development and to outline possible future directions.
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Affiliation(s)
- Carla L Avena-Zampieri
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Jana Hutter
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Mary Rutherford
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Anna Milan
- Neonatal Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Megan Hall
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Alexia Egloff
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - David F A Lloyd
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Surabhi Nanda
- Fetal Medicine Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health, King's College London, London, United Kingdom; Neonatal Unit, King's College Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, United Kingdom; National Institute for Health and Care Research Biomedical Research Centre, Guy's & St Thomas National Health Service Foundation Trust and King's College London, London, United Kingdom
| | - Lisa Story
- Department of Women and Children's Health, King's College London, London, United Kingdom; Centre for the Developing Brain, King's College London, London, United Kingdom; Fetal Medicine Unit, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.
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18
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Sankaran D, Lakshminrusimha S. Pulmonary hypertension in the newborn- etiology and pathogenesis. Semin Fetal Neonatal Med 2022; 27:101381. [PMID: 35963740 DOI: 10.1016/j.siny.2022.101381] [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] [Indexed: 11/19/2022]
Abstract
A disruption in the well-orchestrated fetal-to-neonatal cardiopulmonary transition at birth results in the clinical conundrum of severe hypoxemic respiratory failure associated with elevated pulmonary vascular resistance (PVR), referred to as persistent pulmonary hypertension of the newborn (PPHN). In the past three decades, the advent of surfactant, newer modalities of ventilation, inhaled nitric oxide, other pulmonary vasodilators, and finally extracorporeal membrane oxygenation (ECMO) have made giant strides in improving the outcomes of infants with PPHN. However, death or the need for ECMO occurs in 10-20% of term infants with PPHN. Better understanding of the etiopathogenesis of PPHN can lead to physiology-driven management strategies. This manuscript reviews the fetal circulation, cardiopulmonary transition at birth, etiology, and pathophysiology of PPHN.
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California, Davis, California, USA; Department of Pediatrics, Adventist Health Rideout Hospital, Marysville, CA, USA.
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, California, USA.
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19
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Wegele C, Schreiner Y, Perez Ortiz A, Hetjens S, Otto C, Boettcher M, Schaible T, Rafat N. Impact of Time Point of Extracorporeal Membrane Oxygenation on Mortality and Morbidity in Congenital Diaphragmatic Hernia: A Single-Center Case Series. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070986. [PMID: 35883970 PMCID: PMC9315500 DOI: 10.3390/children9070986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022]
Abstract
Since there are no data available on the influence of the time point of ECMO initiation on morbidity and mortality in patients with congenital diaphragmatic hernia (CDH), we investigated whether early initiation of ECMO after birth is associated with a beneficial outcome in severe forms of CDH. All neonates with CDH admitted to our institution between 2010 until 2020 and undergoing ECMO treatment were included in this study and divided into four different groups: (1) ECMO initiation < 12 h after birth (n = 143), (2) ECMO initiation between 12−24 h after birth (n = 31), (3) ECMO initiation between 24−120 h after birth (n = 48) and (4) ECMO initiation > 120 h after birth (n = 14). The mortality rate in the first (34%) and fourth group (43%) was high and in the second group (23%) and third group (12%) rather low. The morbidity, characterized by chronic lung disease (CLD), did not differ significantly in the three groups; only patients in which ECMO was initiated >120 h after birth had an increased rate of severe CLD. Our data, although not randomized and limited due to small study groups, suggest that very early need for ECMO and ECMO initiation > 120 h after birth is associated with increased mortality.
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Affiliation(s)
- Christian Wegele
- Department of Neonatology, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.W.); (Y.S.); (A.P.O.); (T.S.)
- Department of Neonatology, Pediatric Intensive Care and Sleep Medicine, Vestische Kinder-Jugendklinik Datteln, University Witten/Herdecke, 45711 Datteln, Germany
| | - Yannick Schreiner
- Department of Neonatology, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.W.); (Y.S.); (A.P.O.); (T.S.)
| | - Alba Perez Ortiz
- Department of Neonatology, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.W.); (Y.S.); (A.P.O.); (T.S.)
| | - Svetlana Hetjens
- Department of Biomathematics and Medical Statistics, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
| | - Christiane Otto
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
| | - Michael Boettcher
- Department of Pediatric Surgery, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
| | - Thomas Schaible
- Department of Neonatology, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.W.); (Y.S.); (A.P.O.); (T.S.)
| | - Neysan Rafat
- Department of Neonatology, University Children’s Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.W.); (Y.S.); (A.P.O.); (T.S.)
- Correspondence: ; Tel.: +49-(0)621-383-3510
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20
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Aydin E, Torlak N, Haberman B, Lim FY, Peiro JL. The Survivorship Bias in Congenital Diaphragmatic Hernia. CHILDREN 2022; 9:children9020218. [PMID: 35204938 PMCID: PMC8869836 DOI: 10.3390/children9020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 11/16/2022]
Abstract
Current literature for congenital diaphragmatic hernia (CDH) focuses on the comparison of the overall mortality in CDH patients. Only a few studies concentrate on analyzing the unstable patients who could not achieve surgical repair, as well as those who could but did not survive after. Hence, this study aimed to analyze the effects of various parameters on the timing of death. A retrospective analysis was performed by using the data of all CDH patients from 2003 to 2016 at a single tertiary center. Patients who were diagnosed with left-sided CDH and expired were included in the study regardless of the cause. Of the 66 expired patients, 5 were excluded due to right-sided CDH. The study population constituted a total of 61 patients, of which 31 patients expired prior to CDH repair, and 30 patients expired at different times after CDH repair. Multinomial regression analysis identified that the ECMO need (B = 20.257, p = 0.000, OR: 62.756, 95% CI 10.600–371.384) and O/E LHR (B = 20.376, p = 0.000, OR: 70.663, 95% CI 48.716–102.415) values were the independent predictors that influenced mortality in this cohort. Prenatal pulmonary measurements are the major predictors determining the severity of the disease in patients with CDH.
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Affiliation(s)
- Emrah Aydin
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- Department of Pediatric Surgery, Tekirdağ Namık Kemal University School of Medicine, 59030 Tekirdağ, Turkey
- Correspondence:
| | - Nilhan Torlak
- Cellular and Molecular Medicine, Koç University Graduate School of Health Sciences, 34450 Istanbul, Turkey;
| | - Beth Haberman
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Jose L. Peiro
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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21
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Perveen S, Frigeni M, Benveniste H, Kurepa D. Cellular, molecular, and metabolic aspects of developing lungs in congenital diaphragmatic hernia. Front Pediatr 2022; 10:932463. [PMID: 36458148 PMCID: PMC9706094 DOI: 10.3389/fped.2022.932463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shahana Perveen
- Department Pediatrics, Feinstein Institute for Medical Research, New York, NY, United States.,Department of pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States.,Department Pediatrics/Neonatal Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY, United States
| | - Marta Frigeni
- Department of pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | | | - Dalibor Kurepa
- Department Pediatrics/Neonatal Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY, United States
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22
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Ott KC, Bi M, Scorletti F, Ranginwala SA, Marriott WS, Peiro JL, Kline-Fath BM, Alhajjat AM, Shaaban AF. The interplay between prenatal liver growth and lung development in congenital diaphragmatic hernia. Front Pediatr 2022; 10:983492. [PMID: 36225336 PMCID: PMC9548643 DOI: 10.3389/fped.2022.983492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Liver herniation is a known risk factor for increased severity in CDH and is associated with clinically significant pulmonary hypoplasia and pulmonary hypertension. Better studies are needed to understand the growth of the herniated liver compared to the liver that remains in the abdomen and how this liver growth then affects lung development. Serial hi-resolution fetal MRI enables characterization of liver growth throughout gestation and examination of macroscopic features that may regulate liver growth. Here, we hypothesized that the nature of liver herniation affects liver growth and, in turn, affects lung growth. METHODS Clinical data were retrospectively collected from consecutive cases of prenatally diagnosed isolated left-sided or right-sided CDH from June 2006 to August 2021. Only those cases with MRI lung volumetry for both mid-gestation and late-gestation time points were recruited for analysis. Cases with fetal chromosomal abnormalities and other major structural abnormalities were excluded. Fractional liver volume and liver growth was indexed to estimated fetal weight and compared to lung growth. RESULTS Data was collected from 28 fetuses with a left liver-down CDH (LLD), 37 left liver-up CDH (LLU) and 9 right liver-up CDH (RLU). Overall, RLU fetuses had greater overall and fractional (intra-thoracic vs. intra-abdominal) liver growth when compared to LLD and LLU fetuses. Additionally, intra-thoracic liver growth was consistently slower than intra-abdominal liver growth for either right- or left-sided CDH. When the liver was not herniated, a positive correlation was seen between liver growth and lung growth. However, when the liver was herniated above the diaphragm, this positive correlation was lost. CONCLUSION Right-sided CDH fetuses exhibit greater liver growth compared to left-sided CDH. Liver herniation disrupts the normal positive correlation between liver and lung growth that is seen when the liver is entirely within the abdomen.
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Affiliation(s)
- Katherine C Ott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael Bi
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Federico Scorletti
- Neonatal Surgical Unit, Medical and Surgical Department of the Fetus, Newborn and Infant, Bambino Gesù Children's Hospital, Rome, Italy
| | - Saad A Ranginwala
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - William S Marriott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jose L Peiro
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Beth M Kline-Fath
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Amir M Alhajjat
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Aimen F Shaaban
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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23
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Amodeo I, Borzani I, Corsani G, Pesenti N, Raffaeli G, Macchini F, Condò V, Persico N, Ghirardello S, Colnaghi M, Mosca F, Cavallaro G. Fetal MRI mediastinal shift angle and respiratory and cardiovascular pharmacological support in newborns with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:323-334. [PMID: 34302257 DOI: 10.1007/s00431-021-04207-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
In newborns with congenital diaphragmatic hernia (CDH), the mediastinal shift caused by the herniated organs negatively affects lung development. Assessment of the fetal magnetic resonance imaging (MRI) mediastinal shift angle (MSA) was shown to have an inverse correlation with the total fetal lung volume (TFLV), being associated with neonatal survival. However, a possible association with postnatal morbidity has never been investigated. We hypothesize that the degree of the mediastinal shift could be associated with higher respiratory and cardiocirculatory impairment, requiring intensive treatments and extended hospitalization in survivors. We retrospectively consider a cohort of isolated, left-sided CDH, for whom we calculated the MSA and the observed/expected (O/E) TFLV at fetal MRI. We performed a data collection regarding inotropic or vasoactive support, treatment with pulmonary vasodilators, mechanical ventilation, and length of stay. General linear models were performed. The MSA and O/E TFLV were inversely correlated (Pearson's coefficient - 0.65, p < 0.001), and deceased patients showed higher MSA values then survivors (p = 0.011). Among survivors, an increase in MSA was associated with longer pharmacological treatments (dobutamine: p = 0.016; dopamine: p = 0.049; hydrocortisone: p = 0.003; nitric oxide: p = 0.002; sildenafil: p = 0.039; milrinone: p = 0.039; oxygen: p = 0.066), and mechanical ventilation (p = 0.005), with an increasing trend in the length of hospitalization (p = 0.089).Conclusion: The MSA indirectly reflects lung hypoplasia and is associated with a higher neonatal intensity of cares. However, further studies are needed to consolidate the results.Trial registration: The study is an exploratory post hoc analysis of the registered NeoAPACHE protocol at ClinicalTrials.gov with the identifier NCT04396028. What is Known: • In congenital diaphragmatic hernia, the lung size, liver position, and defect side are the most common prenatal prognostic parameters used in clinical practice for morbidity and mortality prediction. • Lung hypoplasia, strictly associated with lung size, is estimated by observed/expected lung to head ratio and observed/expected total fetal lung volume with prenatal ultrasound and fetal magnetic resonance imaging, respectively. What is New: • A new, faster, more straightforward, and less operator-dependent tool to assess CDH severity could be the mediastinal shift angle calculation with fetal magnetic resonance imaging. • Postnatal clinical severity, considered as a postnatal cardiovascular and respiratory impairment that indirectly reflects lung hypoplasia, is associated with an increased mediastinal shift angle calculation.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Corsani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Radiology Unit, Major Hospital, Crema, Italy
| | - Nicola Pesenti
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, 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
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,NICU, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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24
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Wild KT, Bartholomew D, Edwards TM, Froh E, Spatz DL, Huber M, Hedrick HL, Nawab US. Achieving adequate growth in infants with congenital diaphragmatic hernia prior to discharge. J Pediatr Surg 2021; 56:2200-2206. [PMID: 33888352 DOI: 10.1016/j.jpedsurg.2021.03.048] [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: 11/30/2020] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE To evaluate the enteral feeding requirements, including caloric provisions, of infants with CDH in relation to growth patterns. METHODS A retrospective observational study was conducted on infants with CDH between August 2012 and March 2017. Electronic medical records were reviewed to extract detailed infant feeding data and anthropometric measurements at monthly intervals until discharge. Statistical methods of analysis included generalized linear models, Pearson correlation coefficient, Analysis of variance (ANOVA), Kruskal-Wallis, Wilcoxon rank sum, and Fisher's Exact tests. RESULTS Among 149 infants with CDH, 45% (n = 67) met criteria for malnutrition at discharge. Maternal human milk (HM) was initiated in 95% of infants (n = 142) and continued in 79% of infants (n = 118) at discharge. Overall, 50% received fortification of feeds, including 60% (n = 89) of formula fed infants compared to only 21% (n = 31) of HM fed infants (p<0.001). Infants fed formula had lower weight-for-length z-scores at discharge compared to those fed HM. CONCLUSIONS Infants receiving HM demonstrated improved growth compared to formula fed infants. However, higher calorie feeding regimens need to be initiated earlier to improve growth velocity. Prompt recognition of malnutrition and growth failure with aggressive supplementation may improve the overall growth of infants with CDH and has the potential to improve long term neurodevelopmental outcomes.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States; Division of Human Genetics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, United States.
| | - Dana Bartholomew
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Taryn M Edwards
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Elizabeth Froh
- Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, PA, United States; School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Diane L Spatz
- Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, PA, United States; School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew Huber
- Division of Neonatology, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Ursula S Nawab
- Division of Neonatology, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States
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25
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Phillips R, Shahi N, Meier M, Niemiec S, Ogle S, Acker S, Gien J, Liechty KW, Meyers ML, Marwan A. The novel fetal MRI O/E CLV versus O/E LHR in predicting prognosis in congenital diaphragmatic hernias: can we teach an old dog new tricks? Pediatr Surg Int 2021; 37:1499-1504. [PMID: 34505169 DOI: 10.1007/s00383-021-04936-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE In congenital diaphragmatic hernia (CDH), ultrasound (U/S) measurements of the contralateral lung commonly provide the observed-to-expected lung-to-head ratio (O/E LHR) and are used to determine the severity of pulmonary hypoplasia. Fetal magnetic resonance imaging (MRI) measurement of the observed-to-expected total lung volume (O/E TLV) has been used as an adjunct to O/E LHR in predicting outcomes. Since O/E LHR only measures the contralateral lung, we sought to investigate if MRI measurements of the contralateral lung volume (O/E CLV) can accurately predict outcomes in CDH. We hypothesize that O/E CLV is a better predictor of CDH outcomes than O/E LHR. METHODS We identified all infants with a prenatal diagnosis of CDH at our fetal center who had both MRI and U/S measurements. Using lung volume ratios of right-left 55:45, we calculated O/E CLV from O/E TLV. We used receiver-operating characteristic (ROC) curves to calculate the area under the curve (AUC) to compare the predictive accuracy of O/E CLV to O/E LHR for ECMO support, as well as survival to both discharge and 1 year. RESULTS Seventy-four patients had complete prenatal imaging with 39% requiring ECMO support. The median O/E CLV was 48.0% and the median O/E LHR was 42.3%. O/E CLV was a better predictor of the need for ECMO support (AUC 0.81 vs. 0.74). O/E CLV was a better predictor of survival to discharge (AUC 0.84 vs. 0.64) and 1-year survival (AUC 0.83 vs. 0.63) than O/E LHR. CONCLUSION O/E LHR is a well-validated standard for predicting outcomes and guiding prenatal counseling in CDH. We provide evidence that fetal MRI measurements of the contralateral lung volume corrected for gestational age were more accurate in predicting the need for ECMO and survival. Future prospective studies validating O/E CLV regarding outcomes and ECMO utilization are warranted. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA. .,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephen Niemiec
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah Ogle
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason Gien
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, Anschutz Medical Center, University of Colorado Denver, Denver, USA.,Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, Anschutz Medical Center, University of Colorado Denver, Denver, USA.,Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mariana L Meyers
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, Anschutz Medical Center, University of Colorado Denver, Denver, USA
| | - Ahmed Marwan
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, Anschutz Medical Center, University of Colorado Denver, Denver, USA.,Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Stopenski S, Guner YS, Jolley J, Major C, Hatfield T, Ebanks AH, Nguyen DV, Jancelewicz T, Harting MT, Yu PT. Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia. J Surg Res 2021; 270:245-251. [PMID: 34710705 DOI: 10.1016/j.jss.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn. METHODS Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS). RESULTS Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS. CONCLUSIONS Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.
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Affiliation(s)
- Stephen Stopenski
- Department of Surgery, University of California Irvine, Orange, California.
| | - Yigit S Guner
- Department of Surgery, University of California Irvine, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - Jennifer Jolley
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Carol Major
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Tamera Hatfield
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Ashley H Ebanks
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Orange, California
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas
| | - Peter T Yu
- Department of Surgery, University of California Irvine, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
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27
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Jeong J, Lee BS, Cha T, Jung E, Kim EAR, Kim KS, Kim DY, Namgoong JM, Kim SC, Lee MY, Won HS. Prenatal prognostic factors for isolated right congenital diaphragmatic hernia: a single center's experience. BMC Pediatr 2021; 21:460. [PMID: 34666738 PMCID: PMC8526355 DOI: 10.1186/s12887-021-02931-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is relatively rare compared with left-sided congenital diaphragmatic hernia (LCDH). Clinical data of RCDH, especially with respect to antenatal prediction of neonatal outcome, are lacking. The aim of this study was to report the treatment outcomes of patients with antenatally diagnosed RCDH and to evaluate the predictability of observed-to-expected lung area-to-head circumference ratio (O/E LHR) for perinatal outcomes, focused on mortality or extracorporeal membrane oxygenation (ECMO) requirement. METHODS We retrospectively reviewed the medical records of newborn infants with isolated RCDH. We analyzed and compared the clinical and prenatal characteristics including the fetal lung volume, which was measured as the O/E LHR, between the survivors and the non-survivors. RESULTS A total of 26 (66.7%) of 39 patients with isolated RCDH survived to discharge. The O/E LHR was significantly greater in survivors (64.7 ± 21.2) than in non-survivors (40.5 ± 23.4) (P =.027). It was greater in survivors without ECMO requirement (68.3 ± 15.1) than non-survivors or those with ECMO requirement (46.3 ± 19.4; P = .010). The best O/E LHR cut-off value for predicting mortality in isolated RCDH was 50. CONCLUSIONS The findings in this study suggest that O/E LHR, a well-characterized prognostic indicator in LCDH, could be applied to a fetus with antenatally diagnosed RCDH. A large cohort study is required to verify the association between O/E LHR values and the graded severity of RCDH.
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Affiliation(s)
- Jiyoon Jeong
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Byong Sop Lee
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Teahyen Cha
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Euiseok Jung
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Danzer E, Edgar JC, Eppley E, Goldshore MA, Chotzoglou E, Herkert LM, Oliver ER, Rintoul NE, Panitch H, Adzick NS, Hedrick HL, Victoria T. Predicting neonatal outcomes in infants with giant omphalocele using prenatal magnetic resonance imaging calculated observed-to-expected fetal lung volumes. Prenat Diagn 2021; 41:1439-1448. [PMID: 34473853 DOI: 10.1002/pd.6040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/21/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the association between prenatal magnetic resonance imaging (MRI) based observed/expected total lung volume (O/E TLV) and outcome in neonates with giant omphalocele (GO). METHODS Between 06/2004 and 12/2019, 67 cases with isolated GO underwent prenatal and postnatal care at our institution. MRI-based O/E TLVs were calculated based on normative data from Meyers and from Rypens and correlated with postnatal survival and morbidities. O/E TLV scores were grouped based on severity into <25% (severe), between 25% and 50% (moderate), and >50% (mild) for risk stratification. RESULTS O/E TLV was calculated for all patients according to Meyers nomograms and for 49 patients according to Rypens nomograms. Survival for GO neonates with severe, moderate, and mild pulmonary hypoplasia based on Meyers O/E TLV categories was 60%, 92%, and 96%, respectively (p = 0.04). There was a significant inverse association between Meyers O/E TLV and risk of neonatal morbidities (p < 0.05). A similar trend was observed with Rypens O/E TLV, but associations were less often significant likely related to the smaller sample size. CONCLUSION Neonatal outcomes are related to fetal lung size in isolated GO. Assessment of Meyers O/E TLV allows identification of GO fetuses at greatest risk for complications secondary to pulmonary hypoplasia.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - J Christopher Edgar
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Eppley
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew A Goldshore
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Etze Chotzoglou
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard Panitch
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Teresa Victoria
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Soni S, Moldenhauer JS, Kallan MJ, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2021; 48:372-380. [PMID: 33951652 DOI: 10.1159/000515252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
AIM The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37-38 weeks 6 days) versus full term (39-40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated. MATERIAL AND METHODS A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life. RESULTS A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups - 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13-1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis. CONCLUSIONS Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.
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Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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ATS Core Curriculum 2020. Pediatric Pulmonary Medicine. ATS Sch 2020; 1:456-475. [PMID: 33870313 PMCID: PMC8015762 DOI: 10.34197/ats-scholar.2020-0022re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3- to 4-year recurring cycle of topics. These topics will be presented at the 2020 International Conference. Below is the pediatric pulmonary medicine core, including pediatric hypoxemic respiratory failure; modalities in noninvasive management of chronic respiratory failure in childhood; surgical and nonsurgical management of congenital lung malformations; an update on smoke inhalation lung injury; an update on vaporizers, e-cigarettes, and other electronic delivery systems; pulmonary complications of sarcoidosis; pulmonary complications of congenital heart disease; and updates on the management of congenital diaphragmatic hernia.
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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Perrone EE, Abbasi N, Cortes MS, Umar U, Ryan G, Johnson A, Ladino-Torres M, Ruano R. Prenatal assessment of congenital diaphragmatic hernia at north american fetal therapy network centers: A continued plea for standardization. Prenat Diagn 2020; 41:200-206. [PMID: 33125174 DOI: 10.1002/pd.5859] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Prenatal work-up for congenital diaphragmatic hernia (CDH) is important for risk stratification, standardization, counseling, and optimal therapeutic choice. To determine current practice patterns regarding prenatal CDH work-up, including prenatal ultrasound and magnetic resonance imaging (MRI) use, and to identify areas for standardization of such evaluation between fetal centers. METHODS A survey regarding prenatal CDH work-up was sent to each member center of the North American Fetal Therapy Network (NAFTNet) (n = 36). RESULTS All responded. Sonographic measurement of lung-to-head ratio (LHR) was determined by all, 89% (32/36) of which routinely calculate observed-to-expected LHR. The method for measuring LHR varied: 58% (21/36) used a "trace" method, 25% (9/36) used "longest axis," and 17% (6/36) used an "antero-posterior" method. Fetal MRI was routinely used in 78% (28/36) of centers, but there was significant variability in fetal lung volume measurement. Whereas all generated a total fetal lung volume, the planes, methodology and references values varied significantly. All evaluated liver position, 71% (20/28) evaluated stomach position and 54% (15/28) quantified the degree of liver herniation. More consistency in workup was seen between centers offering fetal intervention. CONCLUSION Prenatal CDH work-up and management differs considerably among North American fetal diagnostic centers, highlighting a need for its standardization.
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Affiliation(s)
- Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Uzma Umar
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hospital, University of Texas Health Science Center, Houston, Texas, USA
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo Ruano
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Lakshminrusimha S, Vali P. Congenital diaphragmatic hernia: 25 years of shared knowledge; what about survival? J Pediatr (Rio J) 2020; 96:527-532. [PMID: 31629706 PMCID: PMC7162701 DOI: 10.1016/j.jped.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Payam Vali
- University of California, Department of Pediatrics, Davis, United States.
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Lakshminrusimha S, Vali P. Congenital diaphragmatic hernia: 25 years of shared knowledge; what about survival? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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36
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A single-center observational study on congenital diaphragmatic hernia: Outcome, predictors of mortality and experience from a tertiary perinatal center in Singapore. Pediatr Neonatol 2020; 61:385-392. [PMID: 32276768 DOI: 10.1016/j.pedneo.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/03/2020] [Accepted: 03/05/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a common birth defect associated with significant mortality and morbidity. There is limited outcome data on CDH in the Southeast Asian region. Rapid accessibility to our CDH Perinatal Center, as a consequence of the small geographic size of our country and efficient land transportation system, has largely eliminated deaths of live outborn babies prior arrival at our center. We selected a study period when extracorporeal membrane oxygenation (ECMO) support was not available at our institution. The data will therefore be relevant in developing management guidelines and antenatal counselling for perinatal centers in this region managing CDH with limited resources, without ECMO facilities. METHODS A retrospective study of antenatally or postnatally diagnosed CDH infants born between January 2002 and June 2005 was performed. We selected this study period as ECMO support was not available over this period. We studied the demographics, clinical characteristics, postnatal predictors of mortality and outcomes of CDH infants in a single tertiary institution. RESULTS A total of 24 patients with CDH were identified. Seventy-nine percent of liveborns with CDH survived to hospital discharge. Antenatal detection rate was 83.3%. Significant postnatal predictors of mortality were preoperative pneumothorax (p = 0.035), high CRIB score (p = 0.007), low one- and five-minute Apgar score (p = 0.011, p = 0.026 respectively) and high pCO2 on initial arterial blood gas (p = 0.007). At one-year follow-up, three patients had delayed gross motor milestones which resolved subsequently. Re-admissions were required for recurrent bronchiolitis (33%) and oesophageal reflux which resolved in all cases. Two (13.3%) infants had surgical complications and needed re-admission for probable adhesive intestinal obstruction; one required adhesiolysis and the other was managed conservatively with good outcome. CONCLUSION A single-center CDH outcome in Singapore, without ECMO use, was good. This is a cohort now with long-term survival outcome which will be valuable to the neonatology community.
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Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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38
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Soni S, Moldenhauer JS, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Perinatal Outcomes in Fetuses Prenatally Diagnosed with Congenital Diaphragmatic Hernia and Concomitant Lung Lesions: A 10-Year Review. Fetal Diagn Ther 2020; 47:630-635. [PMID: 32380499 DOI: 10.1159/000507481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/23/2020] [Indexed: 11/19/2022]
Abstract
AIM To describe perinatal outcomes of fetuses with a prenatal diagnosis of a concomitant lung lesion in the setting of congenital diaphragmatic hernia (CDH) and to compare outcomes with an isolated CDH control group without a lung lesion, matched by ultrasound-based prognostic markers including presence of liver herniation and lung measurements. MATERIAL AND METHODS This was a retrospective case-control study, wherein all pregnancies diagnosed with CDH and concomitant lung lesions were identified between July 1, 2008, and December 31, 2018. For each case, 2 controls with isolated CDH from the same study period were selected after matching for the presence of liver herniation into the thoracic cavity and ultrasound-based lung measurements either observed over expected lung-to-head ratio (LHR) or absolute LHR with their corresponding gestational age. The outcomes analyzed in the 2 groups included survival to hospital discharge, neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen (O2) at day 30 of life. RESULTS A total of 21 pregnancies were identified with CDH and a concomitant lung lesion in the study period. All the lung lesions were stratified into a "low-risk category" with a congenital cystic adenomatoid malformation volume ratio of less than 1.0 at the time of presentation. None of these fetuses developed hydrops or required in utero intervention. Overall survival in the group was 80.7% (17/21) and rate of ECMO was 38.1%. Causes of mortality included pulmonary insufficiency, sepsis, renal failure, and bowel infarction. Upon comparison between the cases and controls, the 2 groups were similar with respect to pregnancy demographics. There were no fetal demises in either group. Outcomes including survival rate, NICU LOS, ECMO requirements and need for supplemental O2 at day 30 of life, were comparable among the 2 groups. CONCLUSIONS In our descriptive series, the presence of a concomitant, low-risk lung lesion in the setting of fetal CDH did not have a significant impact on the natural course of the disease, nor was it associated with a worse prognosis.
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Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA, .,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Mank A, Carrasco Carrasco C, Thio M, Clotet J, Pauws SC, DeKoninck P, Te Pas AB. Tidal volumes at birth as predictor for adverse outcome in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2020; 105:248-252. [PMID: 31256011 DOI: 10.1136/archdischild-2018-316504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the predictive value of tidal volume (Vt) of spontaneous breaths at birth in infants with congenital diaphragmatic hernia (CDH). DESIGN Prospective study. SETTING Tertiary neonatal intensive care unit. PATIENTS Thirty infants with antenatally diagnosed CDH born at Hospital Sant Joan de Déu in Barcelona from September 2013 to September 2015. INTERVENTIONS Spontaneous breaths and inflations given in the first 10 min after intubation at birth were recorded using respiratory function monitor. Only expired Vt of uninterrupted spontaneous breaths was included for analysis. Receiver operating characteristics (ROC) analysis was performed and the area under the curve (AUC) was estimated to assess the predictive accuracy of Vt. MAIN OUTCOME MEASURES Mortality before hospital discharge and chronic lung disease (CLD) at day 28 of life. RESULTS There were 1.233 uninterrupted spontaneous breaths measured, and the overall mean Vt was 2.8±2.1 mL/kg. A lower Vt was found in infants who died (n=14) compared with survivors (n=16) (1.7±1.6 vs 3.7±2.1 mL/kg; p=0.008). Vt was lower in infants who died during admission or had CLD (n=20) compared with survivors without CLD (n=10) (2.0±1.7 vs 4.3±2.2 mL/kg; p=0.004). ROC analysis showed that Vt ≤2.2 mL/kg predicted mortality with 79% sensitivity and 81% specificity (AUC=0.77, p=0.013). Vt ≤3.4 mL/kg was a good predictor of death or CLD (AUC=0.80, p=0.008) with 85% sensitivity and 70% specificity. CONCLUSION Vt of spontaneous breaths measured immediately after birth is associated with mortality and CLD. Vt seems to be a reliable predictor but is not an independent predictor after adjustment for observed/expected lung to head ratio and liver position.
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Affiliation(s)
- Arenda Mank
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Cristina Carrasco Carrasco
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Marta Thio
- Newborn Research, Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Jordi Clotet
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Steffen C Pauws
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Tilburg center for Cognition and Communication, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
| | - Philip DeKoninck
- Obstetrics, Erasmus MC, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Cochius-den Otter SCM, Erdem Ö, van Rosmalen J, Schaible T, Peters NCJ, Cohen-Overbeek TE, Capolupo I, Falk CJ, van Heijst AFJ, Schäffelder R, Brindle ME, Tibboel D. Validation of a Prediction Rule for Mortality in Congenital Diaphragmatic Hernia. Pediatrics 2020; 145:peds.2019-2379. [PMID: 32139379 DOI: 10.1542/peds.2019-2379] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly with a mortality of ∼27%. The Congenital Diaphragmatic Hernia Study Group (CDHSG) developed a simple postnatal clinical prediction rule to predict mortality in newborns with CDH. Our aim for this study is to externally validate the CDHSG rule in the European population and to improve its prediction of mortality by adding prenatal variables. METHODS We performed a European multicenter retrospective cohort study and included all newborns diagnosed with unilateral CDH who were born between 2008 and 2015. Newborns born from November 2011 onward were included for the external validation of the rule (n = 343). To improve the prediction rule, we included all patients born between 2008 and 2015 (n = 620) with prenatally diagnosed CDH and collected pre- and postnatal variables. We build a logistic regression model and performed bootstrap resampling and computed calibration plots. RESULTS With our validation data set, the CDHSG rule had an area under the curve of 79.0%, revealing a fair predictive performance. For the new prediction rule, prenatal herniation of the liver was added, and absent 5-minute Apgar score was taken out. The new prediction rule revealed good calibration, and with an area under the curve of 84.6%, it had good discriminative abilities. CONCLUSIONS In this study, we externally validated the CDHSG rule for the European population, which revealed fair predictive performance. The modified rule, with prenatal liver herniation as an additional variable, appears to further improve the model's ability to predict mortality in a population of patients with prenatally diagnosed CDH.
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Affiliation(s)
| | - Özge Erdem
- Intensive Care and Departments of Pediatric Surgery.,Contributed equally as co-first authors
| | | | - Thomas Schaible
- Department of Neonatology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Nina C J Peters
- Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Titia E Cohen-Overbeek
- Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Carolin J Falk
- Department of Neonatology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Arno F J van Heijst
- Division of Neonatology, Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, Netherlands; and
| | - Regina Schäffelder
- Department of Neonatology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Mary E Brindle
- Department of Surgery and Community Health Sciences, University of Calgary and Alberta Children's Hospital, Calgary, Canada
| | - Dick Tibboel
- Intensive Care and Departments of Pediatric Surgery
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Yu PT, Jen HC, Rice-Townsend S, Guner YS. The role of ECMO in the management of congenital diaphragmatic hernia. Semin Perinatol 2020; 44:151166. [PMID: 31472951 DOI: 10.1053/j.semperi.2019.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.
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Affiliation(s)
- Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States
| | - Howard C Jen
- David Geffen School of Medicine at UCLA, Mattel Children's Hospital at UCLA, Los Angeles, CA, United States
| | - Samuel Rice-Townsend
- Department of Pediatric Surgery, Children's Hospital Boston-Harvard Medical School, Boston, MA, United States
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States.
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Paruszewska-Achtel M, Dombek M, Badura M, Elminowska-Wenda G, Dąbrowska M, Grzonkowska M, Baumgart M, Szpinda-Barczyńska A, Szpinda M. Morphometric study of the diaphragmatic surface of the liver in the human fetus. PLoS One 2020; 15:e0227872. [PMID: 31978157 PMCID: PMC6980541 DOI: 10.1371/journal.pone.0227872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/01/2020] [Indexed: 11/19/2022] Open
Abstract
This study aimed to examine age-specific reference intervals and growth dynamics of the best fit for liver dimensions on the diaphragmatic surface of the fetal liver. The research material consisted of 69 human fetuses of both sexes (32♂, 37♀) aged 18–30 weeks. Using methods of anatomical dissection, digital image analysis and statistics, a total of 10 measurements and 2 calculations were performed. No statistical significant differences between sexes were found (p>0.05). The parameters studied displayed growth models that followed natural logarithmic functions. The mean value of the transverse–to–vertical diameter ratio of the liver throughout the analyzed period was 0.71±0.11. The isthmic ratio decreased significantly from 0.81±0.12 in the 18–19th week to 0.62±0.06 in the 26–27th week, and then increased to 0.68±0.11 in the 28–30th week of fetal life (p<0.01). The morphometric parameters of the diaphragmatic surface of the liver present age-specific reference data. No sex differences are found. The transverse–to–vertical diameter ratio supports a proportionate growth of the fetal liver. Quantitative anatomy of the growing liver may be of relevance in both the ultrasound monitoring of the fetal development and the early detection of liver anomalies.
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Affiliation(s)
- Monika Paruszewska-Achtel
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Małgorzata Dombek
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Mateusz Badura
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Gabriela Elminowska-Wenda
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Maria Dąbrowska
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Magdalena Grzonkowska
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Mariusz Baumgart
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | | | - Michał Szpinda
- Department of Normal Anatomy, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, The Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
- * E-mail:
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Al Baroudi S, Collaco JM, Lally PA, Harting MT, Jelin EB. Clinical features and outcomes associated with tracheostomy in congenital diaphragmatic hernia. Pediatr Pulmonol 2020; 55:90-101. [PMID: 31502766 PMCID: PMC7954084 DOI: 10.1002/ppul.24516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/28/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the clinical features/outcomes associated with tracheostomy in infants with congenital diaphragmatic hernia (CDH). METHODS The study population consisted of liveborn infants reported to the CDH Study Group registry between 2007 and 2017. Subjects were identified as having a tracheostomy if they were discharged or transferred to another hospital with tracheostomy and/or on mechanical ventilation. Multivariate mixed models were used for analyses. RESULTS The registry population consisted of 5434 subjects, of whom 230 (4.2%) underwent tracheostomy placement. Only 3830 (70.5%) infants survived until discharge/transfer. The median age of tracheostomy placement was 3.3 months (range, 1.3-13.4 when known; n = 58 out of 154 survivors). The mortality rate among subjects with tracheostomy was 32.8% with a median of 37 days (range, 8-189 when known; n = 32 out of 75 deceased) ensuing between tracheostomy placement and death. The clinical features found to be associated with increased odds ratio of tracheostomy placement included male sex, birth weight, 5-minute APGAR score, defect size, liver in chest, ECMO use, cardiac abnormality, other congenital abnormalities, pulmonary hypertension, and the presence of a feeding tube. There was center variation in the rate of tracheostomy placement, which may be partially accounted for by disease severity, but not center size. CONCLUSION There are several clinical features that are associated with increased likelihood of tracheostomy placement. Most deaths in subjects with tracheostomies occurred outside the immediate postoperative period. The utility of a standardized protocol for tracheostomy in infants with CDH should be considered.
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Affiliation(s)
- Sahar Al Baroudi
- Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph M Collaco
- Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland
| | - Pamela A Lally
- Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Matthew T Harting
- Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Eric B Jelin
- Pediatric Surgery, Johns Hopkins University, Baltimore, Maryland
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Abbasi N, Cortes MS, Ruano R, Johnson A, Morgan T, Coleman B, Baschat A, Zaretsky M, Lim FY, Bulas D, Benachi A, Ryan G. Variability in antenatal prognostication of fetal diaphragmatic hernia across the North American Fetal Therapy Network (NAFTNet). Prenat Diagn 2019; 40:342-350. [PMID: 31600412 DOI: 10.1002/pd.5560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/22/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate variability in antenatal sonographic prognostication of congenital diaphragmatic hernia (CDH) within the North American Fetal Therapy Network (NAFTNet). METHODS NAFTNet centre were invited to complete a questionnaire and participate in videoconference calls, during which participants were observed while measuring lung area by ultrasound using the anteroposterior (AP) method, longest method, and trace method. Each center identified 1-2 experienced fetal medicine specialist(s) or medical imaging specialists locally to participate in the study. Practices were compared among NAFTNet centre within and without the fetal endoscopic tracheal occlusion (FETO) consortium. RESULTS Nineteen participants from 9 FETO center and 30 participants from 17 non-FETO center completed the survey and 31 participants were interviewed and observed while measuring sonographic lung area. All Centres measured observed-to-expected lung-to-head ratio (o/e LHR) or LHR for CDH prognostication. Image selection criteria for lung area measurement were consistent, including an axial section of the chest with clear lung borders and a 4-chamber cardiac view. Lung area measurement methods varied across NAFTNet, with most centre using longest (4/9 FETO vs. 13/29 non-FETO) or trace (3/9 FETO vs. 11/29 non-FETO) method. Centres differed in expected reference ranges for o/e LHR determination and whether the lowest, highest or average o/e LHR was utilized. CONCLUSION Variability in antenatal sonographic prognostication of CDH was identified across NAFTNet, indicating a need for consensus-based standardization.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Magda Sanz Cortes
- Department of Obstetrics & Gynecology, Texas Children's Fetal Center. Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Dept. of Obstetrics & Gynecology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, University of Texas Health Science Centre, Houston, Texas
| | - Tara Morgan
- The Fetal Treatment Center, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Beverly Coleman
- Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Zaretsky
- Colorado Fetal Care Center, Colorado Children's Hospital, University of Colorado, Aurora, Colorado
| | - Foong Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dorothy Bulas
- Children's National Medical System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alexandra Benachi
- Centre Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, Clamart, France.,Service de Gynécologie-Obstétrique, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, Clamart, France
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Tan YW, Ali K, Andradi G, Sasidharan L, Greenough A, Davenport M. Prognostic value of the oxygenation index to predict survival and timing of surgery in infants with congenital diaphragmatic hernia. J Pediatr Surg 2019; 54:1567-1572. [PMID: 30679011 DOI: 10.1016/j.jpedsurg.2018.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 11/25/2022]
Abstract
AIMS To compare the mean oxygenation index on day1 (MOId1) with the best OI on day1 (BOId1) in predicting 30-day mortality in congenital diaphragmatic hernia (CDH). In addition, to determine whether serial OIs in the first 48 h after birth and preoperative OI (PreOp-OI), were associated with optimal timing of surgery, ventilation requirement and hospital stay in infants with CDH. METHODS The medical records of infants with antenatally diagnosed CDH during 2009-2015 were retrospectively reviewed. Receiver operator characteristic curves were constructed to identify MOId1 and BOId1 cutoff levels to predict 30-day mortality. In those who underwent surgery, the mean OI on each of the first two days (MOId1, MOId2) and PreOp-OI were correlated using Spearman (rs) with the age at surgery, the duration of ventilation and length of stay. Statistical significance was P < 0.05* and < 0.001**. RESULTS Survivors (n = 44) and nonsurvivors (n = 24) were comparable in gestational age, birth weight and defect laterality. Nonsurvivors had higher median BOId1 (15.4 vs 2.9; P < 0.01) and MOId1 (48 vs 7.5; p < 0.01) than survivors. Mortality was best predicted by two cutoffs [BOId1 > 6 (sensitivity 92%, specificity 89%); and MOId1 > 17 (sensitivity 96%, specificity 96%)]. Forty-four infants underwent surgery at a median postnatal age of five (range 2-19) days. MOId1 and MOId2 both correlated significantly with the age at surgery (rs = 0.4**, rs 0.5**) but not ventilation period and length of stay. PreOp-OI correlated significantly with age at surgery, duration of ventilation and length of stay (rs = 0.32*, rs = 0.47**, rs = 0.37*). A PreOp-OI <3 was predictive of optimal timing for surgery with improved duration of ventilation (8 vs 22, P = 0.001) and length of stay (26 vs 47, P = 0.004). However, 11/44 (25%) patients would not achieve a PreOp-OI < 3 by day 7+ of life and might still require surgery, one of them died. CONCLUSION Both MOId1 and BOId1 are highly predictive of mortality in CDH. Oxygenation indices in the first 48 h poorly predicted the timing of surgery. PreOp-OI <3 may be a cutoff for optimal timing for surgery in infants for CDH repair. TYPE OF STUDY Prognostic Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yew-Wei Tan
- Department of Paediatric Surgery, King's College Hospital, London SE5 9RS
| | - Kamal Ali
- Department of Neonatology, King's College Hospital, London SE5 9RS
| | - Gwendolyn Andradi
- Division of Asthma Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College, London, UK
| | | | - Anne Greenough
- Division of Asthma Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College, London, UK; NIHR Biomedical Research Centre at Guys & St. Thomas' NHS Foundation Trust and King's College, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London SE5 9RS.
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Gonçalves AN, Correia-Pinto J, Nogueira-Silva C. Imagiological methods for prediction of fetal pulmonary hypoplasia: a systematic review. J Matern Fetal Neonatal Med 2019; 34:1459-1468. [PMID: 31269833 DOI: 10.1080/14767058.2019.1636029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare the different imagiological methods for prediction of fetal pulmonary hypoplasia (PH) in general diseases and associated with preterm rupture of membranes (PROM), and congenital diaphragmatic hernia (CDH). METHODS According to PRISMA guidelines, all the literature on PH from 1988 to 2018 was reviewed. Twenty-nine articles were selected and analyzed for two- and three- dimensional-ultrasounds (2D and 3D-US) as predictors for the lethal outcome. RESULTS Overall, the results identify a general gap correlating prenatal pulmonary measurements and survival at birth; discrepant predictive values for the same imagiological methods are explained by the group heterogeneity in terms of diseases and degree of severity, with the 2D measurements being more affected than 3D; 2D and 3D-US present equally predictive values for groups with 0% of survival. Regarding PROM, results demonstrate comparable accuracies for similar survival rates suggesting a useful predictive value of 2D-US in outcome estimation; they also identify ultrasonographic methods as a more accurate prognostic factor than gestational age at rupture, latency or amniotic fluid index. In CDH, consistent with previous studies, our review shows magnetic resonance imaging as a better survival predictor followed by the 3D and 2D methods, while 2D-LHR was the more precise prognosticator correlating prenatal PH, survival at birth, and the need for neonatal respiratory support. CONCLUSION Ultrasonographic methods can be valuable predictors for lethal PH and should be validated for a broad set of diseases (e.g. PROM). For that, restricted studies for disease groups and correlating fetal PH with the needed of neonatal support, and survival at birth is critically recommended.
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Affiliation(s)
- Ana N Gonçalves
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal.,Life and Health Sciences Research Institute /3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Jorge Correia-Pinto
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal.,Life and Health Sciences Research Institute /3B's - PT Government Associate Laboratory, Braga, Portugal.,Department of Paediatric Surgery, Hospital de Braga, Braga, Portugal
| | - Cristina Nogueira-Silva
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal.,Life and Health Sciences Research Institute /3B's - PT Government Associate Laboratory, Braga, Portugal.,Department of Obstetrics and Gynaecology, Hospital de Braga, Braga, Portugal
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Delaplain PT, Jancelewicz T, Di Nardo M, Zhang L, Yu PT, Cleary JP, Morini F, Harting MT, Nguyen DV, Guner YS. Management preferences in ECMO mode for congenital diaphragmatic hernia. J Pediatr Surg 2019; 54:903-908. [PMID: 30786989 DOI: 10.1016/j.jpedsurg.2019.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 01/27/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO. METHODS A survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics. RESULTS The survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and "other" (2%). The mean annual center volume was 11.6(±9.6) CDH cases, and the average number treated with ECMO was 4.5 (±6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O2 saturation <80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index >40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons. CONCLUSION While there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH. TYPE OF STUDY Qualitative, Survey. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Patrick T Delaplain
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Lishi Zhang
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
| | - John P Cleary
- Children's Hospital of Orange County, Division of Neonatology, Orange, CA
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
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Burgos CM, Frenckner B, Luco M, Harting MT, Lally PA, Lally KP. Prenatally versus postnatally diagnosed congenital diaphragmatic hernia - Side, stage, and outcome. J Pediatr Surg 2019; 54:651-655. [PMID: 29753526 DOI: 10.1016/j.jpedsurg.2018.04.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 11/19/2022]
Abstract
AIM To compare outcomes between prenatally and postnatally diagnosed CDH in a large multicenter database of prospectively collected data and evaluate factors associated with poorer outcome for prenatally diagnosed CDH. MATERIAL AND METHODS We used information from the multicenter, multinational CDH Study Group database on patients born between 2007 and 2015. We compared differences between prenatally and postnatally diagnosed CDH with respect to survival, side, size, ECMO needs, associated major cardiac malformations and liver position. RESULTS 3746 cases of CDH were entered in the registry between 2007 and 2015, with an overall survival of 71%. Of those, 68% had a prenatal diagnosis. Survival rates were significantly better in the postnatally diagnosed group, 83 vs 65%. There was a higher proportion of bigger defect sizes, C and D, in the prenatally diagnosed group, but the survival rates were similar when patients were stratified by defect size. The rate of ECMO utilization was higher overall in the prenatally diagnosed group, 33 vs 22%, but it was similar within similar defect sizes. Right-sided defects are more commonly missed at prenatal screening than left-sided CDH, 53 vs 35% (p < 0.0001). CONCLUSIONS Prenatally diagnosed CDH is associated with larger defect sizes compared to those with a postnatal diagnosis, and consequently have higher morbidity and mortality. Right-sided CDH are more often missed at prenatal ultrasound. The increasing rate of prenatal detection requires a clear understanding of accurate risk stratification, in order to counsel families and to provide appropriate perinatal management. LEVEL OF EVIDENCE I for a Prognosis Study - This is a high-quality, prospective cohort study with 99% of patients followed to the study end point (death or discharge).
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Affiliation(s)
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Matias Luco
- Department of Neonatology, School of Medicine Pontificia Universidad Católica de, Chile
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
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Kamishima Y. [5. Magnetic Resonance Imaging of Pregnancy and Fetus 5-2. Diagnostic Imaging of the Pregnancy and Fetus]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2019; 74:1480-1488. [PMID: 30568100 DOI: 10.6009/jjrt.2018_jsrt_74.12.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yuki Kamishima
- Nagoya City West Medical Center Department of Radiology, Department of Radiology, Nagoya City University Graduate School of Medical Sciences
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50
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Aydin E, Lim FY, Kingma P, Haberman B, Rymeski B, Burns P, Peiro JL. Congenital diaphragmatic hernia: the good, the bad, and the tough. Pediatr Surg Int 2019; 35:303-313. [PMID: 30680439 DOI: 10.1007/s00383-019-04442-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES We aim to determine factors that are associated with better outcomes of CDH patients. METHODS A retrospective review was performed on all CDH patients admitted to our institution between 2003 and 2016. This study was performed at a single institution which has a fetal care center. Patients admitted with CDH with at least 1-year follow-up during the analysis were included in the study. RESULTS Twenty-six (13.8%) patients had a hernia sac, 124 (59%) patients had liver herniation, and 56 (25.1%) patients had an accompanying syndrome. Overall survival to discharge was 73.1% while overall survival to date was 69.5%. The presence of a hernia sac, liver herniation, and accompanying syndromes showed as independent predictors influencing the survival, B 1.968, p = 0.04, OR 7.158, 95% CI 0.907-56.485, B - 1.178, p = 0.01, OR 3.932, 95% CI 1.798-8.602 and B - 1.032, p = 0.05, OR 2.795, 95% CI 0.976-7.764, respectively. CONCLUSION In our CDH cohort, the presence of a hernia sac was proven to be associated with better outcomes, while thoracic herniation of the liver was associated with worse outcomes. The accompanying syndromes although being more difficult to manage had a little effect on the outcome of the disease itself.
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Affiliation(s)
- Emrah Aydin
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA.
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Paul Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Haberman
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose L Peiro
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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