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Park SH, Kim JY, Seol KH, Roh JH, Lee HN, Kim SH, Jeong J, Namgoong JM, Lee BS, Jung E. Pulmonary Artery Measurements as Postnatal Prognostic Tool in Right Congenital Diaphragmatic Hernia. J Pediatr Surg 2024; 59:1077-1082. [PMID: 38168548 DOI: 10.1016/j.jpedsurg.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is a rare and often fatal congenital anomaly, primarily attributed to lung hypoplasia, which is associated with small branch pulmonary artery (PA). This study investigated whether postnatal PA measurements obtained through echocardiography are associated with mortality or the extracorporeal membrane oxygenation (ECMO) requirement in neonates with RCDH. METHODS A retrospective study was conducted on neonates with RCDH born between 2008 and 2022. Echocardiography was performed on the day of birth. The diameter of the main PA (MPA) was measured at the maximal dimension, and the diameters of the left PA (LPA) and right PA (RPA) were measured at the bifurcation. The primary outcome was mortality or ECMO requirement. Parameters, including the LPA:MPA ratio, RPA:MPA ratio, Nakata index, McGoon ratio, and ejection fraction (EF), were analyzed and compared with the observed-to-expected lung-to-head ratio (o/e LHR), initial blood gas, and defect size as predictive values. RESULTS Among 39 neonates with RCDH, 25 (64.1 %) survived without ECMO. The non-survivor or ECMO group exhibited lower o/e LHR, reduced EF, smaller LPA and RPA diameters, and larger MPA diameter than survivors. Lower LPA:MPA ratio, Nakata index, McGoon ratio, and higher initial PaCO2 were associated with adverse outcomes. Notably, the LPA:MPA ratio showed the highest predictive capability (area under the curve, 0.983; p < 0.001). CONCLUSION The LPA:MPA ratio is a promising postnatal predictor of mortality or ECMO requirement in neonates with RCDH. Additionally, Nakata index, McGoon ratio, and initial PaCO2 are significantly correlated with outcomes. LEVEL OF EVIDENCE This is a level III. TYPE OF STUDY Prognostic study.
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Affiliation(s)
- Sung Hyeon Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Yoo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keon Hee Seol
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joo Hyung Roh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha Na Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiyoon Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Sloan P, Johng S, Daniel JM, Rhee CJ, Mahmood B, Gravari E, Marshall S, Downey AG, Braski K, Gowda SH, Fernandes CJ, Dariya V, Haberman BE, Seabrook R, Makkar A, Gray BW, Cookson MW, Najaf T, Rintoul N, Hedrick HL, DiGeronimo R, Weems MF, Ades A, Chapman R, Grover TR, Keene S. A clinical consensus guideline for nutrition in infants with congenital diaphragmatic hernia from birth through discharge. J Perinatol 2024; 44:694-701. [PMID: 38627594 DOI: 10.1038/s41372-024-01965-9] [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: 11/30/2023] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.
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Affiliation(s)
- Patrick Sloan
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA.
| | - Sandy Johng
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - John M Daniel
- Department of Pediatrics, Division of Neonatology, University of Missouri Kansas School of Medicine, Kansas City, MO, USA
| | - Christopher J Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evangelia Gravari
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Ann G Downey
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katie Braski
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sharada H Gowda
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Beth E Haberman
- Department of Pediatrics, Division of Neonatology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Seabrook
- Department of Pediatrics, Division of Neonatology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Abhishek Makkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Tasnim Najaf
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA
| | - Natalie Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark F Weems
- Division of Neonatology and Le Bonheur Children's Hospital, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Theresa R Grover
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Keene
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, 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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4
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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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Smithers CJ, Zalieckas JM, Rice-Townsend SE, Kamran A, Zurakowski D, Buchmiller TL. The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk. J Pediatr Surg 2023; 58:1656-1662. [PMID: 36709093 DOI: 10.1016/j.jpedsurg.2022.12.030] [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: 08/17/2022] [Revised: 12/11/2022] [Accepted: 12/25/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion. METHODS A retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression. RESULTS 102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48-39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20-85) vs. those who did not (median 9 mg/dL, IQR 7-13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737). CONCLUSION We demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, United States.
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA 98105, United States
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
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Lakshminrusimha S, Fraga MV. Longitudinal Trajectory of Ventricular Function and Pulmonary Hypertension in Congenital Diaphragmatic Hernia. J Pediatr 2023; 260:113550. [PMID: 37315779 DOI: 10.1016/j.jpeds.2023.113550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, UC Davis Children's Hospital, Sacramento, California.
| | - María V Fraga
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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8
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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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Abstract
Congenital diaphragmatic hernia (CDH) is a challenging surgical disease that requires complex preoperative, perioperative, and postoperative care. Survival depends on successful reduction and repair of the defect, and numerous complex decisions must be made regarding timing and preparation for surgery. This review describes the challenges and controversies inherent to surgical CDH care and provides recommendations for management based on the most recent evidence.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, Children's Memorial Hermann Hospital, University of Texas McGovern Medical School, 6431 Fannin Street, MSB: 5.233, Houston, TX 77030, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap Street Second Floor, Memphis, TN 38105, USA.
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10
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Jancelewicz T, Langham MR, Brindle ME, Stiles ZE, Lally PA, Dong L, Wan JY, Guner YS, Harting MT. Survival Benefit Associated With the Use of Extracorporeal Life Support for Neonates With Congenital Diaphragmatic Hernia. Ann Surg 2022; 275:e256-e263. [PMID: 33060376 DOI: 10.1097/sla.0000000000003928] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To measure the survival among comparable neonates with CDH supported with and without ECLS. SUMMARY OF BACKGROUND DATA Despite widespread use in the management of newborns with CDH, ECLS has not been consistently associated with improved survival. METHODS A retrospective cohort study was performed using ECLS-eligible CDH Study Group registry patients born between 2007 and 2019. The primary outcome was in-hospital mortality. Neonates who did and did not receive ECLS were matched based on variables affecting risk for the primary outcome. Iterative propensity score-matched, survival (Cox regression and Kaplan-Meier), and center effects analyses were performed to examine the association of ECLS use and mortality. RESULTS Of 5855 ECLS-eligible CDH patients, 1701 (29.1%) received ECLS. "High-risk" patients were best defined as those with a lowest achievable first-day arterial partial pressure of CO2 of ≥60 mm Hg. After propensity score matching, mortality was higher with ECLS (47.8% vs 21.8%, odds ratio 3.3, 95% confidence interval 2.7-4.0, hazard ratio 2.3, P < 0.0001). For the subgroup of high-risk patients, there was lower mortality observed with ECLS (64.2% vs 84.4%, odds ratio 0.33, 95% confidence interval 0.17-0.65, hazard ratio 0.33, P = 0.001). This survival advantage was persistent using multiple matching approaches. However, this ECLS survival advantage was found to occur primarily at high CDH volume centers that offer frequent ECLS for the high-risk subgroup. CONCLUSIONS Use of ECLS is associated with excess mortality for low- and intermediate-risk neonates with CDH. It is associated with a significant survival advantage among high-risk infants, and this advantage is strongly influenced by center CDH volume and ECLS experience.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Max R Langham
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Zachary E Stiles
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Pamela A Lally
- McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Lei Dong
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jim Y Wan
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yigit S Guner
- Children's Hospital of Orange County, University of California Irvine, Orange, California
| | - Matthew T Harting
- McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
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Yang MJ, Russell KW, Yoder BA, Fenton SJ. Congenital diaphragmatic hernia: a narrative review of controversies in neonatal management. Transl Pediatr 2021; 10:1432-1447. [PMID: 34189103 PMCID: PMC8192986 DOI: 10.21037/tp-20-142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The consequences of most hernias can be immediately corrected by surgical repair. However, this isn't always the case for children born with a congenital diaphragmatic hernia. The derangements in physiology encountered immediately after birth result from pulmonary hypoplasia and hypertension caused by herniation of abdominal contents into the chest early in lung development. This degree of physiologic compromise can vary from mild to severe. Postnatal management of these children remains controversial. Although heavily studied, multi-institutional randomized controlled trials are lacking to help determine what constitutes best practice. Additionally, the results of the many studies currently within the literature that have investigated differing aspect of care (i.e., inhaled nitric oxide, ventilator type, timing of repair, role of extracorporeal membrane oxygenation, etc.) are difficult to interpret due to the small numbers investigated, the varying degree of physiologic compromise, and the contrasting care that exists between institutions. The aim of this paper is to review areas of controversy in the care of these complex kids, mainly: the use of fraction of inspired oxygen, surfactant therapy, gentle ventilation, mode of ventilation, medical management of pulmonary hypertension (inhaled nitric oxide, sildenafil, milrinone, bosentan, prostaglandins), the utilization of extracorporeal membrane oxygenation, and the timing of surgical repair.
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Affiliation(s)
- Michelle J Yang
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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12
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Patel N, Lally PA, Kipfmueller F, Massolo AC, Luco M, Van Meurs KP, Lally KP, Harting MT. Ventricular Dysfunction Is a Critical Determinant of Mortality in Congenital Diaphragmatic Hernia. Am J Respir Crit Care Med 2020; 200:1522-1530. [PMID: 31409095 DOI: 10.1164/rccm.201904-0731oc] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale: Congenital diaphragmatic hernia (CDH) is an anomaly with a high morbidity and mortality. Cardiac dysfunction may be an important and underrecognized contributor to CDH pathophysiology and determinant of disease severity.Objectives: Our aim was to investigate the association between early, postnatal ventricular dysfunction and outcome among infants with CDH.Methods: Multicenter, prospectively collected data in the CDH Study Group (CDHSG) registry, abstracted between 2015 and 2018, were evaluated. Ventricular function on early echocardiograms, defined as obtained within the first 48 hours of life, was categorized into four hierarchical groups: normal function, right ventricular dysfunction only (RVdys), left ventricular dysfunction only (LVdys), and combined RV and LV dysfunction (RV&LVdys). Univariate, multivariate, and Cox proportional hazards regression analyses were performed.Measurements and Main Results: Cardiac function data from early echocardiograms were available for 1,173 (71%) cases and categorized as normal in 711 (61%), RVdys in 182 (15%), LVdys in 61 (5%), and combined RV&LVdys in 219 (19%) cases. Ventricular dysfunction was significantly associated with prenatal diagnosis, CDHSG stage, intrathoracic liver, and patch repair (all P < 0.001). Survival varied by category: normal function, 80%; RVdys, 74%; LVdys, 57%; and RV&LVdys, 51% (P < 0.001). The adjusted risk of death (hazard ratio) for cases with LVdys was 1.96 (95% confidence interval [CI], 1.29-2.98; P = 0.020) and for cases with RV&LVdys was 2.27 (95% CI, 1.77-2.92; P = 0.011). All cardiac dysfunction categories were associated with use of extracorporeal membrane oxygenation (P < 0.005).Conclusions: Early ventricular dysfunction occurs frequently in CDH and is an independent determinant of severity and clinical outcome.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn, Bonn, Germany
| | - Anna Claudia Massolo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Scientific Institute for Research, Hospitalization and Healthcare, Rome, Italy
| | - Matias Luco
- Department of Neonatology, Pontifical Catholic University of Chile, Santiago, Chile; and
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
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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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Abstract
Because congenital diaphragmatic hernia (CDH) is characterized by a spectrum of severity, risk stratification is an essential component of care. In both the prenatal and postnatal periods, accurate prediction of outcomes may inform clinical decision-making, care planning, and resource allocation. This review examines the history and utility of the most well-established risk prediction tools currently available, and provides recommendations for their optimal use in the management of CDH patients.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap St., Second Floor, Memphis, TN, 38112, USA.
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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15
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Risk-stratification enables accurate single-center outcomes assessment in congenital diaphragmatic hernia (CDH). J Pediatr Surg 2019; 54:932-936. [PMID: 30792092 DOI: 10.1016/j.jpedsurg.2019.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 01/27/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Management of CDH is highly variable from center to center, as are patient outcomes. The purpose of this study was to examine risk-stratified survival and extracorporeal membrane oxygenation (ECMO) rates at a single center, and to determine whether adverse outcomes are related to patient characteristics or management. METHODS A retrospective single-center review of CDH patients was performed, and outcomes compared to those reported by the CDH Study Group (CDHSG) registry. Patient demographics, disparities, and clinical characteristics were examined to identify unique features of the cohort. A model derived using the registry that estimates probability of ECMO use or death in CDH newborns was used to risk-stratify patients and assess mortality rates. Observed over expected (O/E) ECMO use rates were calculated to measure whether "excess" or "appropriate" ECMO use was occurring. RESULTS There were 81 CDH patients treated between 2004-2017, and 5034 in the CDHSG registry. Mortality in ECMO-treated patients was higher than the registry. Socioeconomic variables were not significantly associated with outcomes. The strongest predictors of mortality were ECMO use and early blood gas variables. The risk model accurately predicted ECMO use with a c-statistic of 0.79. Compared with the registry, the disparity in mortality rates was greatest for moderate-risk patients. O/E ECMO use was highest in low and moderate-risk patients. CONCLUSIONS ECMO use is a more consistent predictor of mortality than CDH severity at a single center, and there is relative overuse of ECMO in lower-risk patients. Risk stratification allows for more accurate institutional assessment of mortality and ECMO use, and other centers could consider such an adjusted analysis to identify opportunities for outcomes improvement. LEVEL OF EVIDENCE III.
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16
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Sekhon MK, Fenton SJ, Yoder BA. Comparison of early postnatal prediction models for survival in congenital diaphragmatic hernia. J Perinatol 2019; 39:654-660. [PMID: 30770879 DOI: 10.1038/s41372-019-0335-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the PF-PCO2 equation-partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) minus partial pressure of carbon dioxide (PCO2)-to three other tools for postnatal prediction of survival in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN A retrospective analysis of 203 infants with CDH from 1 January 2003 to 30 June 2018. Area under the curve (AUC) analysis was performed for survival and secondary outcomes of survival without extracorporeal membrane oxygenation support (ECMO) and death despite ECMO. Predictive scores were calculated to determine cutoff for PF-PCO2 score. RESULTS The PF-PCO2 tool had the highest AUC (0.84 for survival, 0.92 for survival without ECMO, and 0.83 for death despite ECMO). PF-PCO2 best predicted survival when >-60 and survival without ECMO when >+80. There was no optimal cutoff score for death despite ECMO. CONCLUSION The PF-PCO2 tool best predicted postnatal survival in infants with CDH.
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Affiliation(s)
- Mehtab K Sekhon
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA
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17
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Rafat N, Schaible T. Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia. Front Pediatr 2019; 7:336. [PMID: 31440491 PMCID: PMC6694279 DOI: 10.3389/fped.2019.00336] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/24/2019] [Indexed: 01/04/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by failure of diaphragmatic development with lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). If conventional treatment with gentle ventilation and optimized vasoactive medication fails, extracorporeal membrane oxygenation (ECMO) may be considered. The benefits of ECMO in CDH are still controversial, since there are only few randomized trials demonstrating the advantages of this therapeutic option. At present, there is no precise prenatal and/or early postnatal prognostication parameter to predict reversibility of PPHN in CDH patients. Indications for initiating ECMO include either respiratory or circulatory parameters, which are also undergoing continuous refinement. Centers with higher case numbers and the availability of ECMO published promising survival rates, but data on long-term results, including morbidity and quality of life, are rare. Survival might be influenced by the timing of ECMO initiation and the timing of surgical repair. In this regard a trend toward early initiation of ECMO and early surgery on ECMO exists. The results concerning the cannulation modes are similar and a consensus on time limit for ECMO runs does not exist. The use of ECMO in CDH will continue to be evaluated, and prospective randomized trials and registry network are necessary to help answering the addressed questions of patient selection and management.
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Affiliation(s)
- Neysan Rafat
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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Jancelewicz T, Brindle ME, Harting MT, Tolley EA, Langham MR, Lally PA, Gosain A, Storgion SA, Kays DW. Extracorporeal Membrane Oxygenation (ECMO) Risk Stratification in Newborns with Congenital Diaphragmatic Hernia (CDH). J Pediatr Surg 2018; 53:1890-1895. [PMID: 29754878 DOI: 10.1016/j.jpedsurg.2018.04.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 03/05/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A means for early postnatal stratification of ECMO risk in CDH newborns could be used to comparatively assess the utilization and outcomes of ECMO use between centers. While multiple CDH mortality risk calculators are available, no validated tool exists specifically for prediction of ECMO use. The purpose of this study was to derive and validate an ECMO risk stratification model. METHODS The study population was obtained from CDH Study Group registry for the period between 2007 and 2016. Only centers offering ECMO were included. The cohort was restricted to ECMO candidates and then divided into derivation and validation sets. Using all relevant perinatal predictors in the registry, univariate analysis was performed for the composite outcome of ECMO use or death without ECMO use. The model was derived using the derivation cohort with multivariable logistic regression and automatic stepwise forward selection (P < 0.05 for qualifying variables), and a c-statistic was obtained. The model was then tested on the validation cohort. Sample reuse validation and bootstrap validation were performed. The validated model was then tested for accuracy on CDH subgroups. RESULTS There were 1992 patients in the derivation cohort. Four significant variables were identified in the final ECMO risk model: 1-min and 5-min Apgar scores and highest and lowest post-ductal partial pressure of CO2 during the first 24 h of life. The model c-statistic was 0.824 which was confirmed with cross-validation and bootstrap optimism correction. The validation cohort c-statistic was 0.823 (N = 993). The model had good discrimination for left and right CDH, inborn and outborn patients, patients born before and after 2011, and high and low volume centers. The model performed significantly better for postnatally diagnosed patients. CONCLUSIONS This study represents proof-of-concept that a risk model can accurately estimate the probability of ECMO use in CDH newborns. This stratification could assist centers as a metric for assessment of ECMO usage and outcomes. Refinement and prospective validation of this model should be carried out prior to clinical application. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Mary E Brindle
- Alberta Children's Hospital and Cumming Medical School, University of Calgary, Calgary, AB, Canada
| | - Matthew T Harting
- University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Elizabeth A Tolley
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Max R Langham
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pamela A Lally
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ankush Gosain
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephanie A Storgion
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David W Kays
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Glenn IC, Abdulhai S, McNinch NL, Lally PA, Ponsky TA, Schlager A. Evaluating the utility of the "late ECMO repair": a congenital diaphragmatic hernia study group investigation. Pediatr Surg Int 2018; 34:721-726. [PMID: 29808279 DOI: 10.1007/s00383-018-4283-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Optimal timing of congenital diaphragmatic hernia (CDH) repair in patients requiring extracorporeal membrane oxygenation (ECMO) remains controversial. The "late ECMO repair" is an approach where the patient, once deemed stable for decannulation, is repaired while still on ECMO to enable expeditious return to ECMO if surgery induces instability. The goal of this study was to investigate the potential benefit of this approach by evaluating the rate of return to ECMO after repair. METHODS The CDH Study Group database was used to analyze CDH patients requiring ECMO support. The primary outcome was return to ECMO within 72 h of CDH repair among those repaired following ECMO decannulation ("post-ECMO" patients). Secondary outcomes were death within 72 h of repair and cumulative death and return to ECMO rate. RESULTS A total of 668 patients were repaired post-ECMO decannulation. Six patients (0.9%) in the post-ECMO group required return to ECMO within 72 h of surgery and a total of 19 (2.8%) died or returned to ECMO within 72 h of surgery. CONCLUSION The rate of return to ECMO and death following CDH repair is extremely low and does not justify the risks inherent to "on-ECMO" repair. Patients stable to come off ECMO should undergo repair after decannulation.
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Affiliation(s)
- Ian C Glenn
- Department of Surgery, Akron Children's Hospital, 1 Perkins Sq, Ste 8400, Akron, OH, 44308, USA
| | - Sophia Abdulhai
- Department of Surgery, Akron Children's Hospital, 1 Perkins Sq, Ste 8400, Akron, OH, 44308, USA
| | - Neil L McNinch
- Akron Children's Hospital, Rebecca D. Considine Research Institute, 130 W. Exchange St, Akron, OH, 44302, USA
| | - Pamela A Lally
- Department of Pediatric Surgery and Children's Memorial Hermann Hospital, The University of Texas McGovern Medical School, Suite 5.258, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Todd A Ponsky
- Department of Surgery, Akron Children's Hospital, 1 Perkins Sq, Ste 8400, Akron, OH, 44308, USA
| | - Avraham Schlager
- Department of Surgery, Akron Children's Hospital, 1 Perkins Sq, Ste 8400, Akron, OH, 44308, USA.
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21
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Robertson JO, Criss CN, Hsieh LB, Matsuko N, Gish JS, Mon RA, Johnson KN, Hirschl RB, Mychaliska GB, Gadepalli SK. Comparison of early versus delayed strategies for repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation. J Pediatr Surg 2018; 53:629-634. [PMID: 29173775 DOI: 10.1016/j.jpedsurg.2017.10.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 09/11/2017] [Accepted: 10/20/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE For the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies. METHODS From 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤5days after cannulation ("early protocol", n=30) and >5days after cannulation or after de-cannulation ("late protocol", n=35). We used Cox regression to assess differences in outcomes between groups. RESULTS Survival for the early and late protocol groups was 43.3% and 68.8%, respectively (p=0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8±7.4 vs. 12.6±6.8days, p=0.0216). After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR=3.48, 95% CI=1.28-9.45, p=0.015) and days on ECMO (IRR=1.39, 95% CI=1.07-1.79, p=0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44). CONCLUSIONS Our data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jason O Robertson
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Cory N Criss
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Lily B Hsieh
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Niki Matsuko
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Josh S Gish
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Rodrigo A Mon
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Kevin N Johnson
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Ronald B Hirschl
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - George B Mychaliska
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
| | - Samir K Gadepalli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI.
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22
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McHoney M, Hammond P. Role of ECMO in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2018; 103:F178-F181. [PMID: 29138242 DOI: 10.1136/archdischild-2016-311707] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 10/20/2017] [Accepted: 10/28/2017] [Indexed: 01/06/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is typified morphologically by failure of diaphragmatic development with accompanying lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). Patients who have labile physiology and low preductal saturations despite optimal ventilatory and inotropic support may be considered for extracorporeal membrane oxygenation (ECMO). Systematic reviews into the benefits of ECMO in CDH concluded that any benefit is unclear. Few randomised trials exist to demonstrate clear benefit and guide management. However, ECMO may have its uses in those that have reversibility of their respiratory disease. A few centres and networks have demonstrated an increase in survival rate by post hoc analysis (based on a difference in referral patterns with the availability of ECMO) in their series. One issue may be that of careful patient selection with regard to reversibility of pathophysiology. At present, there is no single test or prognostication that predicts reversibility of PPHN and criteria for referral for ECMO is undergoing continued refinement. Overall survival is similar between cannulation modes. There is no consensus on the time limit for ECMO runs. The optimal timing of surgery for patients on ECMO is difficult to definitively establish, but it seems that repair at an early stage (with careful perioperative management) is becoming less of a taboo, and may improve outcome and help with either coming off ECMO or decisions on withdrawal later. The provision of ECMO will continue to be evaluated, and prospective randomised trial are needed to help answer question of patient selection and management.
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Affiliation(s)
- Merrill McHoney
- Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
| | - Philip Hammond
- Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
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23
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Deeney S, Howley LW, Hodges M, Liechty KW, Marwan AI, Gien J, Kinsella JP, Crombleholme TM. Impact of Objective Echocardiographic Criteria for Timing of Congenital Diaphragmatic Hernia Repair. J Pediatr 2018; 192:99-104.e4. [PMID: 29106923 DOI: 10.1016/j.jpeds.2017.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 07/27/2017] [Accepted: 09/06/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the impact of specific echocardiographic criteria for timing of congenital diaphragmatic hernia repair on the incidence of acute postoperative clinical decompensation from pulmonary hypertensive crisis and/or acute respiratory decompensation, with secondary outcomes including survival to discharge, duration of ventilator support, and length of hospitalization. STUDY DESIGN The multidisciplinary congenital diaphragmatic hernia management team instituted a protocol in 2012 requiring the specific criterion of echocardiogram-estimated pulmonary artery pressure ≤80% systemic blood pressure before repairing congenital diaphragmatic hernias. A retrospective review of 77 neonatal patients with Bochdalek hernias repaired between 2008 and 2015 were reviewed: group 1 included patients repaired before protocol implementation (n = 25) and group 2 included patients repaired after implementation (n = 52). RESULTS The groups had similar baseline characteristics. Postoperative decompensation occurred less often in group 2 compared with group 1 (17% vs 48%, P = .01). Adjusted analysis accounting for repair type, liver herniation, and prematurity yielded similar results (15% vs 37%, P = .04). Group 2 displayed a trend toward improved survival to 30 days postoperatively, though this did not reach statistical significance (94% vs 80%, P = .06). Patient survival to discharge, duration of ventilator support, and length of hospitalization were not different between groups. CONCLUSIONS The implementation of a protocol requiring echocardiogram-estimated pulmonary arterial pressure ≤80% of systemic pressure before congenital diaphragmatic hernia repair may reduce the incidence of acute postoperative decompensation, although there was no difference in longer-term secondary outcomes, including survival to discharge.
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Affiliation(s)
- Scott Deeney
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lisa W Howley
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Maggie Hodges
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kenneth W Liechty
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Ahmed I Marwan
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Jason Gien
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Timothy M Crombleholme
- The Colorado Fetal Care Center, Divisions of Pediatric General, Thoracic and Fetal Surgery, Pediatric Cardiology, Neonatology, and Multidisciplinary Congenital Diaphragmatic Hernia Management Team, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
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Short-Term Neurodevelopmental Outcome in Congenital Diaphragmatic Hernia: The Impact of Extracorporeal Membrane Oxygenation and Timing of Repair. Pediatr Crit Care Med 2018; 19:64-74. [PMID: 29303891 DOI: 10.1097/pcc.0000000000001406] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the need and timing of extracorporeal membrane oxygenation in relation to congenital diaphragmatic hernia repair as modifiers of short-term neurodevelopmental outcomes. DESIGN Retrospective study. SETTING A specialized tertiary care center. PATIENTS Between June 2004 and February 2016, a total of 212 congenital diaphragmatic hernia survivors enrolled in our follow-up program. Neurodevelopmental outcome was assessed at a median age of 22 months (range, 5-37) using the Bayley Scales of Infant Development, third edition. Fifty patients (24%) required extracorporeal membrane oxygenation support. Four patients (8%) were repaired prior to cannulation, 25 (50%) were repaired on extracorporeal membrane oxygenation, and 21 (42%) were repaired after decannulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children with congenital diaphragmatic hernia, who required extracorporeal membrane oxygenation scored on average 4.6 points lower on cognitive composite (p = 0.031) and 9.2 points lower on the motor composite (p < 0.001). Language scores were similar between groups. Mean scores for children with congenital diaphragmatic hernia repaired on extracorporeal membrane oxygenation were significantly lower for cognition (p = 0.021) and motor (p = 0.0005) outcome. Language scores were also lower, but did not reach significance. A total of 40% of children repaired on extracorporeal membrane oxygenation scored below average in all composites, whereas only 9% of the non-extracorporeal membrane oxygenation, 4% of the repaired post-extracorporeal membrane oxygenation, and 25% of the repaired pre-extracorporeal membrane oxygenation patients scored below average across all domains. Only 20% of congenital diaphragmatic hernia survivors repaired on extracorporeal membrane oxygenation support scored within the average range for all composite domains. Duration of extracorporeal membrane oxygenation support was not associated with a higher likelihood of adverse cognitive (p = 0.641), language (p = 0.147), or motor (p = 0.720) outcome. CONCLUSIONS Need for extracorporeal membrane oxygenation in congenital diaphragmatic hernia survivors is associated with worse neurocognitive and neuromotor outcome. Need for congenital diaphragmatic hernia repair while on extracorporeal membrane oxygenation is associated with deficits in multiple domains. Overall time on extracorporeal membrane oxygenation did not impact neurodevelopmental outcome.
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Abstract
Despite wide use and decades of experience, survival of congenital diaphragmatic hernia (CDH) patients treated with extra-corporeal membrane oxygenation (ECMO), as reported by the extra-corporeal life support organization (ELSO), remains unchanged at 50%. High-survival rates both with and without utilizing ECMO have been reported, fueling questions about the utility of ECMO support in this difficult population. This review looks at data from the Congenital Diaphragmatic Hernia Study Group and individual center reports, to evaluate the role of ECMO in CDH, focusing on defining the patients most likely to benefit, and discussing how those benefits can best be achieved. These data show that ECMO improves survival in those CDH patients who are most severely affected, but potential complications of ECMO delivery outweigh benefit in patients with less severely affected. Improved results can be expected by minimizing ECMO complications, and by improving rates of CDH repair in patients that require ECMO.
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Affiliation(s)
- David W Kays
- Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Division of Pediatric Surgery, 601 5th St South, Suite 306, St. Petersburg, Florida 33701.
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Morgan TA, Shum DJ, Basta AM, Filly RA. Prognosis in Congenital Diaphragmatic Hernia Diagnosed During Fetal Life. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vaja R, Bakr A, Sharkey A, Joshi V, Faulkner G, Westrope C, Harvey C. The use of extracorporeal membrane oxygenation in neonates with severe congenital diaphragmatic hernia: a 26-year experience from a tertiary centre†. Eur J Cardiothorac Surg 2017; 52:552-557. [DOI: 10.1093/ejcts/ezx120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/17/2017] [Indexed: 01/13/2023] Open
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Joliat GR, Perentes JY, Ris HB, Halkic N. Pulmonary sequestration mimicking a pancreas herniation in a case of recurrent Bochdalek hernia. J Thorac Dis 2017; 9:E14-E16. [PMID: 28203431 DOI: 10.21037/jtd.2017.01.42] [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: 11/06/2022]
Abstract
In the reported scenario, the patient known for a history of operated Bochdalek hernia or congenital diaphragmatic hernia (CDH) presented with new abdominal pain. The CT-scan suspected the presence of pancreas herniation through a recurrent CDH. Intraoperatively, the patient was found to have a recurrent CDH containing greater omentum concomitantly with a pulmonary sequestration (PS). This case report highlights the fact that intraoperative findings can be different from preoperative radiological diagnosis. In this patient the unusual diaphragmatic hernia content was not identified on preoperative CT.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Division of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland; Division of Thoracic Surgery, University Hospital CHUV, Lausanne, Switzerland
| | | | - Hans-Beat Ris
- Division of Thoracic Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nermin Halkic
- Division of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
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Golden J, Jones N, Zagory J, Castle S, Bliss D. Outcomes of congenital diaphragmatic hernia repair on extracorporeal life support. Pediatr Surg Int 2017; 33:125-131. [PMID: 27837262 DOI: 10.1007/s00383-016-4002-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Extracorporeal life support (ECLS) is applied to refractory pulmonary hypertension in congenital diaphragmatic hernia (CDH). We evaluate the single-center outcomes of infants with CDH to determine the utility of late repair on ECLS versus repair post-decannulation. METHODS Records of infants with CDH (2004-2014) were retrospectively reviewed. RESULTS CDH was diagnosed in 177 infants. Sixty six (37%) underwent ECLS, of which, 11 died prior to repair, 33 were repaired post-decannulation, and 22 were repaired on ECLS. Repair was delayed in patients on ECLS (19 versus 10 days, p < 0.001). Patients repaired on ECLS had longer ECLS runs (22 versus 12 days, p < 0.001) and higher rates of bleeding and mortality than those repaired post-decannulation. Survival was 54% in infants undergoing ECLS, 65% in those who underwent repair, 36% in those repaired during ECLS, and 85% in those who were decannulated prior to repair. Eighteen percent (N = 4) of deaths after repair on ECLS were attributable to surgical bleeding. The remainder was due to pulmonary hypertension or sepsis. CONCLUSION Infants who underwent CDH repair post-decannulation had excellent outcomes and no mortalities attributable to repair. Neonates who underwent repair on ECLS late on bypass had the lowest survival rate with only 18% of mortality in this cohort attributable to surgical bleeding.
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Affiliation(s)
- Jamie Golden
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA
| | - Nicole Jones
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA
| | - Jessica Zagory
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA
| | - Shannon Castle
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA
| | - David Bliss
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA.
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Marwan AI, Shabeka U, Dobrinskikh E. Suggested Mechanisms of Tracheal Occlusion Mediated Accelerated Fetal Lung Growth: A Case for Heterogeneous Topological Zones. Front Pediatr 2017; 5:295. [PMID: 29376042 PMCID: PMC5770375 DOI: 10.3389/fped.2017.00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022] Open
Abstract
In this article, we report an up-to-date summary on tracheal occlusion (TO) as an approach to drive accelerated lung growth and strive to review the different maternal- and fetal-derived local and systemic signals and mechanisms that may play a significant biological role in lung growth and formation of heterogeneous topological zones following TO. Pulmonary hypoplasia is a condition whereby branching morphogenesis and embryonic pulmonary vascular development are globally affected and is classically seen in congenital diaphragmatic hernia. TO is an innovative approach aimed at driving accelerated lung growth in the most severe forms of diaphragmatic hernia and has been shown to result in improved neonatal outcomes. Currently, most research on mechanisms of TO-induced lung growth is focused on mechanical forces and is viewed from the perspective of homogeneous changes within the lung. We suggest that the key principle in understanding changes in fetal lungs after TO is taking into account formation of unique variable topological zones. Following TO, fetal lungs might temporarily look like a dynamically changing topologic mosaic with varying proliferation rates, dissimilar scale of vasculogenesis, diverse patterns of lung tissue damage, variable metabolic landscape, and different structures. The reasons for this dynamic topological mosaic pattern may include distinct degree of increased hydrostatic pressure in different parts of the lung, dissimilar degree of tissue stress/damage and responses to this damage, and incomparable patterns of altered lung zones with variable response to systemic maternal and fetal factors, among others. The local interaction between these factors and their accompanying processes in addition to the potential role of other systemic factors might lead to formation of a common vector of biological response unique to each zone. The study of the interaction between various networks formed after TO (action of mechanical forces, activation of mucosal mast cells, production and secretion of damage-associated molecular pattern substances, low-grade local pulmonary inflammation, and cardiac contraction-induced periodic agitation of lung tissue, among others) will bring us closer to an appreciation of the biological phenomenon of topological heterogeneity within the fetal lungs.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Evgenia Dobrinskikh
- Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, United States
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