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Vandewalle RJ, Greiten LE. Diaphragmatic Defects in Infants: Acute Management and Repair. Thorac Surg Clin 2024; 34:133-145. [PMID: 38705661 DOI: 10.1016/j.thorsurg.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.
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Affiliation(s)
- Robert J Vandewalle
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 844, Little Rock, AR 72202, USA.
| | - Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 677, Little Rock, AR 72202, USA
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Conte L, Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Persico N, Griggio A, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. Congenital diaphragmatic hernia: automatic lung and liver MRI segmentation with nnU-Net, reproducibility of pyradiomics features, and a machine learning application for the classification of liver herniation. Eur J Pediatr 2024; 183:2285-2300. [PMID: 38416256 PMCID: PMC11035462 DOI: 10.1007/s00431-024-05476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
Prenatal assessment of lung size and liver position is essential to stratify congenital diaphragmatic hernia (CDH) fetuses in risk categories, guiding counseling, and patient management. Manual segmentation on fetal MRI provides a quantitative estimation of total lung volume and liver herniation. However, it is time-consuming and operator-dependent. In this study, we utilized a publicly available deep learning (DL) segmentation system (nnU-Net) to automatically contour CDH-affected fetal lungs and liver on MRI sections. Concordance between automatic and manual segmentation was assessed by calculating the Jaccard coefficient. Pyradiomics standard features were then extracted from both manually and automatically segmented regions. The reproducibility of features between the two groups was evaluated through the Wilcoxon rank-sum test and intraclass correlation coefficients (ICCs). We finally tested the reliability of the automatic-segmentation approach by building a ML classifier system for the prediction of liver herniation based on support vector machines (SVM) and trained on shape features computed both in the manual and nnU-Net-segmented organs. We compared the area under the classifier receiver operating characteristic curve (AUC) in the two cases. Pyradiomics features calculated in the manual ROIs were partly reproducible by the same features calculated in nnU-Net segmented ROIs and, when used in the ML procedure, to predict liver herniation (both AUC around 0.85). Conclusion: Our results suggest that automatic MRI segmentation is feasible, with good reproducibility of pyradiomics features, and that a ML system for liver herniation prediction offers good reliability. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04609163?term=NCT04609163&draw=2&rank=1 ; Clinical Trial Identification no. NCT04609163. What is Known: • Magnetic resonance imaging (MRI) is crucial for prenatal congenital diaphragmatic hernia (CDH) assessment. It enables the quantification of the total lung volume and the extent of liver herniation, which are essential for stratifying the severity of CDH, guiding counseling, and patient management. • The manual segmentation of MRI scans is a time-consuming process that is heavily reliant upon the skill set of the operator. What is New: • MRI lung and liver automatic segmentation using the deep learning nnU-Net system is feasible, with good Jaccard coefficient values and satisfactory reproducibility of pyradiomics features compared to manual results. • A feasible ML system for predicting liver herniation could improve prenatal assessments and CDH patient management.
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Affiliation(s)
- Luana Conte
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy.
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy.
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- ASST Fatebenefratelli Sacco, Ospedale Macedonio Melloni, Milan, Italy
| | - Giuseppe Como
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università Degli Studi Di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Aydın E, Durmuş F, Torlak N, Oria M, Güler Bayazıt N, Öztürk Işık E, Aslanyürek B, Peiro JL. Pulmonary vasculature development in congenital diaphragmatic hernia: a novel automated quantitative imaging analysis. Pediatr Surg Int 2024; 40:81. [PMID: 38498203 DOI: 10.1007/s00383-024-05643-x] [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] [Accepted: 01/28/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Impaired fetal lung vasculature determines the degree of pulmonary hypertension in the congenital diaphragmatic hernia (CDH). This study aims to demonstrate the morphometric measurements that differ in pulmonary vessels of fetuses with CDH. METHODS Nitrofen-induced CDH Sprague-Dawley rat fetuses were scanned with microcomputed tomography. The analysis of the pulmonary vascular tree was performed with artificial intelligence. RESULTS The number of segments in CDH was significantly lower than that in the control group on the left (U = 2.5, p = 0.004) and right (U = 0, p = 0.001) sides for order 1(O1), whereas there was a significant difference only on the right side for O2 and O3. The pooled element numbers in the control group obeyed Horton's law (R2 = 0.996 left and R2 = 0.811 right lungs), while the CDH group broke it. Connectivity matrices showed that the average number of elements of O1 springing from elements of O1 on the left side and the number of elements of O1 springing from elements of O3 on the right side were significantly lower in CDH samples. CONCLUSION According to these findings, CDH not only reduced the amount of small order elements, but also destroyed the fractal structure of the pulmonary arterial trees.
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Affiliation(s)
- Emrah Aydın
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal and Placental Research, Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.
| | - Furkan Durmuş
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Turkey
| | - Nilhan Torlak
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal and Placental Research, Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Marc Oria
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal and Placental Research, Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nilgün Güler Bayazıt
- Department A: Mathematical Engineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
| | - Esin Öztürk Işık
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Turkey
| | - Birol Aslanyürek
- Department A: Mathematical Engineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
| | - Jose L Peiro
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal and Placental Research, Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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4
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Fernandes CJ, Gautham KS. Organization of care of infants with congenital diaphragmatic hernia-Building a high-functioning CDH program. J Perinatol 2024; 44:339-347. [PMID: 37798339 DOI: 10.1038/s41372-023-01789-z] [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: 05/14/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
Infants born with congenital diaphragmatic hernia have high mortality and morbidity and require coordinated multidisciplinary care for optimal outcomes. Over the past several decades numerous articles have been published on the technical aspects of the care of these patients demonstrating both the variation in management across institutions as well as the desirability and need for standardization of care. Unfortunately, none have focused on the organization of care for CDH patients encompassing the range from early prenatal diagnosis to long-term postnatal care. However, to achieve optimal care and optimal outcomes, it is important to not only have excellent technical surgical and medical care but also to have an organized, systematic, and purposefully designed program for the delivery of healthcare to infants with this condition. In this article, based on our experience and drawing on general principles of building clinical programs, we describe the important elements of an ideal CDH program.
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Affiliation(s)
- Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.
| | - Kanekal S Gautham
- Nemours Children's Health System, University of Central Florida College of Medicine, Orlando, FL, USA
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5
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Miyake Y, Koga H, Nojiri S, Yamada S, Ochi T, Miyano G, Lane GJ, Yamataka A, Okazaki T. Pulmonary artery diameter ratio as a prognostic indicator of congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000686. [PMID: 38298824 PMCID: PMC10828828 DOI: 10.1136/wjps-2023-000686] [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: 08/21/2023] [Accepted: 12/07/2023] [Indexed: 02/02/2024] Open
Abstract
Background Following on from an earlier study published in 2008 about left pulmonary artery (LPA) flow measured on serial echocardiography being strongly prognostic in left-sided congenital diaphragmatic hernia (CDH) and the ratio of LPA to right pulmonary artery (RPA) diameters being a simple and reliable indicator for commencing nitric oxide (NO) therapy, the ratio of LPA:RPA diameters (PA ratio or PAR) was hypothesized to possibly reflect cardiopulmonary stresses accompanying CDH better. Methods Subjects with isolated left-sided CDH treated between 2007 and 2020 at a single pediatric surgical center were recruited and classified according to survival. Data obtained retrospectively for subject demographics, clinical course, LPA/RPA diameters, and PAR were compared between survivors and non-survivors. The value of PAR for optimizing the prognostic value of PA diameter data in CDH were analyzed with receiver operating characteristic (ROC) curve analysis. Results Of 65 subjects, there were 54 survivors (82.3%) and 11 non-survivors (17.7%); 7 of 11 non-survivors died before surgical repair could be performed. Mean PAR for survivors (0.851±0.152) was significantly higher than for non-survivors (0.672±0.108) (p=0.0003). Mean PAR for non-survivors was not affected by surgical repair. Characteristics of survivors were: LPA ≥2 mm (n=52 of 54; mean PAR=0.866±0.146) and RPA ≥3 mm (n=46 of 54; mean PAR=0.857±0.152). Non-survivors with similar LPA and RPA diameters to survivors had significantly lower mean PAR. ROC curve cut-off for PAR was 0.762. Subjects with high PAR (≥0.762) required high-frequency oscillatory ventilation/NO less than subjects with low PAR (<0.762) (p=0.0244 and p=0.0485, respectively) and subjects with high PAR stabilized significantly earlier than subjects with low PAR (1.71±0.68 days vs 3.20±0.87 days) (p<0.0001). Conclusions PAR would appear to be strongly correlated with clinical outcome in CDH and be useful for planning management of cardiopulmonary instability in CDH.
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Affiliation(s)
- Yuichiro Miyake
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Shuko Nojiri
- Department of Medical Technology Innovation Center, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Shunsuke Yamada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Go Miyano
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
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Teillet B, Manœuvrier F, Rougraff C, Besengez C, Bernard L, Wojtanowski A, Ghesquieres L, Storme L, Mur S, Sharma D, Le Duc K. Intact cord resuscitation in newborns with congenital diaphragmatic hernia: insights from a lamb model. Front Pediatr 2023; 11:1236556. [PMID: 37744447 PMCID: PMC10516551 DOI: 10.3389/fped.2023.1236556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) is a rare condition characterized by pulmonary hypoplasia, vascular dystrophy, and pulmonary hypertension at birth. Validation of the lamb model as an accurate representation of human CDH is essential to translating research findings into clinical practice and understanding disease mechanisms. This article emphasizes the importance of validating the lamb model to study CDH pathogenesis and develop innovative therapeutics. Material and methods At 78 days of gestation, the fetal lamb's left forelimb was exposed through a midline laparotomy and hysterotomy, and a supra diaphragmatic thoracotomy was performed to allow the digestive organs to ascend into the thoracic cavity. At 138 ± 3 days of gestation, lambs were delivered via a cesarean section; then, with umbilical cord intact during 1 hour, the lambs were mechanically ventilated with gentle ventilation in a pressure-controlled mode for 2 h. Results CDH lambs exhibited a lower left lung-to-body weight ratio of 5.3 (2.03), p < 0.05, and right lung-to-body weight ratio of 8.2 (3.1), p < 0.05. They reached lower Vt/kg (tidal volume per kg) during the course of the resuscitation period with 1.2 (0.7) ml/kg at 10 min and 3 (1.65) ml/kg at 60 min (p < 0.05). Compliance of the respiratory system was lower in CDH lambs with 0.5 (0.3) ml/cmH2O at 60 min (p < 0.05) and 0.9 (0.26) ml/cmH2O at 120 min (p < 0.05). Differences between pre- and postductal SpO2 were higher with 15.1% (21.4%) at 20 min and 6.7% (14.5%) at 80 min (p < 0.05). CDH lambs had lower differences between inspired and expired oxygen fractions with 4.55% (6.84%) at 20 min and 6.72% (8.57%) at 60 min (p < 0.05). CDH lamb had lower left ventricle [2.73 (0.5) g/kg, p < 0.05] and lower right ventricle [0.69 (0.8), p < 0.05] to left ventricle ratio. Discussion CDH lambs had significantly lower tidal volume than control lambs due to lower compliance of the respiratory system and higher airway resistance. These respiratory changes are characteristic of CDH infants and are associated with higher mortality rates. CDH lambs also exhibited pulmonary hypertension, pulmonary hypoplasia, and left ventricle hypoplasia, consistent with observations in human newborns. To conclude, our lamb model successfully provides a reliable representation of CDH and can be used to study its pathophysiology and potential interventions.
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Affiliation(s)
- Baptiste Teillet
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Florian Manœuvrier
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatry, Centre Hospitalier Universitaire d’Amiens, Lille, France
| | - Céline Rougraff
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Capucine Besengez
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laure Bernard
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Wojtanowski
- INSERM CIC-IT 1403, Maison Régionale de la Recherche Clinique, CHRU de, Lille, France
| | - Louise Ghesquieres
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Obstetrics, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laurent Storme
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sébastien Mur
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Dyuti Sharma
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Kévin Le Duc
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
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Bressan AF, Maia VO, de Souza Rodrigues B, Bertozi G, Batah SS, Fabro AT, Pelizzo G, Pierucci UM, Tostes RC, Sbragia L, Carneiro FS. CONGENITAL DIAPHRAGMATIC HERNIA INCREASES THE SENSITIVITY OF PULMONARY ARTERIES TO NITRIC OXIDE. Pharmacol Res 2023; 191:106749. [PMID: 37004830 DOI: 10.1016/j.phrs.2023.106749] [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: 02/03/2023] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
Left congenital diaphragmatic hernia (CDH) can lead to pulmonary arteries abnormalities in the contralateral and ipsilateral sides of the diaphragm. Nitric oxide (NO) is the main therapy used to attenuate the vascular effects of CDH, but it is not always effective. We hypothesized that the left and right pulmonary arteries do not respond similarly to NO donors during CDH. Therefore, vasorelaxant responses of the left and right pulmonary arteries to sodium nitroprusside (SNP, a NO donor) were determined in a rabbit experimental model of left CDH. CDH was surgically induced in the fetuses of rabbits on the 25th day of pregnancy. On the 30th day of pregnancy, a midline laparotomy was performed to access the fetuses. The fetuses' left and right pulmonary arteries were isolated and mounted in myograph chambers. Vasodilation was evaluated by cumulative concentration-effect curves to SNP. Protein expression of guanylate cyclase isoforms (GCα, GCβ) and the α isoform of cGMP-dependent protein kinase 1 (PKG1α), and the concentration of NO and cGMP were determined in the pulmonary arteries. The left and right pulmonary arteries of newborns with CDH exhibited increased vasorelaxant responses to SNP (i.e. the potency of SNP was increased) compared to the control group. GCα, GCβ, and PKG1α expression were decreased, while NO and cGMP concentrations were increased in the pulmonary arteries of newborns with CDH compared to the control group. The increased cGMP mobilization may be responsible for the increased vasorelaxant responses to the SNP in the pulmonary arteries during left CDH.
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8
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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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9
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Maia PD, Gien J, Kinsella JP, Zablah J, Morgan G, Ivy DD, Abman SH, Frank BS. Hemodynamic Characterization of Neonates With Congenital Diaphragmatic Hernia-Associated Pulmonary Hypertension by Cardiac Catheterization. J Pediatr 2022; 255:230-235.e2. [PMID: 36463937 DOI: 10.1016/j.jpeds.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022]
Abstract
We examined the results of cardiac catheterization in infants with congenital diaphragmatic hernia (CDH) from 2009 to 2020. Catheterization confirmed pulmonary arterial hypertension in all cases (n = 17) and identified left ventricular (LV) diastolic dysfunction (LVDD) in 53%. LVDD was associated with greater respiratory morbidity. Preprocedural noninvasive assessment showed inconsistent agreement with catheterization results.
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Affiliation(s)
- Paula Dias Maia
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jenny Zablah
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Gareth Morgan
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Steven H Abman
- Pediatric Heart Lung Center, Section of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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10
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Quantitative cardiopulmonary magnetic resonance imaging in neonatal congenital diaphragmatic hernia. Pediatr Radiol 2022; 52:2306-2318. [PMID: 35556152 DOI: 10.1007/s00247-022-05384-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 03/15/2022] [Accepted: 04/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension, impaired cardiac function and lung hypoplasia are common in infants with congenital diaphragmatic hernia (CDH) and are associated with increased morbidity and mortality. Robust noninvasive methods to quantify these abnormalities in early infancy are lacking. OBJECTIVE To determine the feasibility of MRI to quantify cardiopulmonary hemodynamics and function in infants with CDH and to investigate left-right blood flow and lung volume discrepancies. MATERIALS AND METHODS We conducted a prospective MRI study of 23 neonates (isolated left CDH: 4 pre-repair, 7 post-repair, 3 pre- and post-repair; and 9 controls) performed on a small-footprint 1.5-tesla (T) scanner. We calculated MRI-based pulmonary arterial blood flow, left ventricular eccentricity index, cardiac function and lung volume. Using the Wilcoxon rank sum test for continuous data and Fisher exact test for categorical data, we made pairwise group comparisons. RESULTS The right-to-left ratios for pulmonary artery blood flow and lung volume were elevated in pre-repair and post-repair CDH versus controls (flow: P<0.005; volume: P<0.05 pre-/post-repair). Eccentricity index at end-systole significantly differed between pre-repair and post-repair CDH (P<0.01) and between pre-repair CDH and controls (P<0.001). CONCLUSION Cardiopulmonary MRI is a viable method to serially evaluate cardiopulmonary hemodynamics and function in critically ill infants and is useful for capturing left-right asymmetries in pulmonary blood flow and lung volume.
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11
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Han XY, Selesner LT, Butler MW. Congenital Diaphragmatic Hernia. Surg Clin North Am 2022; 102:739-757. [DOI: 10.1016/j.suc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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12
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Diagnosis & management of pulmonary hypertension in congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101383. [PMID: 35995665 DOI: 10.1016/j.siny.2022.101383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) contributes to neonatal morbidity and mortality worldwide. Pulmonary hypertension (PH) is a key component of CDH pathophysiology and critical consideration for management and therapeutic options. PH associated with CDH has traditionally been attributed to pulmonary vascular maldevelopment and associated lung parenchymal hypoplasia, leading to pre-capillary increase in pulmonary vascular resistance (PVR). However, there is increasing recognition that left ventricular hypoplasia, dysfunction and elevated end diastolic pressure may contribute to post-capillary pulmonary hypertension in CDH patients. The interplay of these mechanisms and associated dysfunction in the right and left ventricles results in variable hemodynamic phenotypes in CDH. Clinical assessment of individual phenotype may help guide personalized management strategies, including effective use of pulmonary vasodilators and extra-corporeal membrane oxygenation. Ongoing investigation of the underlying mechanisms of PH in CDH, and efficacy of physiology-based treatment approaches may support improvement in outcomes in this challenging condition.
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13
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Mahmood B. Persistent pulmonary hypertension of newborn. Semin Pediatr Surg 2022; 31:151202. [PMID: 36038220 DOI: 10.1016/j.sempedsurg.2022.151202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Burhan Mahmood
- Division of Newborn Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pennsylvania, USA.
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14
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Cochius - den Otter S, Deprest JA, Storme L, Greenough A, Tibboel D. Challenges and Pitfalls: Performing Clinical Trials in Patients With Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:852843. [PMID: 35498783 PMCID: PMC9051320 DOI: 10.3389/fped.2022.852843] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the lungs and diaphragm, with substantial morbidity and mortality. Although internationally established treatment guidelines have been developed, most recommendations are still expert opinions. Trials in patients with CDH, more in particular randomized controlled trials, are rare. Only three multicenter trials in patients with CDH have been completed, which focused on fetoscopic tracheal occlusion and ventilation mode. Another four are currently recruiting, two with a focus on perinatal transition and two on the treatment of pulmonary hypertension. Herein, we discuss major challenges and pitfalls when performing a clinical trial in infants with CDH. It is essential to select the correct intervention and dose, select the appropriate population of CDH patients, and also define a relevant endpoint that allows a realistic duration and sample size. New statistical approaches might increase the feasibility of randomized controlled trials in patients with CDH. One should also timely perform the trial when there is still equipoise. But above all, awareness of policymakers for the relevance of investigator-initiated trials is essential for future clinical research in this rare disease.
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Affiliation(s)
- Suzan Cochius - den Otter
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jan A. Deprest
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, United Kingdom
| | - Laurent Storme
- Metrics-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Neonatology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center of Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, United Kingdom
- NIHR Biomedical Centre, Guy's and St Thomas NHS Foundation Trust and King's College London, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
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15
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Horn-Oudshoorn EJJ, Knol R, Vermeulen MJ, Te Pas AB, Hooper SB, Cochius-den Otter SCM, Wijnen RMH, Crossley KJ, Rafat N, Schaible T, de Boode WP, Debeer A, Urlesberger B, Roberts CT, Kipfmueller F, Reiss IKM, DeKoninck PLJ. Physiological-based cord clamping versus immediate cord clamping for infants born with a congenital diaphragmatic hernia (PinC): study protocol for a multicentre, randomised controlled trial. BMJ Open 2022; 12:e054808. [PMID: 35304395 PMCID: PMC8935184 DOI: 10.1136/bmjopen-2021-054808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pulmonary hypertension is a major determinant of postnatal survival in infants with a congenital diaphragmatic hernia (CDH). The current care during the perinatal stabilisation period in these infants might contribute to the development of pulmonary hypertension after birth-in particular umbilical cord clamping before lung aeration. An ovine model of diaphragmatic hernia demonstrated that cord clamping after lung aeration, called physiological-based cord clamping (PBCC), avoided the initial high pressures in the lung vasculature while maintaining adequate blood flow, thereby avoiding vascular remodelling and aggravation of pulmonary hypertension. We aim to investigate if the implementation of PBCC in the perinatal stabilisation period of infants born with a CDH could reduce the incidence of pulmonary hypertension in the first 24 hours after birth. METHODS AND ANALYSIS We will perform a multicentre, randomised controlled trial in infants with an isolated left-sided CDH, born at ≥35.0 weeks. Before birth, infants will be randomised to either PBCC or immediate cord clamping, stratified by treatment centre and severity of pulmonary hypoplasia on antenatal ultrasound. PBCC will be performed using a purpose-built resuscitation trolley. Cord clamping will be performed when the infant is considered respiratory stable, defined as a heart rate >100 bpm, preductal oxygen saturation >85%, while using a fraction of inspired oxygen of <0.5. The primary outcome is pulmonary hypertension diagnosed in the first 24 hours after birth, based on clinical and echocardiographic parameters. Secondary outcomes include neonatal as well as maternal outcomes. ETHICS AND DISSEMINATION Central ethical approval was obtained from the Medical Ethical Committee of the Erasmus MC, Rotterdam, The Netherlands (METC 2019-0414). Local ethical approval will be obtained by submitting the protocol to the regulatory bodies and local institutional review boards. TRIAL REGISTRATION NUMBER NCT04373902.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Suzan C M Cochius-den Otter
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboudumc University Medical Center, Nijmegen, The Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Intensive Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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16
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Congenital Diaphragmatic Hernia Repair in a Patient With Pallister-Killian Mosaic Syndrome and Left Ventricular Hypoplasia. Cureus 2022; 14:e23095. [PMID: 35464544 PMCID: PMC9001027 DOI: 10.7759/cureus.23095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/06/2022] Open
Abstract
We present the case of a two-week-old infant with congenital diaphragmatic hernia (CDH) and Pallister-Killian mosaic syndrome (PKS) for CDH repair. We discuss the pathophysiologic findings of both conditions and the resulting anesthetic challenges from their interplay.
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17
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Hari Gopal S, Patel N, Fernandes CJ. Use of Prostaglandin E1 in the Management of Congenital Diaphragmatic Hernia-A Review. Front Pediatr 2022; 10:911588. [PMID: 35844758 PMCID: PMC9283565 DOI: 10.3389/fped.2022.911588] [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: 04/02/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly, whose presentation is complicated by pulmonary hypertension (PH), pulmonary hypoplasia, and myocardial dysfunction, each of which have significant impact on short-term clinical management and long-term outcomes. Despite many advances in therapy and surgical technique, optimal CDH management remains a topic of debate, due to the variable presentation, complex pathophysiology, and continued impact on morbidity and mortality. One of the more recent management strategies is the use of prostaglandin E1 (PGE1) infusion in the management of PH associated with CDH. PGE1 is widely used in the NICU in critical congenital cardiac disease to maintain ductal patency and facilitate pulmonary and systemic blood flow. In a related paradigm, PGE1 infusion has been used in situations of supra-systemic right ventricular pressures, including CDH, with the therapeutic intent to maintain ductal patency as a "pressure relief valve" to reduce the effective afterload on the right ventricle (RV), optimize cardiac function and support pulmonary and systemic blood flow. This paper reviews the current evidence for use of PGE1 in the CDH population and the opportunities for future investigations.
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Affiliation(s)
- Srirupa Hari Gopal
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Caraciolo J Fernandes
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
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18
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Thodika FMSA, Dimitrova S, Nanjundappa M, Davenport M, Nicolaides K, Dassios T, Greenough A. Prediction of survival in infants with congenital diaphragmatic hernia and the response to inhaled nitric oxide. Eur J Pediatr 2022; 181:3683-3689. [PMID: 35900449 PMCID: PMC9508000 DOI: 10.1007/s00431-022-04568-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/04/2022] [Accepted: 07/14/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED The use of inhaled nitric oxide (iNO) in treating pulmonary hypertension in infants with congenital diaphragmatic hernia (CDH) is controversial. Our aims were to identify factors associated with survival in CDH infants and whether this was influenced by the response to iNO. Results of CDH infants treated in a tertiary surgical and medical perinatal centre in a ten year period (2011-2021) were reviewed. Factors affecting survival were determined. To assess the response to iNO, blood gases prior to and 30 to 60 min after initiation of iNO were analysed and PaO2/FiO2 ratios and oxygenation indices (OI) calculated. One hundred and five infants were admitted with CDH; 46 (43.8%) infants died. The CDH infants who died had a lower median observed to expected lung to head ratio (O/E LHR) (p < 0.001) and a higher median highest OI on day 1 (HOId1) (p < 0.001). HOId1 predicted survival after adjusting for gestational age, Apgar score at 5 min and O/E LHR (odds ratio 0.948 (95% confidence intervals 0.913-0.983)). Seventy-two infants (68.6%) received iNO; 28 survived to discharge. The median PaO2 (46.7 versus 58.8 mmHg, p < 0.001) and the median PaO2/FiO2 ratio (49.4 versus 58.8, p = 0.003) improved post iNO initiation. The percentage change in the PaO2/FiO2 ratio post iNO initiation was higher in infants who survived (69.4%) compared to infants who died (10.2%), p = 0.018. CONCLUSION The highest OI on day 1 predicted survival. iNO improved oxygenation in certain CDH infants and a positive response was more likely in those who survived. WHAT IS KNOWN • The use of iNO is controversial in infants with CDH with respect to whether it improves survival. WHAT IS NEW • We have examined predictors of survival in CDH infants including the response to iNO and demonstrated that the highest oxygenation index on day 1 predicted survival (AUCROC =0.908). • Certain infants with CDH responded to iNO and those with a greater response were more likely to survive.
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Affiliation(s)
- Fahad M. S. Arattu Thodika
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Svilena Dimitrova
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
| | - Mahesh Nanjundappa
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Kypros Nicolaides
- Fetal Medicine Unit, King’s College Hospital NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK ,Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK. .,Fetal Medicine Unit, King's College Hospital NHS Foundation Trust, London, UK. .,NIHR Biomedical Research Centre Based at Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK.
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19
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Olutoye Ii OO, Short WD, Gilley J, Hammond Ii JD, Belfort MA, Lee TC, King A, Espinoza J, Joyeux L, Lingappan K, Gleghorn JP, Keswani SG. The Cellular and Molecular Effects of Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:925106. [PMID: 35865706 PMCID: PMC9294219 DOI: 10.3389/fped.2022.925106] [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: 04/21/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a complex disease associated with pulmonary hypoplasia and pulmonary hypertension. Great strides have been made in our ability to care for CDH patients, specifically in the prenatal improvement of lung volume and morphology with fetoscopic endoluminal tracheal occlusion (FETO). While the anatomic effects of FETO have been described in-depth, the changes it induces at the cellular and molecular level remain a budding area of CDH research. This review will delve into the cellular and molecular effects of FETO in the developing lung, emphasize areas in which further research may improve our understanding of CDH, and highlight opportunities to optimize the FETO procedure for improved postnatal outcomes.
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Affiliation(s)
- Oluyinka O Olutoye Ii
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Walker D Short
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jamie Gilley
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - J D Hammond Ii
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Luc Joyeux
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jason P Gleghorn
- Department of Biomedical Engineering, University of Delaware, Newark, DE, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
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20
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Amodeo I, Borzani I, Raffaeli G, Persico N, Amelio GS, Gulden S, Colnaghi M, Villamor E, Mosca F, Cavallaro G. The role of magnetic resonance imaging in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:3243-3257. [PMID: 35794403 PMCID: PMC9395465 DOI: 10.1007/s00431-022-04540-6] [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: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
UNLABELLED In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity. CONCLUSION Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment. WHAT IS KNOWN • MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling. WHAT IS NEW • Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Irene Borzani
- grid.414818.00000 0004 1757 8749Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Persico
- grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Simeone Amelio
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Silvia Gulden
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Mariarosa Colnaghi
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Eduardo Villamor
- grid.412966.e0000 0004 0480 1382Department of Pediatrics, School for Oncology and Reproduction (GROW), Maastricht University Medical Center, University of Maastricht, MUMC+), Maastricht, the Netherlands
| | - Fabio Mosca
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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21
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Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Griggio A, Conte L, Macchini F, Condò V, Persico N, Fabietti I, Ghirardello S, Pierro M, Tafuri B, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. A maChine and deep Learning Approach to predict pulmoNary hyperteNsIon in newbornS with congenital diaphragmatic Hernia (CLANNISH): Protocol for a retrospective study. PLoS One 2021; 16:e0259724. [PMID: 34752491 PMCID: PMC8577746 DOI: 10.1371/journal.pone.0259724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/25/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Outcome predictions of patients with congenital diaphragmatic hernia (CDH) still have some limitations in the prenatal estimate of postnatal pulmonary hypertension (PH). We propose applying Machine Learning (ML), and Deep Learning (DL) approaches to fetuses and newborns with CDH to develop forecasting models in prenatal epoch, based on the integrated analysis of clinical data, to provide neonatal PH as the first outcome and, possibly: favorable response to fetal endoscopic tracheal occlusion (FETO), need for Extracorporeal Membrane Oxygenation (ECMO), survival to ECMO, and death. Moreover, we plan to produce a (semi)automatic fetus lung segmentation system in Magnetic Resonance Imaging (MRI), which will be useful during project implementation but will also be an important tool itself to standardize lung volume measures for CDH fetuses. METHODS AND ANALYTICS Patients with isolated CDH from singleton pregnancies will be enrolled, whose prenatal checks were performed at the Fetal Surgery Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (Milan, Italy) from the 30th week of gestation. A retrospective data collection of clinical and radiological variables from newborns' and mothers' clinical records will be performed for eligible patients born between 01/01/2012 and 31/12/2020. The native sequences from fetal magnetic resonance imaging (MRI) will be collected. Data from different sources will be integrated and analyzed using ML and DL, and forecasting algorithms will be developed for each outcome. Methods of data augmentation and dimensionality reduction (feature selection and extraction) will be employed to increase sample size and avoid overfitting. A software system for automatic fetal lung volume segmentation in MRI based on the DL 3D U-NET approach will also be developed. ETHICS AND DISSEMINATION This retrospective study received approval from the local ethics committee (Milan Area 2, Italy). The development of predictive models in CDH outcomes will provide a key contribution in disease prediction, early targeted interventions, and personalized management, with an overall improvement in care quality, resource allocation, healthcare, and family savings. Our findings will be validated in a future prospective multicenter cohort study. REGISTRATION The study was registered at ClinicalTrials.gov with the identifier NCT04609163.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- Monza and Brianza Mother and Child Foundation, San Gerardo Hospital, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Luana Conte
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, 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, 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
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Pierro
- NICU, Bufalini Hospital, Azienda Unità Sanitaria Locale della Romagna, Cesena, Italy
| | - Benedetta Tafuri
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Giuseppe Como
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università degli Studi di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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22
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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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23
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Marulanda K, Tsihlis ND, McLean SE, Kibbe MR. Emerging antenatal therapies for congenital diaphragmatic hernia-induced pulmonary hypertension in preclinical models. Pediatr Res 2021; 89:1641-1649. [PMID: 33038872 PMCID: PMC8035353 DOI: 10.1038/s41390-020-01191-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023]
Abstract
Congenital diaphragmatic hernia (CDH)-related deaths are the largest contributor to in-hospital neonatal deaths in children with congenital malformations. Morbidity and mortality in CDH are directly related to the development of pulmonary hypertension (PH). Current treatment consists of supportive measures. To date, no pharmacotherapy has been shown to effectively reverse the hallmark finding of pulmonary vascular remodeling that is associated with pulmonary hypertension in CDH (CDH-PH). As such, there is a great need for novel therapies to effectively manage CDH-PH. Our review aims to evaluate emerging therapies, and specifically focuses on those that are still under investigation and not approved for clinical use by the Food and Drug Administration. Therapies were categorized into antenatal pharmacotherapies or antenatal regenerative therapies and assessed on their method of administration, safety profile, the effect on pulmonary vascular pathophysiology, and overall efficacy. In general, emerging antenatal pharmaceutical and regenerative treatments primarily aim to alleviate pulmonary vascular remodeling by restoring normal function and levels of key regulatory factors involved in pulmonary vascular development and/or in promoting angiogenesis. Overall, while these emerging therapies show great promise for the management of CDH-PH, most require further assessment of safety and efficacy in preclinical models before translation into the clinical setting. IMPACT: Emerging antenatal therapies for congenital diaphragmatic hernia-induced pulmonary hypertension (CDH-PH) show promise to effectively mitigate vascular remodeling in preclinical models. Further investigation is needed in preclinical and human studies to evaluate safety and efficacy prior to translation into the clinical arena. This review offers a comprehensive and up-to-date summary of emerging therapies currently under investigation in experimental animal models. There is no cure for CDH-PH. This review explores emerging therapeutic options for the treatment of CDH-PH and evaluates their impact on key molecular pathways and clinical markers of disease to determine efficacy in the preclinical stage.
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Affiliation(s)
- Kathleen Marulanda
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Nick D Tsihlis
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- Division of Pediatric Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Melina R Kibbe
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA.
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24
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Seabrook RB, Grover TR, Rintoul N, Weems M, Keene S, Brozanski B, DiGeronimo R, Haberman B, Hedrick H, Gien J, Ali N, Chapman R, Daniel J, Harrison HA, Johnson Y, Porta NFM, Uhing M, Zaniletti I, Murthy K. Treatment of pulmonary hypertension during initial hospitalization in a multicenter cohort of infants with congenital diaphragmatic hernia (CDH). J Perinatol 2021; 41:803-813. [PMID: 33649432 DOI: 10.1038/s41372-021-00923-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/02/2020] [Accepted: 01/14/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Describe inpatient pulmonary hypertension (PH) treatment and factors associated with therapy at discharge in a multicenter cohort of infants with CDH. METHODS Six years linked records from Children's Hospitals Neonatal Database and Pediatric Health Information System were used to describe associations between prenatal/perinatal factors, clinical outcomes, echocardiographic findings and PH medications (PHM), during hospitalization and at discharge. RESULTS Of 1106 CDH infants from 23 centers, 62.8% of infants received PHM, and 11.6% of survivors were discharged on PHM. Survivors discharged on PHM more frequently had intrathoracic liver, small for gestational age, and low 5 min APGARs compared with those discharged without PHM (p < 0.0001). Nearly one-third of infants discharged without PHM had PH on last inpatient echo. CONCLUSIONS PH medication use is common in CDH. Identification of infants at risk for persistent PH may impact ongoing management. Post-discharge follow-up of all CDH infants with echocardiographic evidence of PH is warranted.
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Affiliation(s)
- Ruth B Seabrook
- Nationwide Children's Hospital and the Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Theresa R Grover
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Natalie Rintoul
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Weems
- LeBonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah Keene
- Children's Healthcare of Atlanta at Egleston, Emory Children's Pediatric Institute, and Emory University School of Medicine, Atlanta, GA, USA
| | - Beverly Brozanski
- St Louis Children's Hospital and the Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Beth Haberman
- Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Holly Hedrick
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Gien
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Rachel Chapman
- Children's Hospital Los Angeles and the Fetal & Neonatal Institute, Department of Pediatrics. USC Keck School of Medicine, Los Angeles, CA, USA
| | - John Daniel
- Children's Mercy Hospitals & Clinics, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | | | - Nicolas F M Porta
- Ann & Robert H Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Uhing
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Karna Murthy
- Ann & Robert H Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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25
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Aleem S, Robbins C, Murphy B, Elliott S, Akinyemi C, Paredes N, Tolia VN, Zimmerman KO, Goldberg RN, Benjamin DK, Greenberg RG. The use of supplemental hydrocortisone in the management of persistent pulmonary hypertension of the newborn. J Perinatol 2021; 41:794-800. [PMID: 33589734 PMCID: PMC8052278 DOI: 10.1038/s41372-021-00943-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/28/2020] [Accepted: 01/19/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Characterize association between hydrocortisone receipt and hospital outcomes of infants with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN Cohort study of infants ≥34 weeks with PPHN who received inhaled nitric oxide at <7 days of age (2010-2016). We generated propensity scores, and performed inverse probability-weighted regression to estimate hydrocortisone effect on outcomes: death, chronic lung disease (CLD), oxygen at discharge. RESULTS Of 2743 infants, 30% received hydrocortisone, which was associated with exposure to mechanical ventilation, sedatives, paralytics, or vasopressors (p < 0.001). There was no difference in death, CLD, or oxygen at discharge. In infants with meconium aspiration syndrome, hydrocortisone was associated with decreased oxygen at discharge (odds ratio 0.56; 95% confidence interval 0.21, 0.91). CONCLUSIONS There was no association between hydrocortisone receipt and death, CLD, or oxygen at discharge in our cohort. Prospective studies are needed to evaluate the effectiveness of hydrocortisone in infants with PPHN.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | | | | | | | - Veeral N Tolia
- Department of Neonatology, Baylor University Medical Center, Dallas, TX, USA
- Pediatrix Medical Group, Dallas, TX, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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26
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Mandell E, Kinsella JP, Abman SH. Persistent pulmonary hypertension of the newborn. Pediatr Pulmonol 2021; 56:661-669. [PMID: 32930508 DOI: 10.1002/ppul.25073] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/07/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a significant clinical problem characterized by refractory and severe hypoxemia secondary to elevated pulmonary vascular resistance resulting in right-to-left extrapulmonary shunting of deoxygenated blood. PPHN is associated with diverse cardiopulmonary disorders and a high early mortality rate for infants with severe PPHN. Surviving infants with PPHN have an increased risk of long-term morbidities. PPHN physiology can be categorized by (1) maladaptation: pulmonary vessels have normal structure and number but have abnormal vasoreactivity; (2) excessive muscularization: increased smooth muscle cell thickness and increased distal extension of muscle to vessels that are usually not muscularized; and (3) underdevelopment: lung hypoplasia associated with decreased pulmonary artery number. Treatment involves adequate lung recruitment, optimization of cardiac output and left ventricular function, and pulmonary vasodilators such as inhaled nitric oxide. Infants who fail to respond to conventional therapy should be evaluated for lethal lung disorders including alveolar-capillary dysplasia, T-box transcription factor 4 gene, thyroid transcription factor-1, ATP-binding cassette A3 gene, and surfactant protein diseases.
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Affiliation(s)
- Erica Mandell
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John P Kinsella
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Pulmonary Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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27
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Varghese NP, Tillman RH, Keller RL. Pulmonary hypertension is an important co-morbidity in developmental lung diseases of infancy: Bronchopulmonary dysplasia and congenital diaphragmatic hernia. Pediatr Pulmonol 2021; 56:670-677. [PMID: 33561308 DOI: 10.1002/ppul.25258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/30/2020] [Accepted: 12/18/2020] [Indexed: 12/11/2022]
Abstract
Bronchopulmonary dysplasia (BPD) following preterm birth and congenital diaphragmatic hernia (CDH) are both forms of developmental lung disease that may result in persistent pulmonary and pulmonary vascular morbidity in childhood. The pulmonary vascular disease (PVD) which accompanies BPD and CDH is due to developmental abnormalities and ongoing perinatal insults. This may be accompanied by evidence of elevated right heart pressures and pulmonary vascular resistance, leading to diagnosis of pulmonary hypertension (PH). The development of PH in these conditions is associated with increased morbidity and mortality in the vulnerable BPD and CDH populations. We present a review of PVD pathogenesis and evaluation in BPD and CDH and discuss management of related sequelae of PH co-morbidity for affected infants.
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Affiliation(s)
| | - Robert H Tillman
- Pediatric Pulmonary Medicine, Atrium Health, Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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28
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Guslits E, Steurer MA, Nawaytou H, Keller RL. Longitudinal B-Type Natriuretic Peptide Levels Predict Outcome in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2021; 229:191-198.e2. [PMID: 32997999 DOI: 10.1016/j.jpeds.2020.09.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/18/2020] [Accepted: 09/23/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate B-type natriuretic peptide (BNP) as a longitudinal biomarker of clinical outcome in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN We conducted a retrospective study of 49 infants with CDH, classifying the cohort by respiratory status at 56 days, based on a proposed definition of bronchopulmonary dysplasia for infants ≥32 weeks' gestation: good outcome (alive with no respiratory support) and poor outcome (ongoing respiratory support or death). BNP levels were available at age 1-5 weeks. Longitudinal BNP trends were assessed using mixed-effects modeling. Receiver operating characteristic curves were generated to identify BNP cutoffs maximizing correct outcome classification at each time point. The time to reach BNP cutoff by outcome was assessed using Kaplan-Meier curves for weeks 3-5. RESULTS Twenty-nine infants (59%) had a poor outcome. Infants with a poor outcome were more likely than those with a good outcome to have liver herniated into the thorax (90% vs 50%; P = .002) and to undergo nonprimary repair (93% vs 35%; P < .001). Mixed-effects modeling demonstrated a differing decline in BNP over time by outcome group (P = .003 for interaction). BNP accurately predicted outcome at 3-5 weeks (area under the curve, 0.81-0.82). BNP cutoffs that maximized correct outcome classification decreased over time from 285 pg/mL at 3 weeks to 100 pg/mL at 4 weeks and 48 pg/mL at 5 weeks. Time to reach the cutoffs of 100 pg/mL and 48 pg/mL were longer in the poor outcome group (log-rank P = .006 and <.0001, respectively). CONCLUSIONS Elevated BNP accurately predicts poor outcome in infants with CDH at age 3-5 weeks, with declining cutoffs over 3-5 weeks of age.
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Affiliation(s)
- Elyssa Guslits
- Department of Pediatrics, Critical Care, University of California San Francisco, San Francisco, CA
| | - Martina A Steurer
- Department of Pediatrics, Critical Care, University of California San Francisco, San Francisco, CA
| | - Hythem Nawaytou
- Department of Pediatrics, Cardiology, University of California San Francisco, CA
| | - Roberta L Keller
- Department of Pediatrics, Neonatology, University of California San Francisco, CA
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29
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Comparini RG, Falcão MC, Johnston C, Carvalho WBD. Electrical Impedance Tomography in Congenital Diaphragmatic Hernia. Clinics (Sao Paulo) 2021; 76:e3210. [PMID: 34287483 PMCID: PMC8266173 DOI: 10.6061/clinics/2021/e3210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Rafael Gonçalves Comparini
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mario Cicero Falcão
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cíntia Johnston
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Werther Brunow de Carvalho
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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30
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Amodeo I, Pesenti N, Raffaeli G, Macchini F, Condò V, Borzani I, Persico N, Fabietti I, Bischetti G, Colli AM, Ghirardello S, Gangi S, Colnaghi M, Mosca F, Cavallaro G. NeoAPACHE II. Relationship Between Radiographic Pulmonary Area and Pulmonary Hypertension, Mortality, and Hernia Recurrence in Newborns With CDH. Front Pediatr 2021; 9:692210. [PMID: 34322463 PMCID: PMC8311172 DOI: 10.3389/fped.2021.692210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 12/19/2022] Open
Abstract
Congenital diaphragmatic hernia is a rare disease with high mortality and morbidity due to pulmonary hypoplasia and pulmonary hypertension. The aim of the study is to investigate the relationship between radiographic lung area and systolic pulmonary artery pressure (sPAP) on the first day of life, mortality, and hernia recurrence during the first year of life in infants with a congenital diaphragmatic hernia (CDH). A retrospective data collection was performed on 77 CDH newborns. Echocardiographic sPAP value, deaths, and recurrence cases were recorded. Lung area was calculated by tracing the lung's perimeter, excluding mediastinal structures, and herniated organs, on the preoperative chest X-ray performed within 24 h after birth. Logistic and linear regression analyses were performed. Deceased infants showed lower areas and higher sPAP values. One square centimeter of rising in the total, ipsilateral, and contralateral area was associated with a 22, 43, and 24% reduction in mortality risk. sPAP values showed a decreasing trend after birth, with a maximum of 1.84 mmHg reduction per unitary increment in the ipsilateral area at birth. Recurrence patients showed lower areas, with recurrence risk decreasing by 14 and 29% per unit increment of the total and ipsilateral area. In CDH patients, low lung area at birth reflects impaired lung development and defect size, being associated with increased sPAP values, mortality, and recurrence risk. Clinical Trial Registration: The manuscript is an exploratory secondary analysis of the trial registered at ClinicalTrials.gov with identifier NCT04396028.
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Affiliation(s)
- Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Pesenti
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Bischetti
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Maria Colli
- Cardiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvana Gangi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariarosa Colnaghi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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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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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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Larsen UL, Jepsen S, Strøm T, Qvist N, Toft P. Congenital diaphragmatic hernia presenting with symptoms within the first day of life; outcomes from a non-ECMO centre in Denmark. BMC Pediatr 2020; 20:196. [PMID: 32381070 PMCID: PMC7204041 DOI: 10.1186/s12887-020-02072-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Between 1998 and 2015, we report on the survival of congenital diaphragmatic hernia (CDH)-infants presenting with symptoms within the first 24 h of life, treated at Odense University Hospital (OUH), a tertiary referral non-extracorporeal membrane oxygenation (ECMO) hospital for paediatric surgery. Methods We performed a retrospective cohort study of prospectively identified CDH-infants at our centre. Data from medical records and critical information systems were obtained. Baseline data included mode of delivery and infant condition. Outcome data included 24-h, 28-day, and 1 year mortality rates and management data included intensive care treatment, length of stay in the intensive care unit, time of discharge from hospital, and surgical intervention. Descriptive analyses were performed for all variables. Survivors and non-survivors were compared for baseline and treatment data. Results Ninety-five infants were identified (44% female). Of these, 77% were left-sided hernias, 52% were diagnosed prenatally, and 6.4% had concurrent malformations. The 28-day mortality rate was 21.1%, and the 1 year mortality rate was 22.1%. Of the 21 non-survivors, nine died within the first 24 h, and 10 were sufficiently stabilised to undergo surgery. A statistically significant difference was observed between survivors and non-survivors regarding APGAR score at 1 and 5 min., prenatal diagnosis, body length at birth, and delivery at OUH. Conclusions Our outcome results were comparable to published data from other centres, including centres using ECMO.
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Affiliation(s)
- Ulla Lei Larsen
- Research Unit for Department of Anaesthesiology & Intensive Care, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Odense, Denmark. .,OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Søren Jepsen
- Department of Anaesthesiology & Intensive Care, Odense University Hospital, Odense, Denmark
| | - Thomas Strøm
- Research Unit for Department of Anaesthesiology & Intensive Care, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark: University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Research Unit for Department of Anaesthesiology & Intensive Care, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Odense, Denmark
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34
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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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35
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Wehrmann M, Patel SS, Haxel C, Cassidy C, Howley L, Cuneo B, Gien J, Kinsella JP. Implications of Atrial-Level Shunting by Echocardiography in Newborns with Congenital Diaphragmatic Hernia. J Pediatr 2020; 219:43-47. [PMID: 32014282 DOI: 10.1016/j.jpeds.2019.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/08/2019] [Accepted: 12/17/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine whether postnatal echocardiographic indices of left ventricular (LV) size and function are associated with atrial-level shunt direction and investigate whether a relationship exists between LV function and LV size in patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN This was a single-center retrospective study of 51 neonates with CDH evaluated at Children's Hospital Colorado. Initial postnatal echocardiograms were analyzed for cardiac dimensions, valvar integrity, cardiac time intervals, and biventricular function. Comparisons were made between neonates with left-to-right vs right-to-left atrial-level shunting, as well as between those with decreased (ejection fraction <55%) vs normal (ejection fraction ≥55%) LV function. RESULTS The majority (82.4%) of infants with CDH had a left-to-right atrial-level shunt, and 84.3% had systemic or suprasystemic pulmonary artery pressure. Decreased LV function was demonstrated in 37.2% and was associated with smaller LV volumes and worse outcomes, including the need for extracorporeal membrane oxygenation (ECMO) and survival. CONCLUSIONS Left-to-right atrial-level shunting is common in neonates with severe CDH, even in the presence of suprasystemic pulmonary artery pressure. LV dysfunction correlates with decreased LV volumes and is associated with adverse neonatal outcomes, including increased need for ECMO and decreased survival.
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Affiliation(s)
- Melissa Wehrmann
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Sonali S Patel
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Caitlin Haxel
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Pediatric Cardiology, University of Vermont Lerner College of Medicine, University of Vermont Children's Hospital, Burlington, VT
| | - Courtney Cassidy
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lisa Howley
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of Pediatric Cardiology, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Bettina Cuneo
- Department of Pediatrics, Section of Cardiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Jason Gien
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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36
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Abstract
Congenital diaphragmatic hernia (CDH) is a neonatal pathology in which intrathoracic herniation of abdominal viscera via diaphragmatic defect results in aberrant pulmonary and cardiovascular development. Despite decades of study and many advances in the diagnosis and treatment of CDH, morbidity and mortality remain high, largely due to pulmonary hypertension (PH), along with pulmonary hypoplasia and cardiac dysfunction. In patients with CDH, hypoplastic pulmonary vasculature and alterations in multiple molecular pathways lead to pathophysiologic pulmonary vasculopathy and, for severe CDH, sustained, elevated pulmonary arterial pressures. This review addresses the multiple anatomic and physiologic changes that underlie CDH-associated PH (CDH-PH), along with the multimodal treatment strategies that exist currently and future therapies currently under investigation.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA
| | - 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, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA.
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37
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Amodeo I, Raffaeli G, Pesenti N, Macchini F, Condò V, Borzani I, Persico N, Fabietti I, Ophorst M, Ghirardello S, Gangi S, Colnaghi M, Mosca F, Cavallaro G. The NeoAPACHE Study Protocol I: Assessment of the Radiographic Pulmonary Area and Long-Term Respiratory Function in Newborns With Congenital Diaphragmatic Hernia. Front Pediatr 2020; 8:581809. [PMID: 33194913 PMCID: PMC7661933 DOI: 10.3389/fped.2020.581809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/08/2020] [Indexed: 12/18/2022] Open
Abstract
In newborns with congenital diaphragmatic hernia (CDH), the radiographic lung area is correlated with functional residual capacity (FRC) and represents an alternative method to estimate lung hypoplasia. In a cohort of newborn CDH survivors, we retrospectively evaluated the relationship between radiographic lung area measured on the 1st day of life and long-term respiratory function. As a secondary analysis, we compared radiographic lung areas and respiratory function between patients undergoing fetal endoscopic tracheal occlusion (FETO) and patients managed expectantly (non-FETO). Total, ipsilateral, and contralateral radiographic areas were obtained by tracing lung perimeter as delineated by the diaphragm and rib cage, excluding mediastinal structures and herniated organs. Tidal volume (VT), respiratory rate (RR), and their Z-Scores when compared to the norm were collected from pulmonary function tests (PFTs) performed at 12 ± 6 months of age. Linear regression analyses using the absolute Z-Score values for each parameter were performed. In CDH survivors, an increase in total and ipsilateral lung area measured at birth was related to a reduction in the absolute Z-Score for VT in PFTs (p = 0.046 and p = 0.023, respectively), indicating a trend toward an improvement in pulmonary volumes and VT normalization. Radiographic lung areas were not significantly different between FETO and non-FETO patients, suggesting a volumetric lung increase due to prenatal intervention. However, the mean Z-Score value for RR was significantly higher in the FETO group (p < 0.001), probably due to impaired diaphragmatic motility in the most severe cases. Further analyses are necessary to better characterize the role of the radiographic pulmonary area in the prognostic evaluation of respiratory function in patients with CDH. Clinical Trial Registration: This trial was registered at ClinicalTrials.gov with the identifier NCT04396028.
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Affiliation(s)
- Ilaria Amodeo
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Nicola Pesenti
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marijke Ophorst
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Gangi
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariarosa Colnaghi
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit (NICU), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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38
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Kim MS, Choi YJ, Lee S, Kim WS, Suh DI, Kim MJ. Natural courses and prognostic factors of pulmonary underdevelopment except for congenital diaphragmatic hernia. ALLERGY ASTHMA & RESPIRATORY DISEASE 2020. [DOI: 10.4168/aard.2020.8.4.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min Soo Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Jung Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seunghyun Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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39
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Abstract
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
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Affiliation(s)
- Mark L Kovler
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States
| | - Eric B Jelin
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States.
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40
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Prayer F, Metzelder M, Krois W, Brugger PC, Gruber GM, Weber M, Scharrer A, Rokitansky A, Langs G, Prayer D, Unger E, Kasprian G. Three-dimensional reconstruction of defects in congenital diaphragmatic hernia: a fetal MRI study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:816-826. [PMID: 30985045 PMCID: PMC6619026 DOI: 10.1002/uog.20296] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/30/2019] [Accepted: 04/10/2019] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To assess the clinical feasibility and validity of fetal magnetic resonance imaging (MRI)-based three-dimensional (3D) reconstruction to locate, classify and quantify diaphragmatic defects in congenital diaphragmatic hernia (CDH). METHODS This retrospective study included 46 cases of CDH which underwent a total of 69 fetal MRI scans (65 in-vivo and four postmortem) at the Medical University of Vienna during the period 1 January 2002 to 1 January 2017. Scans were performed between 16 and 38 gestational weeks using steady-state free precession, T2-weighted and T1-weighted sequences. MRI data were retrieved from the hospital database and manual segmentation of the diaphragm was performed with the open-source software, ITK-SNAP. The resulting 3D models of the fetal diaphragm and its defect(s) were validated by postmortem MRI segmentation and/or comparison of 3D model-based classification of the defect with a reference classification based on autopsy and/or surgery reports. Surface areas of the intact diaphragm and of the defect were measured and used to calculate defect-diaphragmatic ratios (DDR). The need for prosthetic patch repair and, in cases with repeated in-vivo fetal MRI scans, diaphragm growth dynamics, were analyzed based on DDR. RESULTS Fetal MRI-based manual segmentation of the diaphragm in CDH was feasible for all 65 (100%) of the in-vivo fetal MRI scans. Based on the 3D diaphragmatic models, one bilateral and 45 unilateral defects (n = 47) were further classified as posterolateral (23/47, 48.9%), lateral (7/47, 14.9%) or hemidiaphragmatic (17/47, 36.2%) defects, and none (0%) was classified as anterolateral. This classification of defect location was correct in all 37 (100%) of the cases in which this information could be verified. Nineteen cases had a follow-up fetal MRI scan; in five (26.3%) of these, the initial CDH classification was altered by the results of the second scan. Thirty-three fetuses underwent postnatal diaphragmatic surgical repair; 20 fetuses (all of those with DDR ≥ 54 and 88% of those with DDR > 30) received a diaphragmatic patch, while the other 13 underwent primary surgical repair. Individual DDRs at initial and at follow-up in-vivo fetal MRI correlated significantly (P < 0.001). CONCLUSIONS MRI-based 3D reconstruction of the fetal diaphragm in CDH has been validated to visualize, locate, classify and quantify the defect. Planning of postnatal surgery may be optimized by MRI-based prediction of the necessity for patch placement and the ability to personalize patch design based on 3D-printable templates. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F. Prayer
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - M. Metzelder
- Department of Surgery, Division of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - W. Krois
- Department of Surgery, Division of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - P. C. Brugger
- Center for Anatomy and Cell Biology, Department of AnatomyMedical University of ViennaViennaAustria
| | - G. M. Gruber
- Center for Anatomy and Cell Biology, Department of AnatomyMedical University of ViennaViennaAustria
| | - M. Weber
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - A. Scharrer
- Department of PathologyMedical University of ViennaViennaAustria
| | - A. Rokitansky
- Department of Pediatric Surgery, Social Medical Centre EastDanube HospitalViennaAustria
| | - G. Langs
- Computational Imaging Research Lab, Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - D. Prayer
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - E. Unger
- Center of Medical Physics and Biomedical EngineeringMedical University of ViennaViennaAustria
| | - G. Kasprian
- Department of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
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41
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Gaffar S, Ellini AR, Ahmad I, Chen Y, Ashrafi AH. Left ventricular cardiac output is a reliable predictor of extracorporeal life support in neonates with congenital diaphragmatic hernia. J Perinatol 2019; 39:648-653. [PMID: 30837654 DOI: 10.1038/s41372-019-0348-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 01/19/2019] [Accepted: 01/23/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Congenital diaphragmatic hernia (CDH) is a treatable condition but despite optimal management, some patients require extracorporeal life support (ECLS). This study evaluates the association of left ventricular (LV) cardiac output and the need for ECLS. STUDY DESIGN Single center, retrospective chart review from 1/1/2012 through 7/1/2018. Twenty-seven patients met criteria for evaluation with six patients (22%) requiring ECLS. Echocardiography was used to assess ventricular function. RESULTS There was a statistically significant decrease in LV cardiac index of 1.33 L /min/m2 vs 1.80 L /min/m2 (p = 0.04) for patients requiring ECLS and non-ECLS, respectively. There was no difference between the 2 groups with regards to vasoactive medication use, surfactant use, iNO use, severity of pulmonary hypertension, or right ventricular (RV) function. CONCLUSION In newborns with CDH, decreased LV cardiac output is more strongly associated with need for ECLS than severity of pulmonary hypertension or RV dysfunction.
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Affiliation(s)
- Sharib Gaffar
- CHOC Children's Hospital, Department of Pediatrics, University of California Irvine, Orange, CA, USA
| | - Ahmad R Ellini
- CHOC Children's Hospital, Division of Pediatric Cardiology, Orange, CA, USA
| | - Irfan Ahmad
- CHOC Children's Hospital, Division of Neonatology, Orange, CA, USA
| | - Yanjun Chen
- Department of Biostatistics, Epidemiology, and Research Design, University of California Irvine, Orange, CA, USA
| | - Amir H Ashrafi
- CHOC Children's Hospital, Division of Neonatology, Orange, CA, USA.
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42
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Montalva L, Antounians L, Zani A. Pulmonary hypertension secondary to congenital diaphragmatic hernia: factors and pathways involved in pulmonary vascular remodeling. Pediatr Res 2019; 85:754-768. [PMID: 30780153 DOI: 10.1038/s41390-019-0345-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/10/2019] [Indexed: 02/06/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth defect that is characterized by pulmonary hypoplasia and pulmonary hypertension (PHTN). PHTN secondary to CDH is a result of vascular remodeling, a structural alteration in the pulmonary vessel wall that occurs in the fetus. Factors involved in vascular remodeling have been reported in several studies, but their interactions remain unclear. To help understand PHTN pathophysiology and design novel preventative and treatment strategies, we have conducted a systematic review of the literature and comprehensively analyzed all factors and pathways involved in the pathogenesis of pulmonary vascular remodeling secondary to CDH in the nitrofen model. Moreover, we have linked the dysregulated factors with pathways involved in human CDH. Of the 358 full-text articles screened, 75 studies reported factors that play a critical role in vascular remodeling secondary to CDH. Overall, the impairment of epithelial homeostasis present in pulmonary hypoplasia results in altered signaling to endothelial cells, leading to endothelial dysfunction. This causes an impairment of the crosstalk between endothelial cells and pulmonary artery smooth muscle cells, resulting in increased smooth muscle cell proliferation, resistance to apoptosis, and vasoconstriction, which clinically translate into PHTN.
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Affiliation(s)
- Louise Montalva
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Lina Antounians
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Augusto Zani
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada. .,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada.
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Kipfmueller F, Heindel K, Geipel A, Berg C, Bartmann P, Reutter H, Mueller A, Holdenrieder S. Expression of soluble receptor for advanced glycation end products is associated with disease severity in congenital diaphragmatic hernia. Am J Physiol Lung Cell Mol Physiol 2019; 316:L1061-L1069. [PMID: 30838867 DOI: 10.1152/ajplung.00359.2018] [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: 02/08/2023] Open
Abstract
Pulmonary hypertension (PH) and lung hypoplasia are major contributors to morbidity and mortality in newborns with congenital diaphragmatic hernia (CDH). The soluble receptor for advanced glycation end products (sRAGE) is a marker of endothelial function and might be associated with disease severity in CDH newborns. In a cohort of 30 CDH newborns and 20 healthy control newborns, sRAGE concentration was measured at birth and at 6 h, 12 h, 24 h, 48 h, and 7-10 days. In healthy newborns, sRAGE was significantly higher at birth and at 48 h compared with CDH newborns (both P < 0.001). Among CDH newborns, sRAGE was significantly lower at birth (P = 0.033) and at 7-10 days (P = 0.035) in patients receiving extracorporeal membrane oxygenation (ECMO) compared with patients not receiving ECMO. In contrast, CDH newborns receiving ECMO had significantly higher values at 6 h (P = 0.001), 12 h (P = 0.004), and 48 h (0.032). Additionally, sRAGE correlated significantly with PH severity, intensity and duration of mechanical ventilation, and prenatally assessed markers of CDH severity (lung size, liver herniation). The probability to receive ECMO therapy was five times higher in CDH newborns with sRAGE concentrations below the calculated cutoff of 650 pg/ml at birth (P = 0.002) and nine times higher in CDH newborns with sRAGE concentrations above the cutoff of 3,500 pg/ml at 6 h (P = 0.001). These findings suggest a potential involvement of sRAGE in the pathophysiology of CDH and may act as a therapeutic target in future treatment approaches.
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Affiliation(s)
- Florian Kipfmueller
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn , Bonn , Germany
| | - Katrin Heindel
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn , Bonn , Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University of Bonn , Bonn , Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University of Bonn , Bonn , Germany
| | - Peter Bartmann
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn , Bonn , Germany
| | - Heiko Reutter
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn , Bonn , Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn , Bonn , Germany
| | - Stefan Holdenrieder
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn , Bonn , Germany.,Institute for Laboratory Medicine, German Heart Center of the State of Bavaria and the Technical University Munich , Munich , Germany
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Lawrence KM, Berger K, Herkert L, Franciscovich C, O'Dea CLH, Waqar LN, Partridge E, Hanna BD, Peranteau WH, Avitabile CM, Hopper RK, Rintoul NE, Hedrick HL. Use of prostaglandin E1 to treat pulmonary hypertension in congenital diaphragmatic hernia. J Pediatr Surg 2019; 54:55-59. [PMID: 30442461 DOI: 10.1016/j.jpedsurg.2018.10.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Prostaglandin E1 (PGE) has been used to maintain ductus arteriosus patency and unload the suprasystemic right ventricle (RV) in neonates with congenital diaphragmatic hernia (CDH) and severe pulmonary hypertension (PH). Here we evaluate the PH response in neonates with CDH and severe PH treated with PGE. METHODS We performed a retrospective chart review of CDH infants treated at our center between 2011 and 2016. In a subset, PGE was initiated for echocardiographic evidence of severe PH, metabolic acidosis, or hypoxemia. To assess PH response, we evaluated laboratory data, including B-type natriuretic peptide (BNP) and echocardiograms before and after PGE treatment. Categorical and continuous data were analyzed with Fisher's exact tests and Mann-Whitney t-tests, respectively. RESULTS Fifty-seven infants were treated with PGE a mean 17 ± 2 days. BNP levels declined after 1.4 ± 0.2 days of treatment and again after 5.2 ± 0.6 days. After 6 ± 0.8 days of treatment, echocardiographic estimates of severe PH by tricuspid regurgitation jet velocity, ductus arteriosus direction, and ventricular septum position also improved significantly. Treatment was not associated with postductal hypoxemia or systemic hypoperfusion. CONCLUSIONS In patients with CDH and severe PH, PGE is well tolerated and associated with improved BNP and echocardiographic indices of PH, suggesting successful unloading of the RV. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kendall M Lawrence
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kelsey Berger
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christine Franciscovich
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carol Lynn H O'Dea
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lindsay N Waqar
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily Partridge
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian D Hanna
- Department of Pediatrics, Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania
| | - Catherine M Avitabile
- Department of Pediatrics, Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania
| | - Rachel K Hopper
- Department of Pediatrics, Lucille Packard Children's Hospital, Palo Alto, California
| | - Natalie E Rintoul
- Department of Pediatrics, Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania.
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Congenital diaphragmatic hernia repair in patients on extracorporeal membrane oxygenation: How early can we repair? J Pediatr Surg 2019; 54:50-54. [PMID: 30482539 DOI: 10.1016/j.jpedsurg.2018.10.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The benefits to early repair (<72 h postcannulation) of infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) are increasingly recognized. Yet it is not known if even earlier repair (<24 h) results in comparable or improved patient outcomes. The goal of this study was to compare "super-early" (<24 h) to early repair (24-72 h) of CDH patients on ECMO. METHODS A retrospective review of infants with CDH placed on ECMO (2004-2017; n = 72) was performed. Data collected on the patients repaired while on ECMO within 72 h of cannulation (n = 33) included pre- and postnatal disease severity stratification variables and postnatal outcomes. Comparison groups were those patients repaired within 24 h of cannulation (n = 14) and those repaired between 24 and 72 h postcannulation (n = 19). RESULTS Patients undergoing "super-early" (<24 h) repair had an average survival of 71.4% compared to the average survival of 59.7% in the early repair group. Pre- and postnatal variables predicting disease severity were not significantly different between the groups. Mean hospital stays, ventilator days, and cannulation days were statistically similar between the groups. CONCLUSIONS Repair of patients with CDH patients on ECMO at less than 24 h postcannulation achieves outcomes that are comparable to those of repair between 24 and 72 h. While the present data suggest that there is not a "too early" time point for CDH repair on ECMO, larger multicenter studies are needed to validate our findings and determine the overall benefits. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Antenatal sildenafil administration to prevent pulmonary hypertension in congenital diaphragmatic hernia (SToP-PH): study protocol for a phase I/IIb placenta transfer and safety study. Trials 2018; 19:524. [PMID: 30261903 PMCID: PMC6161420 DOI: 10.1186/s13063-018-2897-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/31/2018] [Indexed: 01/28/2023] Open
Abstract
Background Congenital diaphragmatic hernia is an orphan disease with high neonatal mortality and significant morbidity. An important cause for this is pulmonary hypertension, for which no effective postnatal therapy is available to date. An innovative strategy aiming at treating or preventing pulmonary hypertension more effectively is urgently needed. Prenatal sildenafil administration to expectant mothers prevented fetal and neonatal vascular changes leading to pulmonary hypertension in several animal models, and is, therefore, a promising approach. Before transferring this antenatal medical approach to the clinic, more information is needed on transplacental transfer and safety of sildenafil in humans. Methods This is a randomized, investigator-blinded, double-armed, parallel-group, phase I/IIb study with as a primary objective to measure the in-vivo transplacental transfer of sildenafil in women in the second and early third trimester of pregnancy (sub-study 1; weeks: 20.0–32.6) and at term (sub-study 2; weeks: 36.6–40). Participants will be randomized to two different sildenafil doses: 25 or 75 mg. In sub-study 1, a single dose of the investigational product will be administered to women undergoing termination of pregnancy, and maternal and fetal blood samples will be collected for determination of sildenafil concentrations. In sub-study 2, sildenafil will be administered three times daily from 3 days before planned delivery until actual delivery, following which maternal and umbilical cord samples will be collected. Proxies of maternal and fetal tolerance as well as markers of fetal pulmonary vasodilation will also be measured. Discussion This is the first study evaluating in-vivo transplacental passage of sildenafil in humans. Trial registration EU Clinical Trials Register 2016–002619-17, validated on 12 August 2016. Trial sponsor: UZ Leuven, Herestraat 49, 3000 Leuven. Electronic supplementary material The online version of this article (10.1186/s13063-018-2897-8) contains supplementary material, which is available to authorized users.
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Abstract
Although patent ductus arteriosus is essential in fetal life, interventions to close or minimize the adverse hemodynamic effects associated with the left-to-right shunt are often needed after birth, especially in extremely premature infants. However, there are clinical conditions where maintaining patency of the ductus is essential for survival. In this article we discuss use of prostaglandin E1 in the management of congenital heart defects, pulmonary hypertension and left ventricular failure in early neonatal period.
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Affiliation(s)
- Jennifer Shepherd
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kai-Hsiang Hsu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Circulating microRNAs are associated with Pulmonary Hypertension and Development of Chronic Lung Disease in Congenital Diaphragmatic Hernia. Sci Rep 2018; 8:10735. [PMID: 30013141 PMCID: PMC6048121 DOI: 10.1038/s41598-018-29153-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/28/2018] [Indexed: 01/16/2023] Open
Abstract
Pulmonary hypertension (PH) contributes to high mortality in congenital diaphragmatic hernia (CDH). A better understanding of the regulatory mechanisms underlying the pathology in CDH might allow the identification of prognostic biomarkers and potential therapeutic targets. We report the results from an expression profiling of circulating microRNAs (miRNAs) in direct post-pulmonary blood flow of 18 CDH newborns. Seven miRNAs differentially expressed in children that either died or developed chronic lung disease (CLD) up to 28 days after birth, compared to those who survived without developing CLD during this period, were identified. Target gene and pathway analyses indicate that these miRNAs functions include regulation of the cell cycle, inflammation and morphogenesis, by targeting molecules responsive to growth factors, cytokines and cellular stressors. Furthermore, we identified hub molecules by constructing a protein-protein interaction network of shared targets, and ranked the relative importance of the identified miRNAs. Our results suggest that dysregulations in miRNAs let-7b-5p, -7c-5p, miR-1307-3p, -185-3p, -8084, -331-3p and -210-3p may be detrimental for the development and function of the lungs and pulmonary vasculature, compromise cardiac function and contribute to the development of CLD in CDH. Further investigation of the biomarker and therapeutic potential of these circulating miRNAs is encouraged.
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Kipfmueller F, Schroeder L, Berg C, Heindel K, Bartmann P, Mueller A. Continuous intravenous sildenafil as an early treatment in neonates with congenital diaphragmatic hernia. Pediatr Pulmonol 2018; 53:452-460. [PMID: 29316358 DOI: 10.1002/ppul.23935] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 12/02/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is an important contributor of morbidity and mortality in infants with congenital diaphragmatic hernia (CDH). Treatment options are limited, but sildenafil might improve oxygenation and PH in neonates with CDH. OBJECTIVE Aim of this study is to assess effects of intravenous sildenafil on oxygenation and PH in neonates with CDH. METHODS A retrospective chart review was performed in all neonates with CDH born in our institution between September 2012 and December 2014. Indication for sildenafil was an OI > 15, PH > 2/3 systemic pressure, or a difference in pre- and postductal oxygen saturation (≥8%). A sildenafil bolus was administered followed by a maintenance infusion of 1.6 mg/kg/d. Primary outcome was improved oxygenation after starting sildenafil. Patients were compared according to improvement in oxygenation (responder vs non-responder). RESULTS A total of 26 of 44 neonates were treated with intravenous sildenafil and in all sildenafil were initiated within the first 24 h of life (median age 3.1 h). Improved oxygenation was observed in 11 infants (42.3%). Among the 15 non-responders (57.6%) ECMO was started in 13 and two infants died without ECMO. Vasopressor support increased significantly during the first hours after commencing sildenafil in responders and non-responders. Echocardiographic indices demonstrated an effect on pulmonary arterial pressure within the first 24 h after starting sildenafil. CONCLUSIONS Treatment of neonates with intravenous sildenafil during the first day of life was associated with acute improvement in oxygenation in more than 40% of patients. However, a significant increase in vasopressor support was observed.
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Affiliation(s)
- Florian Kipfmueller
- Department of Neonatology and Pediatric Critical Care Medicine, University Children's Hospital Bonn, Bonn, Germany
| | - Lukas Schroeder
- Department of Neonatology and Pediatric Critical Care Medicine, University Children's Hospital Bonn, Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University of Bonn Medical Center, Bonn, Germany
| | - Katrin Heindel
- Department of Neonatology and Pediatric Critical Care Medicine, University Children's Hospital Bonn, Bonn, Germany
| | - Peter Bartmann
- Department of Neonatology and Pediatric Critical Care Medicine, University Children's Hospital Bonn, Bonn, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Critical Care Medicine, University Children's Hospital Bonn, Bonn, Germany
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Barrière F, Michel F, Loundou AD, Fouquet V, Kermorvant E, Blanc S, Carricaburu E, Desrumaux A, Pidoux O, Arnaud A, Berte N, Blanc T, Lavrand F, Levard G, Rayet I, Samperiz S, Schneider A, Marcoux MO, Winer N, Chaussy Y, Datin-Dorriere V, Ballouhey Q, Binet A, Muszynski C, Breaud J, Garenne A, Storme L, Boubnova J. One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register. J Pediatr 2018; 193:204-210. [PMID: 29212620 DOI: 10.1016/j.jpeds.2017.09.074] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 08/11/2017] [Accepted: 09/27/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes. STUDY DESIGN We reviewed the first-year outcome of all cases of CDH reported to the French National Register in 2011. RESULTS A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30-8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29-80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25-62). Of these survivors, 71 (76%) were followed up for 1 year. CONCLUSIONS Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.
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Affiliation(s)
- François Barrière
- Pediatric Intensive Care Unit, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France.
| | - Fabrice Michel
- Pediatric Intensive Care Unit, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Anderson D Loundou
- Department of Public Health, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Virginie Fouquet
- Department of Pediatric Surgery, Paris South University Hospitals, AP-HP, Le Kremlin-Bicêtre, France
| | - Elsa Kermorvant
- Neonatal Intensive Care Unit, Necker-Enfants Malades, AP-HP, Paris Descartes University, Paris, France
| | - Sébastien Blanc
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant University Hospital, Hospices Civils de Lyon, Bron, France
| | | | - Amélie Desrumaux
- Neonatal Intensive Care Unit, Couple-Enfant Hospital, Grenoble, France
| | - Odile Pidoux
- Department of Neonatology, University Hospital, Montpellier, France
| | - Alexis Arnaud
- Department of Pediatric Surgery, Hôpital Sud, University Hospital, Rennes, France
| | - Nicolas Berte
- Department of Surgery, University Hospital, Nancy, France
| | - Thierry Blanc
- Neonatal Intensive Care Unit, University Hospital, Rouen, France
| | - Frederic Lavrand
- Department of Pediatric Surgery, University of Bordeaux, Pellegrin-Enfant Hospital, Bordeaux, France
| | - Guillaume Levard
- Department of Pediatric Surgery, University Hospital, Poitiers, France
| | - Isabelle Rayet
- Neonatal and Pediatric Intensive Care Unit, Hôpital Nord, Saint-Etienne, France
| | - Sylvain Samperiz
- Neonatal and Pediatric Intensive Care Unit, Felix Guyon Hospital, La Réunion, France
| | - Anne Schneider
- Department of Pediatric Surgery, Hautepierre Hospital University Medical Center, Strasbourg, France
| | | | - Norbert Winer
- Department of Gynecology and Obstetrics, Hôtel-Dieu University Hospital, Nantes, France
| | - Yann Chaussy
- Department of Pediatric Surgery, Jean Minjoz University Hospital, Besançon, France
| | | | - Quentin Ballouhey
- Department of Pediatric Surgery, University Hospital, Limoges, France
| | - Aurélien Binet
- Department of Pediatric Surgery, Clocheville University Hospital, Tours, France
| | - Charles Muszynski
- Department of Obstetrics and Gynecology, Amiens University Hospital, Amiens, France
| | - Jean Breaud
- Department of Pediatric Surgery, Nice Pediatric Hospital, University of Nice-Sophia Antipolis, Nice, France
| | - Armelle Garenne
- Pediatric Department, Brest University Hospital, Brest, France
| | - Laurent Storme
- Department of Neonatal Medicine, Lille University Hospital, Lille, France
| | - Julia Boubnova
- Department of Pediatric Surgery, La Timone Children Hospital, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
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