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Vellvé K, Garcia-Canadilla P, Nogueira M, Youssef L, Arranz A, Nakaki A, Boada D, Blanco I, Faner R, Figueras F, Agustí À, Gratacós E, Crovetto F, Bijnens B, Crispi F. Pulmonary vascular reactivity in growth restricted fetuses using computational modelling and machine learning analysis of fetal Doppler waveforms. Sci Rep 2024; 14:5919. [PMID: 38467666 PMCID: PMC10928161 DOI: 10.1038/s41598-024-54603-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
The aim of this study was to investigate the pulmonary vasculature in baseline conditions and after maternal hyperoxygenation in growth restricted fetuses (FGR). A prospective cohort study of singleton pregnancies including 97 FGR and 111 normally grown fetuses was carried out. Ultrasound Doppler of the pulmonary vessels was obtained at 24-37 weeks of gestation and data were acquired before and after oxygen administration. After, Machine Learning (ML) and a computational model were used on the Doppler waveforms to classify individuals and estimate pulmonary vascular resistance (PVR). Our results showed lower mean velocity time integral (VTI) in the main pulmonary and intrapulmonary arteries in baseline conditions in FGR individuals. Delta changes of the main pulmonary artery VTI and intrapulmonary artery pulsatility index before and after hyperoxygenation were significantly greater in FGR when compared with controls. Also, ML identified two clusters: A (including 66% controls and 34% FGR) with similar Doppler traces over time and B (including 33% controls and 67% FGR) with changes after hyperoxygenation. The computational model estimated the ratio of PVR before and after maternal hyperoxygenation which was closer to 1 in cluster A (cluster A 0.98 ± 0.33 vs cluster B 0.78 ± 0.28, p = 0.0156). Doppler ultrasound allows the detection of significant changes in pulmonary vasculature in most FGR at baseline, and distinct responses to hyperoxygenation. Future studies are warranted to assess its potential applicability in the clinical management of FGR.
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Affiliation(s)
- Kilian Vellvé
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Patricia Garcia-Canadilla
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Interdisciplinary Cardiovascular Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Mariana Nogueira
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lina Youssef
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela Arranz
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ayako Nakaki
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - David Boada
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
| | - Isabel Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Pneumology Department, Respiratory Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
| | - Rosa Faner
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
| | - Francesc Figueras
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Àlvar Agustí
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Pneumology Department, Respiratory Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
- Cathedra Salud Respiratoria, University of Barcelona, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Francesca Crovetto
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | | | - Fàtima Crispi
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.
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Huntley ES, Hernandez-Andrade E, Papanna R, Bergh E, Espinoza J, Soto E, Lopez SM, Harting MT, Johnson A. Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2024; 51:191-202. [PMID: 38194948 DOI: 10.1159/000536171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/03/2024] [Indexed: 01/11/2024]
Abstract
INTRODUCTION The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH). METHODS CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated. RESULTS Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02). CONCLUSION Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eric Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Maternal Fetal Medicine, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Suzanne M Lopez
- Department of Pediatrics, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
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Weller K, Edel GG, Steegers EAP, Reiss IKM, DeKoninck PLJ, Rottier RJ, Eggink AJ, Peters NCJ. Prenatal assessment of pulmonary vasculature development in fetuses with congenital diaphragmatic hernia: A literature review. Prenat Diagn 2023; 43:1296-1309. [PMID: 37539818 DOI: 10.1002/pd.6412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/17/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
Pathophysiological studies have shown that pulmonary vascular development is impaired in fetuses with a congenital diaphragmatic hernia (CDH), leading to a simplified vascular tree and increased vascular resistance. Multiple studies have described prenatal ultrasound parameters for the assessment of the pulmonary vasculature, but none of these parameters are used in daily clinical practice. We provide a comprehensive review of the literature published between January 1990 and February 2022 describing these parameters, and aim to explain the clinical relevance of these parameters from what is known from pathophysiological studies. Prenatal detection of a smaller diameter of the contralateral (i.e. contralateral to the diaphragmatic defect) first branch of the pulmonary artery (PA), higher pulsatility indices (PI), higher peak early diastolic reverse flow values, and a lower vascularization index seem of added value for the prediction of survival and, to a lesser extent, morbidity. Integration within the routine evaluation is complicated by the lack of uniformity of the methods used. To address the main components of the pathophysiological changes, we recommend future prenatal studies in CDH with a focus on PI values, PA diameters and pulmonary vascular branching.
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Affiliation(s)
- Katinka Weller
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gabriëla G Edel
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robbert J Rottier
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Huntley ES, Hernandez-Andrade E, Fishel Bartal M, Papanna R, Bergh EP, Lopez S, Soto E, Harting MT, Johnson A. Does Prediction of Neonatal Mortality by the Observed/Expected Lung-To-Head Ratio Change during Pregnancy in Fetuses with Left Congenital Diaphragmatic Hernia? Fetal Diagn Ther 2023; 50:438-445. [PMID: 37285832 DOI: 10.1159/000531406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate prediction of neonatal mortality in fetuses with isolated left congenital diaphragmatic hernia (CDH) when the observed/expected lung-to-head ratio (O/E LHR) was estimated at two different gestational time points during pregnancy. METHODS Forty-four (44) fetuses with isolated left CDH were included. O/E LHR was estimated at the time of referral (first scan) and before delivery (last scan). The main outcome was neonatal death due to respiratory complications. RESULTS There were 10/44 (22.7%) perinatal deaths. The areas under (AU) the ROC curves were: first scan, 0.76, best O/E LHR cut-off 35.5% with 76% sensitivity and 70% specificity; last scan, AU-ROC 0.79, best O/E LHR cut-off 35.2%, with 79.0% sensitivity and 80% specificity. Considering an O/E LHR cut-off ≤35% to define high-risk fetuses at any examination, prediction for perinatal mortality showed: 80% sensitivity, 73.5% specificity, 47.1% positive and 92.6% negative predictive values, and 3.02 (95% CI 1.59-5.73) positive and 0.27 (95% CI 0.08-0.96) negative likelihood ratios. Prediction was similar in the two evaluations as 16/21 (76.2%) of fetuses considered at risk had an O/E LHR ≤35% in the two examinations; in the remaining 5 cases, two were identified only in the first and three only in the last scan. CONCLUSION The O/E LHR is a good predictor of perinatal death in fetuses with left isolated CDH. Approximately 80% of fetuses at risk of perinatal death can be identified with an O/E LHR ≤35%, and 90% of them will have similar O/E LHR values at the first and at the last ultrasound examinations prior to delivery. In general, 88.6% of all CDH fetuses have a similar severity classification based on the O/E LHR at the first diagnostic ultrasound or at the ultrasound examination prior to delivery.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Michal Fishel Bartal
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Eric P Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Suzanne Lopez
- Department of Pediatrics Neonatology services, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Maternal Fetal Medicine Division, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
- Department of Pediatrics Neonatology services, McGovern Medical School at The University of Texas, Health Science Center, Houston, Texas, USA
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Moon-Grady AJ, Byrne FA, Lusk LA, Keller RL. Expected small left heart size in the presence of congenital diaphragmatic hernia: Fetal values and Z-scores for infants confirmed to have no heart disease postnatally. Front Pediatr 2022; 10:1083370. [PMID: 36561485 PMCID: PMC9763578 DOI: 10.3389/fped.2022.1083370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In fetuses with left-sided congenital diaphragmatic hernia (CDH), left heart structures may appear small, but usually normalize after birth in the absence of structural cardiac anomalies. To decrease the possibility of an erroneous diagnosis of structural heart disease, we identify normal values for left heart structures in the presence of left CDH and secondarily investigate the relationship of left heart size and survival to neonatal hospital discharge. METHODS Left heart structures [mitral valve (MV) and aortic valve (AoV) annulus diameter, left ventricle (LV) length and width] were measured by fetal echocardiogram in fetuses with left CDH and no congenital heart disease. We generated linear regression models to establish the relationship of gestational age for each left heart structure using data from fetuses who survived after birth. We calculated z-scores (normalized to gestational age), and assessed the relationship of survival to the size of each structure. RESULTS One hundred forty-two fetuses underwent fetal echocardiogram (median 25 weeks' gestation, IQR 23, 27 weeks). Left heart structures were deemed small when using published normative data from unaffected fetuses (z-scores: MV -1.09 ± 1.35, AoV -2.12 ± 1.16, LV length -1.36 ± 1.24, LV width -4.79 ± 0.79). CDH-specific models derived from log-transformed values yielded left-shifted distributions, reflecting the small structures (mean z-score lower by: MV 0.99 ± 0.30, AoV 2.04 ± 0.38, LV length 1.30 ± 0.36, and LV width 4.69 ± 0.28; p < 0.0001 for all comparisons). Non-survivors had worse z-scores than survivors for all measurements, but this did not reach statistical significance. CONCLUSIONS Log-transformed linear models generated new normative data for fetal left heart structures in left CDH, which may be used to allay antenatal concerns regarding structural left heart anomalies. There were no significant differences in z-scores between survivors and non-survivors, suggesting that in the absence of true structural disease, cardiac evaluation is not predictive in isolation and that causes of mortality are likely multifactorial in this population.
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Affiliation(s)
- Anita J Moon-Grady
- Division of Pediatric Cardiology, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States.,Fetal Treatment Center, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States
| | - Francesca A Byrne
- Pacific Cardiovascular Associates, Pediatric Cardiology, Orange, CA, United States
| | - Leslie A Lusk
- Division of Neonatology, Department of Pediatrics UCSF Benioff Children's Hospital, Oakland, CA, United States
| | - Roberta L Keller
- Fetal Treatment Center, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States.,Division of Neonatology, University of California San Francisco, Benioff Children's Hospital, San Francisco CA, United States
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6
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Basurto D, Fuenzalida J, Martinez-Portilla RJ, Russo FM, Pertierra A, Martínez JM, Deprest J, Gratacós E, Gómez O. Intrapulmonary artery Doppler to predict mortality and morbidity in fetuses with mild or moderate left-sided congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2021; 58:590-596. [PMID: 34090307 DOI: 10.1002/uog.23701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/17/2021] [Accepted: 05/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES In fetuses with isolated left-sided congenital diaphragmatic hernia (LCDH), prenatal detection of severe pulmonary hypoplasia is important, as fetal therapy can improve survival. Cases with mild or moderate lung hypoplasia still carry a considerable risk of mortality and morbidity, but there has been less interest in the accurate prediction of outcome in these cases. In this study of fetuses with mild or moderate isolated LCDH, we aimed to investigate: (1) the association between intrapulmonary artery (IPA) Doppler findings and mortality at discharge; (2) whether adding IPA Doppler findings improves the prediction of mortality based on lung size and liver herniation; and (3) the association between IPA Doppler findings and early neonatal morbidity. METHODS This was a retrospective study of all consecutive fetuses assessed at the BCNatal and UZ Leuven hospitals between 2008 and 2020 with a prenatal diagnosis of isolated, non-severe LCDH, defined as observed-to-expected lung-to-head ratio (o/e-LHR) > 25%, that were managed expectantly during pregnancy followed by standardized neonatal management. An additional inclusion criterion was the availability of IPA Doppler measurements. The primary outcome was the association between IPA Doppler findings and mortality at discharge. Other predictors included o/e-LHR, liver herniation and gestational age at birth. Secondary outcomes were the association between IPA Doppler findings and the presence of pulmonary hypertension (PHT), need for supplemental oxygen at discharge and need for extracorporeal membrane oxygenation. IPA pulsatility index (PI) values were converted into Z-scores. Logistic regression analysis was performed to investigate the associations between predictor variables and outcome, and the best model was chosen based on the Nagelkerke R2 . RESULTS Observations for 70 non-severe LCDH cases were available. Fifty-four (77%) fetuses survived until discharge. On logistic regression analysis, higher IPA-PI was associated with an increased risk of mortality (odds ratio (OR), 3.96 (95% CI, 1.62-9.70)), independently of o/e-LHR (OR, 0.87 (95% CI, 0.79-0.97)). An IPA-PI Z-score cut-off of 1.8 predicted mortality with a detection rate of 69% and specificity of 93%. Adding IPA-PI to o/e-LHR improved significantly the model's performance (Nagelkerke R2 , 46% for o/e-LHR + IPA-PI vs 28% for o/e-LHR (P < 0.002)), with a detection rate of 81% at a 10% false-positive rate. IPA-PI was associated with PHT (OR, 2.20 (95% CI, 1.01-4.59)) and need for oxygen supplementation at discharge (OR, 1.90 (95% CI, 1.10-3.40)), independently of lung size. CONCLUSIONS In fetuses with mild or moderate LCDH, IPA-PI was associated with mortality and morbidity, independently of lung size. A model combining o/e-LHR with IPA-PI identified up to four in five cases that eventually died, despite being considered to have non-severe pulmonary hypoplasia. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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MESH Headings
- Extracorporeal Membrane Oxygenation/statistics & numerical data
- Female
- Fetal Diseases/diagnostic imaging
- Fetal Diseases/mortality
- Fetus/diagnostic imaging
- Fetus/embryology
- Fetus/pathology
- Head/diagnostic imaging
- Head/embryology
- Head/pathology
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/mortality
- Humans
- Hypertension, Pulmonary/congenital
- Hypertension, Pulmonary/diagnostic imaging
- Hypertension, Pulmonary/embryology
- Infant, Newborn
- Logistic Models
- Lung/diagnostic imaging
- Lung/embryology
- Lung/pathology
- Morbidity
- Odds Ratio
- Predictive Value of Tests
- Pregnancy
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/embryology
- Pulsatile Flow
- Retrospective Studies
- Ultrasonography, Doppler/statistics & numerical data
- Ultrasonography, Prenatal/statistics & numerical data
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Affiliation(s)
- D Basurto
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Fuenzalida
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - R J Martinez-Portilla
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - F M Russo
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - A Pertierra
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Clinical Department of Neonatology, Sant Joan de Déu University Hospital, Barcelona, Spain
| | - J M Martínez
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - J Deprest
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - E Gratacós
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - O Gómez
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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7
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Abstract
OBJECTIVE To compare Doppler blood flow velocity measures in the right and left proximal branch of the fetal pulmonary artery at 30 gestational weeks. METHODS Doppler blood flow velocity waveforms were recorded in both fetal proximal pulmonary artery branches in 62 healthy fetuses at 30 gestational weeks. Pulsatility index, peak systolic velocity, time averaged maximum velocity, time velocity integral, fetal heart rate, acceleration- and ejection time with their ratio, time of one heart cycle and time velocity integral were recorded. Paired-samples t-test was used to compare measures from the right and left pulmonary branch. RESULTS We observed significantly higher peak systolic velocity, time averaged maximum velocity, time velocity integral, acceleration time and acceleration time/ejection time ratio in the right compared to the left pulmonary artery (p < .001). Sampling angle, pulsatility index, fetal heart rate, ejection time and time of one heart cycle were similar in both pulmonary branches. CONCLUSION Our study conducted at 30 weeks gestational age found significantly different blood flow velocity waveform measures in the right and left pulmonary artery branches in contrast to previous reports of similar velocities.
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Affiliation(s)
- Katarina Hilde
- Division of Gynaecology and Obstetrics, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Karin C Lødrup Carlsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Guttorm Haugen
- Division of Gynaecology and Obstetrics, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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8
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Cruz-Martinez R, Martínez-Rodríguez M, Nieto-Castro B, Gámez-Varela A, Cruz-Lemini M, Luna-García J, Juárez-Martínez I. Longitudinal changes in lung size and intrapulmonary-artery Doppler during the second half of pregnancy in fetuses with congenital diaphragmatic hernia. Prenat Diagn 2018; 39:45-51. [PMID: 30511776 DOI: 10.1002/pd.5401] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 11/24/2018] [Accepted: 11/28/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of the study are to evaluate longitudinal changes in lung size and intrapulmonary-artery (IPa) Doppler in fetuses with congenital diaphragmatic hernia (CDH) and assess their contribution in predicting neonatal survival. METHODS The observed/expected lung-to-head ratio (O/E-LHR) and IPa-pulsatility index (PI) and peak early diastolic reversed flow (PEDRF) were evaluated in a cohort of left-sided CDH fetuses managed expectantly during pregnancy. Longitudinal changes were analyzed by multilevel analysis, and their value to predict survival using the multiple logistic regression and decision-tree analysis was assessed. RESULTS A total of 232 scans were performed on 69 CDH fetuses. The O/E-LHR values remained unchanged during fetal monitoring, whereas IPa-PI and PEDRF showed a progressive increase throughout follow-up, becoming abnormal on average at 30 weeks of gestation. Absent/reversed end-diastolic velocity (EDV) in the IPa was observed in 20.3%. O/E-LHR and IPa Doppler indices were significantly associated with probability of survival (O/E-LHR ≥ 26%, odds ratio [OR] 19.0; IPa-PI <+2.0 z score, OR 3.0; and positive EDV, OR 7.4). All cases with IPa-reversed EDV died after birth. CONCLUSION While lung size remains stable during pregnancy, CDH fetuses show progressive deterioration in intrapulmonary blood flow. IPa Doppler evaluation may aid in predicting survival of CDH fetuses managed expectantly during pregnancy.
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Affiliation(s)
- Rogelio Cruz-Martinez
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Miguel Martínez-Rodríguez
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Belén Nieto-Castro
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Alma Gámez-Varela
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Monica Cruz-Lemini
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Jonahtan Luna-García
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Israel Juárez-Martínez
- Department of Fetal Surgery, Children and Women's Specialty Hospital of Queretaro, Queretaro, Mexico Fetal Medicine Mexico Foundation, Queretaro, Mexico
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9
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Russo FM, Eastwood MP, Keijzer R, Al-Maary J, Toelen J, Van Mieghem T, Deprest JA. Lung size and liver herniation predict need for extracorporeal membrane oxygenation but not pulmonary hypertension in isolated congenital diaphragmatic hernia: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 49:704-713. [PMID: 27312047 DOI: 10.1002/uog.16000] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 05/29/2016] [Accepted: 06/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To identify antenatal predictors of persistent pulmonary hypertension (PPH) and the need for extracorporeal membrane oxygenation (ECMO) in fetuses with congenital diaphragmatic hernia (CDH). METHODS We performed a systematic literature review on antenatal diagnostic tests in fetuses with isolated CDH. The primary outcomes assessed were PPH within 28 days of age and the need for ECMO. Quality of studies was assessed with the QUADAS-2 tool. Meta-analysis was performed when at least three studies reported on the same test. Sensitivity analysis was performed according to prenatal management of CDH (tracheal occlusion vs expectant management). RESULTS Thirty-eight studies met the inclusion criteria. Fifteen reported on the incidence of PPH only, 19 on the need for ECMO only and four reported on both outcomes. The general quality of the studies was moderate; most studies were retrospective (61%) and single-center series (92%). One study included only fetuses undergoing tracheal occlusion, 22 included only fetuses managed expectantly in utero and 15 included both populations. We could not identify antenatal predictors of PPH. The need for ECMO was predicted by parameters indicative of lung size: lung-to-head ratio (LHR) (relative risk (RR) for LHR < 1, 1.65 (95% CI, 1.27-2.14)) and observed/expected LHR (standardized mean difference (SMD), -0.70 (95% CI, -0.98 to -0.42)) measured by ultrasound and observed/expected total lung volume (SMD, -1.00 (95% CI, -1.52 to -0.48)) measured by magnetic resonance imaging. Liver herniation was also associated with an increased risk of need for ECMO (RR, 3.04 (95% CI, 2.23-4.14)). These results were confirmed by a sensitivity analysis of studies that included only expectantly managed cases. Data on vascular assessment for the prediction of PPH could not be pooled as most of the parameters were evaluated in a single series or in different series by the same principal investigator. CONCLUSIONS In fetuses with CDH, lung size and liver herniation predict the need for ECMO, however a predictor for PPH is still lacking. Further studies aimed at diagnosing impaired vascular development in utero should therefore be undertaken. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F M Russo
- Academic Department of Development and Regeneration, Organ Systems Cluster, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - M P Eastwood
- Academic Department of Development and Regeneration, Organ Systems Cluster, KU Leuven, Leuven, Belgium
| | - R Keijzer
- Departments of Surgery, Pediatrics & Child Health and Physiology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Biology of Breathing, Winnipeg, Manitoba, Canada
| | - J Al-Maary
- Departments of Surgery, Pediatrics & Child Health and Physiology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Biology of Breathing, Winnipeg, Manitoba, Canada
| | - J Toelen
- Academic Department of Development and Regeneration, Organ Systems Cluster, KU Leuven, Leuven, Belgium
- Clinical Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - T Van Mieghem
- Academic Department of Development and Regeneration, Organ Systems Cluster, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J A Deprest
- Academic Department of Development and Regeneration, Organ Systems Cluster, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
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10
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Derderian SC, Jayme CM, Cheng LS, Keller RL, Moon-Grady AJ, MacKenzie TC. Mass Effect Alone May Not Explain Pulmonary Vascular Pathology in Severe Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2015; 39:117-24. [PMID: 26667230 DOI: 10.1159/000434643] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/27/2015] [Indexed: 11/19/2022]
Abstract
Congenital diaphragmatic hernia (CDH) and congenital pulmonary airway malformation (CPAM) are diseases in which chest-occupying lesions can result in severe pulmonary hypoplasia. However, significant postnatal mortality due to pulmonary hypertension (PH) is more often seen in patients with CDH. We analyzed prenatal echocardiographic parameters of pulmonary vascular pathology in these groups to understand whether PH in patients with CDH is secondary to a mass effect or to underlying disease. We analyzed pre- and postnatal characteristics of 26 patients with severe CDH and 23 patients with severe CPAM from 2009 to 2012. Severe mediastinal compression, indicated by a low cardiothoracic ratio, was evident in both groups. However, fetuses with severe CDH had smaller pulmonary arteries bilaterally and higher pulsatility indices in the ipsilateral lung than those with severe CPAM. Prenatal modified McGoon indices were significantly lower in patients with CDH versus CPAM. Consistent with these prenatal measurements, postnatal PH was seen more frequently in patients with CDH compared to CPAM. Patients with severe CDH have prenatal evidence of pulmonary vascular remodeling compared to patients with severe CPAM. These results suggest a multifactorial origin for PH in CDH and support the idea of using prenatal medical therapies to promote vascular remodeling in these patients.
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11
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Cruz-Martínez R, Cruz-Lemini M, Mendez A, Illa M, García-Baeza V, Martinez JM, Gratacós E. Learning Curve for Intrapulmonary Artery Doppler in Fetuses with Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2015; 39:256-60. [DOI: 10.1159/000441026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 09/03/2015] [Indexed: 11/19/2022]
Abstract
Objective: To assess the learning curve for intrapulmonary artery Doppler in fetuses with congenital diaphragmatic hernia (CDH). Methods: Three fetal medicine fellows with the theoretic knowledge, but without prior experience, in the evaluation of intrapulmonary artery Doppler in CDH fetuses were selected. Each trainee and 1 experienced explorer assessed the intrapulmonary artery in the contralateral lung to the side of the hernia for calculation of 2 Doppler parameters - pulsatility index (PI) and peak early diastolic reversed flow (PEDRF) - in a cohort of 90 consecutive CDH fetuses. The average difference between the 3 trainees and the expert was calculated. A difference below 15% was considered as accurate measurement. The average learning curve was delineated using the cumulative sum analysis (CUSUM). Results: Among the total 270 intrapulmonary artery Doppler measurements performed by the 3 trainees, the number of failed examinations was 14 (15.6%) and 16 (17.8%) for PI and PEDRF, respectively. The CUSUM plots demonstrate that the learning curve was achieved by 53 and 63 tests performed for calculations of the intrapulmonary artery PI and PEDRF, respectively. Conclusion: Competence in Doppler evaluation of the intrapulmonary artery in CDH fetuses is achieved only after intensive continuous training.
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12
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Spaggiari E, Stirnemann JJ, Sonigo P, Khen-Dunlop N, De Saint Blanquat L, Ville Y. Prenatal prediction of pulmonary arterial hypertension in congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2015; 45:572-577. [PMID: 24976012 DOI: 10.1002/uog.13450] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/12/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the role of prenatal prognostic markers obtained routinely by ultrasound examination and magnetic resonance imaging (MRI) in the prediction of development of postnatal pulmonary arterial hypertension (PAH) in isolated congenital diaphragmatic hernia (CDH). METHODS One hundred and ten cases of isolated CDH were referred to our fetal medicine unit between January 2004 and April 2013. Mortality and morbidity rates were reviewed for those presenting with postnatal PAH. The following prenatal markers were evaluated as potential predictive factors of PAH: liver position, side of the CDH defect, lung area to head circumference ratio (LHR) and observed/expected LHR (o/e-LHR), which were measured by ultrasound, and observed/expected total fetal lung volume (o/e-TFLV), which was measured by MRI. Univariable logistic regression was used to assess associations. RESULTS PAH was significantly associated with perinatal mortality and morbidity (P < 0.001). The occurrence of PAH decreased significantly with an increasing LHR, o/e-LHR and o/e-TFLV and was significantly increased for cases with an intrathoracic liver, but not for those with right-sided defects. Univariable regression revealed that o/e-TFLV (odds ratio (OR), 0.9 (95% CI, 0.86-0.95); P < 0.05 for percentage unit change in o/e), LHR (OR, 0.19 (95% CI, 0.09-0.40); P < 0.05 for unit change), o/e-LHR (OR, 0.95 (95% CI, 0.93-0.98); P < 0.05 for percentage unit change in o/e) and liver position (OR, 2.82 (95% CI, 1.13-7.00); P < 0.05 for intrathoracic liver) were significant predictors of subsequent PAH. No differences were found after adjusting for gestational age at delivery. The areas under the receiver-operating characteristics curve were 0.80 and 0.75 for o/e-TFLV and o/e-LHR, respectively. CONCLUSION In cases of CDH, PAH is associated with high rates of mortality and morbidity. Routinely obtained prenatal markers, usually used for the assessment of pulmonary hypoplasia, are also relevant for the postnatal prediction of PAH.
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MESH Headings
- Female
- Gestational Age
- Head
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/embryology
- Hypertension, Pulmonary/pathology
- Infant, Newborn
- Liver/embryology
- Liver/pathology
- Lung/embryology
- Lung/pathology
- Lung Volume Measurements/methods
- Predictive Value of Tests
- Pregnancy
- Prognosis
- Survival Rate
- Ultrasonography, Prenatal
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Affiliation(s)
- E Spaggiari
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris, France; University Paris Descartes, Sorbonne Paris-Cité, Paris, France
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13
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Deprest J, Brady P, Nicolaides K, Benachi A, Berg C, Vermeesch J, Gardener G, Gratacos E. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med 2014; 19:338-48. [PMID: 25447987 DOI: 10.1016/j.siny.2014.09.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, and Academic Department of Development and Regeneration, Organ System Cluster, Leuven, Belgium; TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial).
| | - Paul Brady
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Kypros Nicolaides
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Harris Birthright Centre, King's College Hospital, London, UK
| | - Alexandra Benachi
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine Beclere, University Paris Sud, Clamart, France
| | - Christoph Berg
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, and Department of Obstetrics and Gynecology, University of Cologne, Germany
| | - Joris Vermeesch
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Glenn Gardener
- Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Eduard Gratacos
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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14
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Abstract
Lung hypoplasia and pulmonary hypertension are classical features of congenital diaphragmatic hernia (CDH) and represent the main determinants of survival. The mechanisms leading to pulmonary hypertension in this malformation are still poorly understood, but may combine altered vasoreactivity, pulmonary artery remodeling, and a hypoplastic pulmonary vascular bed. Efforts have been directed at correcting the "reversible" component of pulmonary hypertension of CDH. However, pulmonary hypertension in CDH is often refractory to pulmonary vasodilators. A new emerging pattern of late (months after birth) and chronic (months to years after birth) pulmonary hypertension are described in CDH survivors. The true incidence and implications for outcome and management need to be confirmed by follow-up studies from referral centers with high patient output. In order to develop more efficient strategies to treat pulmonary hypertension and improve survival in most severe cases, the ultimate therapeutic goal would be to promote lung and vascular growth.
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Affiliation(s)
- M Pierro
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Sprott Center for Stem Cell Research, Department of Pediatrics, Division of Neonatology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
| | - B Thébaud
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Sprott Center for Stem Cell Research, Department of Pediatrics, Division of Neonatology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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15
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DeKoninck P, Jimenez J, Russo FM, Hodges R, Gratacós E, Deprest J. Assessment of pulmonary vascular reactivity to oxygen using fractional moving blood volume in fetuses with normal lung development and pulmonary hypoplasia in congenital diaphragmatic hernia. Prenat Diagn 2014; 34:977-81. [DOI: 10.1002/pd.4408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/27/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Philip DeKoninck
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Julio Jimenez
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Francesca M. Russo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Ryan Hodges
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Eduard Gratacós
- Maternal-Fetal Medicine Department; Institut Clínic de Ginecologia, Obstetrícia i Neonatologia (ICGON), Hospital Clínic; Barcelona Spain
- Institut d'Investigacions Biomèdiques Augusto Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
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16
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Prat Ortells J, Albert A, Tarrado X, Krauel L, Cruz R, Moreno-Álvarez Ó, Fuste V, Castañón M. Airway and vascular maturation stimulated by tracheal occlusion do not correlate in the rabbit model of diaphragmatic hernia. Pediatr Res 2014; 75:487-92. [PMID: 24366514 DOI: 10.1038/pr.2013.244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 07/29/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND In animal models of congenital diaphragmatic hernia (CDH), tracheal occlusion (TO) has induced maturation of both airway spaces and vascular structures. Airway and vascular response to TO are assumed to occur in parallel. This study aims to describe and measure the relationship between airway and vascular maturation induced by TO. METHODS A rabbit model of CDH on gestational day (GD) 23 and TO on GD 28 (term = GD 31) has been used. Two study groups have been defined: DH (diaphragmatic hernia) and TO (DH treated with TO). Animals were collected on GD 30 and blood flow data of the pulmonary artery (pulsatility index (PI) and fractional moving blood volume) were ultrasonographically measured. Lung morphometry consisted of measurements of radial alveolar count (RAC) and arterial muscular thickness. RESULTS Animals in the DH group (n = 9) had the worst hemodynamic parameters; their lungs were hypoplastic and had the thickest arterial muscular layer. Animals in the TO group (n = 10) had all these effects reversed. There were no correlations among hemodynamic, airway, and vascular parameters, except for RAC and PI (r = -0.528, P = 0.043). CONCLUSION Airway and vascular maturation after TO appear to be uncorrelated effects. TO could trigger several pathways that separately regulate airway and vascular responses.
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Affiliation(s)
- Jordi Prat Ortells
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Asteria Albert
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Lucas Krauel
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Rogelio Cruz
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Óscar Moreno-Álvarez
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Victoria Fuste
- Department of Pathology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Montserrat Castañón
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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17
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Spaggiari E, Stirnemann J, Bernard JP, De Saint Blanquat L, Beaudoin S, Ville Y. Prognostic value of a hernia sac in congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2013; 41:286-290. [PMID: 22605546 DOI: 10.1002/uog.11189] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/30/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH). METHODS Our database was searched to identify all consecutive cases of CDH referred to our fetal medicine unit between January 2004 and August 2011. Presence or absence of a hernia sac was assessed in liveborn cases using surgery or postnatal autopsy reports. We studied the correlation between the presence of a hernia sac and prenatal findings and perinatal morbidity and mortality. RESULTS Over the study period, there were 70 cases with isolated CDH born alive in which either a surgery or autopsy report was available. Neonatal death, either preoperative or postoperative, occurred in 1/18 (5.6%) infants with a hernia sac and in 17/52 (32.7%) cases without a hernia sac (P = 0.03). Patients with a hernia sac had a significantly higher observed to expected pulmonary volume on prenatal magnetic resonance imaging (51.9 vs 39.3%, P = 0.01). Neonatal morbidity in surviving infants was lower in the group with a hernia sac, although not significantly. CONCLUSION The presence of a hernia sac is associated with a higher pulmonary volume and a better overall prognosis for CDH.
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Affiliation(s)
- E Spaggiari
- Department of Obstetrics and Maternal-Fetal Medicine, GHU Necker Enfants-Malades, AP-HP and Université Paris Descartes, Paris, France
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18
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Aubry E, Fayoux P, Jani J, Deprest J, Deruelle P, Houfflin-Debarge V, Storme L. Tracheal occlusion alters pulmonary circulation in the fetal lamb with normally developing lungs. J Pediatr Surg 2013; 48:481-7. [PMID: 23480900 DOI: 10.1016/j.jpedsurg.2012.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 07/17/2012] [Accepted: 08/14/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tracheal occlusion (TO) promotes fetal lung growth through an increase in intraluminal pressure. Although evidence suggests that fetal TO (FETO) decreases the occurrence of pulmonary hypertension in severe congenital diaphragmatic hernia, controversies on its effect on the pulmonary circulation remain. Therefore, we investigated the effects of FETO on the lung hemodynamics in a chronically catheterized fetal lamb model. METHODS Fifteen pregnant ewes were operated on between 125 and 128 days of gestation (term: 145 days). Catheters and ultrasonic flow transducer were placed through a left thoracotomy in the lamb fetus to determine aortic, pulmonary and left atrial pressures, and left pulmonary artery blood flow. A balloon was positioned between the carina and vocal cords under fetoscopic control. The animals were assigned to either control (n=6) or FETO (n=9) groups. TO was performed by inflating the balloon. We studied the acute effects of temporary (2-h) and prolonged (4-day) TO on basal pulmonary vascular tone and on the pulmonary vascular reactivity to acetylcholine and to increased fetal oxygen tension. RESULTS We found that left pulmonary blood flow (LPA) increased and pulmonary vascular resistance (PVR) decreased by 20% during brief TO (p<0.05). After balloon deflation, LPA blood flow further increased by 40%, and PVR decreased by 50% compared to baseline values (p<0.05). In contrast, no change in LPA blood flow or PVR was observed during prolonged TO. Moreover, the vasodilator responses to acetylcholine and to increased fetal PaO2 were blunted during TO. CONCLUSIONS These data indicate that antenatal tracheal occlusion promotes active pulmonary vasodilation, which is partly blunted by the mechanical effects of elevation of the intraluminal pressure.
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Affiliation(s)
- Estelle Aubry
- EA4489, Environnement Périnatal et Croissance, Faculté de Médecine, IFR 114, Université de Lille 2, France
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Cruz-Martinez R, Castañon M, Moreno-Alvarez O, Acosta-Rojas R, Martinez JM, Gratacos E. Usefulness of lung-to-head ratio and intrapulmonary arterial Doppler in predicting neonatal morbidity in fetuses with congenital diaphragmatic hernia treated with fetoscopic tracheal occlusion. Ultrasound Obstet Gynecol 2013; 41:59-65. [PMID: 22689226 DOI: 10.1002/uog.11212] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To explore the potential value of intrapulmonary artery Doppler velocimetry in predicting neonatal morbidity in fetuses with left-sided congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO). METHODS Observed/expected lung-to-head ratio (O/E-LHR), and intrapulmonary Doppler pulsatility index and peak early-diastolic reversed flow were evaluated within 24 h before FETO in a consecutive cohort of 51 fetuses with left-sided CDH at between 24 and 33 weeks' gestation. Lung Doppler parameters were converted into Z-scores and defined as abnormal if the pulsatility index had a Z-score of > 1.0 or the peak early-diastolic reversed flow had a Z-score of > 3.5. The association of O/E-LHR and Doppler velocimetry with neonatal outcome was assessed using multiple linear or logistic regression analysis adjusted for gestational age at birth. RESULTS Among the 26 fetuses that survived, 18 (69.2%) had normal and eight (30.8%) had abnormal Doppler values. O/E-LHR was not associated with neonatal morbidity in surviving fetuses. Compared with the group with normal Doppler parameters, cases with abnormal intrapulmonary Doppler were associated with a significant increase in the duration of mechanical ventilation (average increase of 21.2 (95% CI, 9.99-32.5) days; P < 0.01), conventional ventilation (15.2 (95% CI, 7.43-23.0) days; P < 0.01), high-frequency ventilation (6.34 (95% CI, 0.69-11.99) days; P < 0.05), nitric oxide therapy (5.73 (95% CI, 0.60-10.9) days; P < 0.05), oxygen support (36.5 (95% CI, 16.3-56.7) days; P < 0.01), parenteral nutrition (19.1 (95% CI, 7.53-30.7) days; P < 0.01) and stay in neonatal intensive care unit (42.7 (95% CI, 22.9-62.6) days; P < 0.001), and with significantly higher rates of high-frequency ventilation (87.5 vs. 44.4%;P < 0.05), oxygen requirement at 28 days of age (75.0 vs. 11.1%; P < 0.01), gastroesophageal reflux (62.5 vs. 22.2%; P < 0.05) and tube feeding at discharge (37.5 vs. 5.56%; P < 0.05). CONCLUSION As previously reported, O/E-LHR did not predict neonatal morbidity. In contrast, intrapulmonary artery Doppler evaluation was predictive of neonatal morbidity in CDH fetuses treated with FETO.
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Affiliation(s)
- R Cruz-Martinez
- Department of Maternal-Fetal Medicine, Institute Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
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Ruano R, da Silva MM, Campos JA, Papanna R, Moise K Jr, Tannuri U, Zugaib M. Fetal pulmonary response after fetoscopic tracheal occlusion for severe isolated congenital diaphragmatic hernia. Obstet Gynecol 2012; 119:93-101. [PMID: 22183216 DOI: 10.1097/AOG.0b013e31823d3aea] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the response in lung growth and vascularity after fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia in the prediction of neonatal survival. METHODS Between January 2006 and December 2010, fetal lung parameters (observed-to-expected lung-to-head ratio; observed-to-expected lung volume; and contralateral lung vascularization index) were evaluated before fetal tracheal occlusion and were evaluated longitudinally every 2 weeks in 72 fetuses with severe isolated congenital diaphragmatic hernia. Thirty-five fetuses underwent fetal endoscopic tracheal occlusion and 37 cases did not. RESULTS Survival rate was significantly higher in the fetal endoscopic tracheal occlusion group (54.3%) than in the no fetal endoscopic tracheal occlusion group (5.4%, P<.01). Fetal endoscopic tracheal occlusion resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with fetuses that did not go to the fetal intervention (increase of the observed-to-expected lung-to-head ratio, observed-to-expected total lung volume, and contralateral pulmonary vascularization index 56.2% compared with 0.3%, 37.9% compared with 0.1%, and 98.6% compared with 0.0%, respectively; P<.01). Receiver operating characteristic curves indicated that the observed-to-expected total fetal lung volume was the single best predictor of neonatal survival before fetal endoscopic tracheal occlusion (cutoff 0.23, area under the curve [AUC] 0.88, relative risk 5.3, 95% confidence interval [CI] 1.4-19.7). However, the contralateral lung vascularization index at 4 weeks after fetal endoscopic tracheal occlusion was more accurate in the prediction of neonatal outcome (cutoff 24.0%, AUC 0.98, relative risk 9.9, 95% CI 1.5-66.9) with the combination of observed-to-expected lung volumes and contralateral lung vascularization index at 4 weeks being the best predictor of outcome (AUC 0.98, relative risk 16.6, 95% CI 2.5-112.3). CONCLUSION Fetal endoscopic tracheal occlusion improves survival rate by increasing the lung size and pulmonary vascularity in fetuses with severe congenital diaphragmatic hernia. The pulmonary response after fetal endoscopic tracheal occlusion can be used to predict neonatal survival.
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Deprest J, De Coppi P. Antenatal management of isolated congenital diaphragmatic hernia today and tomorrow: ongoing collaborative research and development. Journal of Pediatric Surgery Lecture. J Pediatr Surg 2012; 47:282-90. [PMID: 22325377 DOI: 10.1016/j.jpedsurg.2011.11.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 11/10/2011] [Indexed: 12/29/2022]
Abstract
The diagnosis of congenital diaphragmatic hernia should be made prenatally in virtually all cases where routine maternal ultrasonography is available. At that time, the prognosis can be predicted based on whether it is isolated and assessment of lung size and/or the position of the liver. Prenatal intervention may be offered in those selected fetuses that have a predicted poor outcome. The aim of this procedure is to reverse the key determinant of survival-pulmonary hypoplasia. Percutaneous fetal endoscopic tracheal occlusion by a balloon is a minimally invasive procedure that has been shown safe and yields a 50% survival rate in severe cases. The outcome can be predicted by the gestational age at birth, the lung size before and after balloon placement, and whether the balloon has been removed prenatally. Currently, the added value of prenatal intervention is being investigated in the Tracheal Occlusion To Accelerate Lung Growth trial ((TOTAL); a European and North American collaboration). Future developments may include better prediction of outcome by more complex algorithms reflecting combinations of prenatal predictors, gene expression profiling to reflect lung development and response to tracheal occlusion, and alternative prenatal strategies for salvaging the worst cases. Fetuses with severe hypoplasia usually require postnatal operative repair using prosthetic patches, and tissue engineering offers the potential for ex utero culture.
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Ruano R, Yoshisaki CT, da Silva MM, Ceccon MEJ, Grasi MS, Tannuri U, Zugaib M. A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2012; 39:20-27. [PMID: 22170862 DOI: 10.1002/uog.10142] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/04/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Severe pulmonary hypoplasia and pulmonary arterial hypertension are associated with reduced survival in congenital diaphragmatic hernia (CDH). We aimed to determine whether fetal endoscopic tracheal occlusion (FETO) improves survival in cases of severe isolated CDH. METHODS Between May 2008 and July 2010, patients whose fetuses had severe isolated CDH (lung-to-head ratio < 1.0, liver herniation into the thoracic cavity and no other detectable anomalies) were assigned randomly to FETO or to no fetal intervention (controls). FETO was performed under maternal epidural anesthesia supplemented with fetal intramuscular anesthesia. Tracheal balloon placement was achieved with ultrasound guidance and fetoscopy between 26 and 30 weeks of gestation. All cases that underwent FETO were delivered by the EXIT procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was survival to 6 months of age. Other maternal and neonatal outcomes were also evaluated. RESULTS Twenty patients were enrolled randomly to FETO and 21 patients to standard postnatal management. The mean gestational age at randomization was similar in both groups (P = 0.83). Delivery occurred at 35.6 ± 2.4 weeks in the FETO group and at 37.4 ± 1.9 weeks in the controls (P < 0.01). In the intention-to-treat analysis, 10/20 (50.0%) infants in the FETO group survived, while 1/21 (4.8%) controls survived (relative risk (RR), 10.5 (95% CI, 1.5-74.7), P < 0.01). In the received-treatment analysis, 10/19 (52.6%) infants in the FETO group and 1/19 (5.3%) controls survived (RR, 10.0 (95% CI, 1.4-70.6) P < 0.01). CONCLUSION FETO improves neonatal survival in cases with isolated severe CDH.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Universidade de São Paulo, São Paulo, Brazil.
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Dekoninck P, Gratacos E, Van Mieghem T, Richter J, Lewi P, Ancel AM, Allegaert K, Nicolaides K, Deprest J. Results of fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia and the set up of the randomized controlled TOTAL trial. Early Hum Dev 2011; 87:619-24. [PMID: 21907109 DOI: 10.1016/j.earlhumdev.2011.08.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/03/2011] [Indexed: 11/29/2022]
Abstract
In isolated congenital diaphragmatic hernia, lung size and/or the position of the liver are predictive of neonatal outcome. Percutaneous Fetal Endoscopic Tracheal Occlusion (FETO) by a balloon can be undertaken to prompt lung growth in the worst cases. The feasibility and safety of FETO is no longer at stake, and it is associated with an apparent increase in neonatal survival. The gestational age at birth, the pre-existing lung size, the ability to remove the balloon prior to birth, and the lung response are predicting outcome. The most frequent complication is preterm premature rupture of the membranes, and as a consequence preterm delivery, which also complicates balloon removal. We have set up a randomized trial for the formal evaluation of FETO in Europe, including criteria for fetoscopy centers. Training of European as well as North American centers is taking place, so that the procedure could be safely and more widely offered.
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Affiliation(s)
- Philip Dekoninck
- Division of Woman and Child, University Hospitals Leuven, 3000 Leuven, Belgium
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Rodrigues HCML, Deprest J, Cruz-Martinez R, van den Berg PP. Use of data from predictive tests following fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia. Fetal Diagn Ther 2011; 29:261-2. [PMID: 21389679 DOI: 10.1159/000324102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 12/22/2010] [Indexed: 11/19/2022]
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Done E, Allegaert K, Lewi P, Jani J, Gucciardo L, Van Mieghem T, Gratacos E, Devlieger R, Van Schoubroeck D, Deprest J. Maternal hyperoxygenation test in fetuses undergoing FETO for severe isolated congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2011; 37:264-271. [PMID: 20652932 DOI: 10.1002/uog.7753] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To predict neonatal survival and pulmonary hypertension by measurement of fetal pulmonary artery reactivity to maternal hyperoxygenation in fetuses with severe congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion (FETO). METHODS Thirty-eight fetuses underwent FETO at around 28 weeks' gestation and the balloon was removed at 34 weeks in most cases. We performed a hyperoxygenation test and measured the lung-to-head ratio of each fetus before and after each procedure. Outcome measures were neonatal survival, occurrence of pulmonary hypertension and its response to inhaled nitric oxide (iNO). RESULTS Fetuses that survived had a larger increase in lung size and decrease of resistance in the first branch of the main pulmonary artery than did those that died. Both measures were also predictive of pulmonary hypertension unresponsive to iNO. The hyperoxygenation test and lung-to-head ratio were both best predictive for neonatal survival when measured following removal of the balloon (P < 0.002). Discriminant analysis confirmed that these two parameters are independent predictors of outcome. CONCLUSIONS In fetuses undergoing FETO, pulmonary vascular reactivity in relation to oxygen and lung size are independent predictors of neonatal survival and pulmonary hypertension. The hyperoxygenation test merits further study in expectantly managed cases.
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Affiliation(s)
- E Done
- Department of Obstetrics and Gynaecology, Division of Woman and Child, University Hospitals Leuven, Leuven, Belgium
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Yamamoto M, Ville Y. Fetal lung assessment in congenital diaphragmatic hernia: evidence for growth. Ultrasound Obstet Gynecol 2010; 35:522-524. [PMID: 20443196 DOI: 10.1002/uog.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- M Yamamoto
- Unidad de Medicina Materno Fetal, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
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