Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia

Rafat, Neysan; Schaible, Thomas

doi:10.3389/fped.2019.00336

Cited by 46 publications

(31 citation statements)

References 60 publications

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“…Additionally, the incidence of ECLS utilization was nearly 2-fold higher in patients with severe CDH-PH on adjusted analysis. This corroborates previous reports that PH is a significant risk factor for ECLS initiation in CDH [12]. Our findings suggest that CDH-PH detected before 48 HOL is independently predictive of early respiratory outcomes.…”

Section: Discussionsupporting

confidence: 92%

Early, Postnatal Pulmonary Hypertension Severity Predicts Inpatient Outcomes in Congenital Diaphragmatic Hernia

et al. 2021

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Introduction: Pulmonary hypertension (PH) is the major pathophysiologic consequence of congenital diaphragmatic hernia (CDH). We aimed to evaluate the association between early CDH-associated PH (CDH-PH) and inpatient outcomes. Methods: The CDH Study Group registry was queried for infants born 2015–2019 with echocardiograms before 48h of life. PH was categorized using echocardiographic findings: none, mild (right ventricular systolic pressure <2/3 systemic), moderate (between 2/3 systemic and systemic), or severe (supra-systemic). Univariate and multivariate analyses were performed. Adjusted Poisson regression was used to assess the primary composite outcome of mortality or oxygen support at 30 days. Results: Of 1,472 patients, 86.5% had CDH-PH: 13.9% mild (n = 193), 44.4% moderate (n = 631), and 33.2% severe (n = 468). On adjusted analysis, the primary outcome of mortality or oxygen support at 30 days occurred more frequently in infants with moderate (incidence rate ratio [IRR] 1.8, 95% confidence interval [CI], 1.2–2.6) and severe CDH-PH (IRR 2.0, 95% CI, 1.3–2.9). Extracorporeal life support (ECLS) utilization was associated only with severe CDH-PH after adjustment (IRR 1.8, 95% CI, 1.0–3.3). Discussion/Conclusion: Early, postnatal CDH-PH is independently associated with increased risk for mortality or oxygen support at 30 days and utilization of ECLS. Early echocardiogram is a valuable prognostic tool for early, inpatient outcomes in neonates with CDH.

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Section: Discussionsupporting

confidence: 92%

Early, Postnatal Pulmonary Hypertension Severity Predicts Inpatient Outcomes in Congenital Diaphragmatic Hernia

et al. 2021

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“…Often it is claimed that advances in neonatal and surgical care lead to a substantial improvement in outcome 35 . Although in our study population survival was not affected by the center of antenatal or postnatal management, we do not claim that our findings can be extrapolated to other settings, with different postnatal management protocols, including the wide use of ECMO 36 .…”

Section: Discussionmentioning

confidence: 56%

Fetal endoscopic tracheal occlusion reverses the natural history of right‐sided congenital diaphragmatic hernia: European multicenter experience

Russo

Cordier

Basurto

et al. 2021

Ultrasound in Obstet & Gyne

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Objective To evaluate the neonatal outcome of fetuses with isolated right‐sided congenital diaphragmatic hernia (iRCDH) based on prenatal severity indicators and antenatal management. Methods This was a retrospective review of prospectively collected data on consecutive cases diagnosed with iRCDH before 30 weeks' gestation in four fetal therapy centers, between January 2008 and December 2018. Data on prenatal severity assessment, antenatal management and perinatal outcome were retrieved. Univariate and multivariate logistic regression analysis were used to identify predictors of survival at discharge and early neonatal morbidity. Results Of 265 patients assessed during the study period, we excluded 40 (15%) who underwent termination of pregnancy, two cases of unexplained fetal death, two that were lost to follow‐up, one for which antenatal assessment of lung hypoplasia was not available and six cases which were found to have major associated anomalies or syndromes after birth. Of the 214 fetuses with iRCDH included in the neonatal outcome analysis, 86 were managed expectantly during pregnancy and 128 underwent fetal endoscopic tracheal occlusion (FETO) with a balloon. In the expectant‐management group, lung size measured by ultrasound or by magnetic resonance imaging was the only independent predictor of survival (observed‐to‐expected lung‐to‐head ratio (o/e‐LHR) odds ratio (OR), 1.06 (95% CI, 1.02–1.11); P = 0.003). Until now, stratification for severe lung hypoplasia has been based on an o/e‐LHR cut‐off of 45%. In cases managed expectantly, the survival rate was 15% (4/27) in those with o/e‐LHR ≤ 45% and 61% (36/59) for o/e‐LHR > 45% (P = 0.001). However, the best o/e‐LHR cut‐off for the prediction of survival at discharge was 50%, with a sensitivity of 78% and specificity of 72%. In the expectantly managed group, survivors with severe pulmonary hypoplasia stayed longer in the neonatal intensive care unit than did those with mildly hypoplastic lungs. In fetuses with an o/e‐LHR ≤ 45% treated with FETO, survival rate was higher than in those with similar lung size managed expectantly (49/120 (41%) vs 4/27 (15%); P = 0.014), despite higher prematurity rates (gestational age at birth: 34.4 ± 2.7 weeks vs 36.8 ± 3.0 weeks; P < 0.0001). In fetuses treated with FETO, gestational age at birth was the only predictor of survival (OR, 1.25 (95% CI, 1.04–1.50); P = 0.02). Conclusions Antenatal measurement of lung size can predict survival in iRCDH. In fetuses with severe lung hypoplasia, FETO was associated with a significant increase in survival without an associated increase in neonatal morbidity. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

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“…Importantly, extremely preterm human fetuses during their canalicular phase of lung development are 500–750 g (Kiserud et al, 2018), while the smallest sheep used in AP studies are twice that size (~1.0 kg) (Arens et al, 2011; Church, Coughlin, et al, 2018; Church, Perkins, et al, 2018; Church, Werner, et al, 2018; El‐Sabbagh et al, 2018; Gray et al, 2013; Hornick et al, 2018; Lawrence et al, 2018; Miura et al, 2012, 2015, 2016; Partridge, Davey, Hornick, McGovern, et al, 2017; Reoma et al, 2009; Rochow et al, 2013; Schoberer et al, 2014; Usuda et al, 2017; Westin et al, 1958; Zapol et al, 1969). Fetal size is associated with hemodynamic factors such as umbilical vessel caliber and blood pressure that are important for ECMO support (Rafat & Schaible, 2019; Tanaka et al, 2019). Furthermore, the vascular anatomy of the sheep umbilical cord is different from that of humans, with sheep having two umbilical arteries and two umbilical veins in contrast to human fetuses that have only one umbilical vein (UV) (Benirschke & Kaufmann, 2000; Steven, 1968).…”

Section: Introductionmentioning

confidence: 99%

Achieving sustained extrauterine life: Challenges of an artificial placenta in fetal pigs as a model of the preterm human fetus

et al. 2021

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Artificial placenta (AP) technology aims to maintain fetal circulation, while promoting the physiologic development of organs. Recent reports of experiments performed in sheep indicate the intrauterine environment can be recreated through the cannulation of umbilical vessels, replacement of the placenta with a low‐resistance membrane oxygenator, and incubation of the fetus in fluid. However, it remains to be seen whether animal fetuses similar in size to the extremely preterm human infant that have been proposed as a potential target for this technology can be supported in this way. Preterm Yucatan miniature piglets are similar in size to extremely preterm human infants and share similar umbilical cord anatomy, raising the possibility to serve as a good model to investigate the AP. To characterize fetal cardiovascular physiology, the carotid artery (n = 24) was cannulated in utero and umbilical vein (UV) and umbilical artery were sampled. Fetal UV flow was measured by MRI (n = 16). Piglets were delivered at 98 ± 4 days gestation (term = 115 days), cannulated, and supported on the AP (n = 12) for 684 ± 228 min (range 195–3077 min). UV flow was subphysiologic (p = .002), while heart rate was elevated on the AP compared with in utero controls (p = .0007). We observed an inverse relationship between heart rate and UV flow (r2 = .4527; p < .001) with progressive right ventricular enlargement that was associated with reduced contractility and ultimately hydrops and circulatory collapse. We attribute this to excessive afterload imposed by supraphysiologic circuit resistance and augmented sympathetic activity. We conclude that short‐term support of the preterm piglet on the AP is feasible, although we have not been able to attain normal fetal physiology. In the future, we propose to investigate the feasibility of an AP circuit that incorporates a centrifugal pump in our miniature pig model.

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Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia

Cited by 46 publications

References 60 publications

Early, Postnatal Pulmonary Hypertension Severity Predicts Inpatient Outcomes in Congenital Diaphragmatic Hernia

Early, Postnatal Pulmonary Hypertension Severity Predicts Inpatient Outcomes in Congenital Diaphragmatic Hernia

Fetal endoscopic tracheal occlusion reverses the natural history of right‐sided congenital diaphragmatic hernia: European multicenter experience

Achieving sustained extrauterine life: Challenges of an artificial placenta in fetal pigs as a model of the preterm human fetus

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