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Hari Gopal S, Martinek KF, Vacher C, Becker J, Varghese NP, Yilmaz Furtun B, Hagan JL, Gowda SH, Pammi M, Devaraj S, Fernandes CJ. Utility of urinary NT-proBNP in congenital diaphragmatic hernia: a prospective pilot study. Pediatr Res 2024:10.1038/s41390-024-03600-x. [PMID: 39415038 DOI: 10.1038/s41390-024-03600-x] [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: 04/30/2024] [Revised: 09/08/2024] [Accepted: 09/13/2024] [Indexed: 10/18/2024]
Abstract
BACKGROUND Echocardiography is the reference standard for diagnosing pulmonary hypertension (PH) and cardiac dysfunction (CD) in congenital diaphragmatic hernia (CDH). The use of an adjunct non-invasive biomarker would be invaluable. Plasma N-terminal brain Natriuretic Peptide (NT-proBNP) has been evaluated as a biomarker in CDH. Our objective was to investigate the utility of urinary NT-proBNP as an adjunct biomarker in CDH. METHODS Prospective observational study of neonates with CDH. Urinary NT-proBNP and its ratio to urinary creatinine (UNBCR) were analyzed at 24 h of life (HOL). Spearman's correlation was used to quantify the association between the urinary NT-proBNP with corresponding plasma concentrations. Logistic regression and receiver operating characteristic (ROC) curve analyses were used to examine urinary NT-proBNP and UNBCR's association with need for ECMO. The Kruskal-Wallis test was used to compare urinary NT-proBNP concentrations with echocardiography parameters of PH and CD. RESULTS Urinary NT-proBNP and UNBCR positively correlated with plasma concentrations. Patients with high right ventricular (RV) pressures had higher urinary NT-proBNP concentrations. Both urinary NT-proBNP and UNBCR concentrations increased with worsening left and right ventricular dysfunction on first postnatal echocardiogram. CONCLUSION We report the feasibility of urinary NT-proBNP as a non-invasive biomarker to assess PH and CD in CDH. IMPACT STATEMENT Non-invasive biomarkers are an important area of research in neonates as they have the potential to decrease the need for blood sampling, which may cause pain, stress, and induce iatrogenic anemia. Use of non-invasive biomarkers could be especially useful in congenital diaphragmatic hernia (CDH) who may need Extra-Corporeal Life Support (ECLS) for their management. We evaluated the potential utility of the urinary NT-proBNP in CDH. Plasma NT-proBNP has been studied in neonates with CDH; however, urinary NT-proBNP has not been explored, making this the first study to examine its potential as a biomarker.
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Affiliation(s)
- Srirupa Hari Gopal
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA.
| | - Kelly Frances Martinek
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Candice Vacher
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Judith Becker
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Nidhy P Varghese
- Division of Pediatric Pulmonology/Pulmonary Hypertension, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Betul Yilmaz Furtun
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Joseph L Hagan
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Sharada H Gowda
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Mohan Pammi
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Sridevi Devaraj
- Department of Pathology, Baylor College of Medicine, Houston, USA
| | - Caraciolo J Fernandes
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
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Dadoun SE, Shanahan MA, Parobek CM, Burnett BA, King A, Ketwaroo P, Donepudi RV, Adams AD. Prenatal Prognosis of Omphalocele Using Magnetic Resonance Imaging Measurement of Fetal Lung Volumes. Am J Obstet Gynecol MFM 2024; 6:101457. [PMID: 39098636 DOI: 10.1016/j.ajogmf.2024.101457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/22/2024] [Accepted: 07/26/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Omphalocele is a congenital midline abdominal wall defect resulting in herniation of viscera into a membrane-covered sac. Pulmonary complications, including pulmonary hypoplasia, pulmonary hypertension, and prolonged respiratory support are a leading cause of neonatal morbidity and mortality. OBJECTIVE(S) This study aimed to assess the role of fetal MRI-derived lung volumes and omphalocele defect size as clinical tools to prognosticate postnatal pulmonary morbidity and neonatal mortality in those with a prenatally diagnosed omphalocele (PDO). STUDY DESIGN This was a retrospective cohort study of all pregnancies with PDO at our fetal center from 2007-2023. Pregnancies with aneuploidy or concurrent life-limiting fetal anomalies were excluded. Using fetal MRI, observed-to-expected total fetal lung volume (O/E TLV) ratios were determined by a previously published method. The transverse diameter of the abdominal defect was also measured. The O/E TLV ratios and abdominal defect measurements were compared with postnatal outcomes. The primary outcome was death at any time. Secondary outcomes included death in the first 30 days of life or before discharge from birth hospitalization, the requirement of respiratory support with intubation and mechanical ventilation, or development of pulmonary hypertension. RESULTS Of 101 pregnancies with a PDO, 54 pregnancies (53.5%) with prenatally diagnosed omphalocele met inclusion criteria. There was a significant increase in the rate of death when compared between the three O/E TLV classifications: 1/36 (2.8%) in the O/E≥50% group, 3/14 (21.4%) in the O/E 25%-49.9% group, and 4/4 (100%) in the O/E<25% group (P<.001). The rate of intubation increased with the severity of O/E TLV classification, with 27.8% in the O/E≥50% group, 64.3% in the O/E 25%-49.9% group, and 100% in the O/E<25% group (P=.003). The rate of pulmonary hypertension was also higher in the O/E 25%-49.9% (50.0%) and the O/E<25% (50.0%) groups compared to the O/E≥50% group (8.3%, P=.002). There was no association between the transverse diameter of the abdominal wall defect and the primary outcome of death (OR=1.08 95% CI=[0.65-1.78], P=.77). CONCLUSIONS In our cohort of patients with PDO, O/E TLV<50% is associated with death, need for intubation, prolonged intubation, and pulmonary hypertension. In contrast, omphalocele size demonstrated no prognostic value for these outcomes. The strong association between low fetal lung volume on MRI and poor neonatal outcomes highlights the utility of fetal MRI for estimating postnatal prognosis. Clinicians can utilize fetal lung volumes to direct perinatal counseling and optimize the plan of care.
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Affiliation(s)
- Simon E Dadoun
- Department of Obstetrics & Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Dadoun).
| | - Matthew A Shanahan
- Division of Maternal-Fetal Medicine, Dept of Obstetrics, Gynecology, & Reproductive Sciences, Magee-Womens Hospital University of Pittsburgh School of Medicine, Pittsburgh, PA (Shanahan)
| | - Christian M Parobek
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek, Burnett, Donepudi, and Adams); Department of Molecular and Human Genetics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek and Adams)
| | - Brian A Burnett
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek, Burnett, Donepudi, and Adams)
| | - Alice King
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (King)
| | - Pamela Ketwaroo
- Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Ketwaroo)
| | - Roopali V Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek, Burnett, Donepudi, and Adams)
| | - April D Adams
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek, Burnett, Donepudi, and Adams); Department of Molecular and Human Genetics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX (Parobek and Adams)
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Ibarra C, Bergh E, Tsao K, Johnson A. Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151436. [PMID: 39018717 DOI: 10.1016/j.sempedsurg.2024.151436] [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: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.
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Affiliation(s)
- Claudia Ibarra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eric Bergh
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States.
| | - Kuojen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
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Farladansky-Gershnabel S, Jayapal P, Zalcman M, Barth RA, Rubesova E, Hintz SR, Zhang J, Leonard SA, El-Sayed YY, Blumenfeld YJ. A Novel Fetal Magnetic Resonance Imaging Lung Volume Nomogram Stratified by Estimated Fetal Weight. Fetal Diagn Ther 2024; 51:478-485. [PMID: 38843783 PMCID: PMC11475777 DOI: 10.1159/000539709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/31/2024] [Indexed: 07/03/2024]
Abstract
INTRODUCTION Fetal magnetic resonance imaging (MRI) lung volume nomograms are increasingly used to prognosticate neonatal outcomes in fetuses with suspected pulmonary hypoplasia. However, pregnancies complicated by fetal anomalies associated with pulmonary hypoplasia may also be complicated by fetal growth restriction (FGR). If a small lung volume is suspected in such cases, it is often unclear whether the lungs are "small" because of underlying lung pathology, or small fetal size. Existing MRI lung volume nomograms have mostly been stratified by gestational age (GA), rather than estimated fetal weight (EFW). Therefore, we aimed to develop a novel fetal lung volume nomogram stratified by EFW. METHODS Consecutive fetal MRIs performed at a quaternary medical center from 2019 to 2021 were analyzed. MRIs performed due to fetal lung anomalies and cases with FGR were excluded. All MRIs were performed without IV contrast on GE 3 or 1.5 Tesla scanners (GE Healthcare). Images were reviewed by three experienced fetal radiologists. Freehand ROI in square centimeter was drawn around the contours of the lungs on consecutive slices from the apex to the base. The volume of the right, left and total lungs were calculated in mL. Lung volumes were plotted by both EFW and GA. RESULTS Among 301 MRI studies performed during the study period, 170 cases met inclusion criteria and were analyzed. MRIs were performed between 19- and 38-week gestation, and a sonographic EFW was obtained within a mean of 2.9 days (SD ± 5.5 days, range 0-14 days) of each MRI. Nomograms stratified by both EFW and GA were created using 200 g. and weekly intervals respectively. A formula using EFW to predict total lung volume was calculated: LV = 0.07497804 EFW0.88276 (R2 = 0.87). CONCLUSIONS We developed a novel fetal lung volume nomogram stratified by EFW. If validated, this nomogram may assist clinicians predict outcomes in cases of fetal pulmonary hypoplasia with concomitant FGR.
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Affiliation(s)
- Sivan Farladansky-Gershnabel
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Praveen Jayapal
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Max Zalcman
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Richard A Barth
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Erika Rubesova
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jiaqi Zhang
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, 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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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Gehle DB, Meyer LC, Jancelewicz T. The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000752. [PMID: 38645885 PMCID: PMC11029407 DOI: 10.1136/wjps-2023-000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.
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Affiliation(s)
- Daniel B Gehle
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Logan C Meyer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Hari Gopal S, Martinek KF, Holmes A, Hagan JL, Fernandes CJ. Oxygen saturation index: an adjunct for oxygenation index in congenital diaphragmatic hernia. J Perinatol 2024; 44:354-359. [PMID: 38071241 DOI: 10.1038/s41372-023-01845-8] [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: 07/10/2023] [Revised: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Our objective was to investigate the correlation of Oxygen Saturation Index (OSI) with Oxygenation Index (OI) and determine OSImax values that could predict need for ECMO and death in Congenital Diaphragmatic Hernia (CDH). STUDY DESIGN This is a retrospective cohort study of infants with CDH admitted to a tertiary level VI NICU. Pearson's correlation coefficient and simple linear regression analysis were used to investigate the OSI: OI correlation, and logistic regression analysis to investigate OSImax values that predicted need for ECMO and death. RESULTS Among the 180 infants, OSImax value of >13 at 6 h of life (HOL) best predicted need for ECMO and death. There was a strong correlation between OSI: OI paired values (r = 0.876, p < 0.001). The linear regression equation was OI = -2.4 + 2.4(OSI). CONCLUSION OSI could be used as a valuable adjunct to OI in the clinical management of newborn infants with CDH.
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Affiliation(s)
- Srirupa Hari Gopal
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.
| | - Kelly F Martinek
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Amanda Holmes
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joseph L Hagan
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
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Narang K, Wyatt M, O'Leary P, Qureshi MY, Kolbe A, Stephens EH, Dearani JA, Ruano R. Novel approach to prenatal predictors of outcomes for fetuses with severe Ebstein anomaly. J Matern Fetal Neonatal Med 2023; 36:2271626. [PMID: 37904503 DOI: 10.1080/14767058.2023.2271626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/11/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Ebstein anomaly (EA) is a cardiac malformation with highly variable presentation and severity with limited perinatal management options. We present incorporation of fetal lung measurements into a multidisciplinary evaluation for counseling and predicting postnatal outcomes in patients with severe EA. METHODS Five fetuses with severe fetal EA were reviewed. Third trimester sonographic observed/expected total lung area (O/E TLA) and lung to head ratio (O/E LHR), fetal MRI total fetal lung volume ratio (O/E-TFLV), echocardiographic cardio-thoracic ratio (CT ratio), sonographic estimated fetal weight (EFW) by Hadlock formula and presence of hydrops, were used to guide perinatal management. RESULTS Three of five had appropriate fetal growth, were delivered at term in a cardiac operative suite, and underwent immediate intervention with good neonatal outcomes. Two had severe fetal growth restriction (FGR), CT ratios > 0.8 and O/E LHR and TLA < 25%. One of which delivered prematurely with neonatal demise and one suffered in utero demise at 34 weeks. CONCLUSIONS FGR, hydrops, increased CT ratio and reduced O/E LHR and TFLV are potential prognosticators of poor outcomes in severe EA, and should be validated in larger cohorts that would allow for a statistical analysis of the predictive utility of these measurements.
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Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michelle Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Patrick O'Leary
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amy Kolbe
- Pediatric Radiology Division, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rodrigo Ruano
- Division Chief of Maternal-Fetal Medicine, Director UHealth Jackson Fetal Care, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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10
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Smithers CJ, Zalieckas JM, Rice-Townsend SE, Kamran A, Zurakowski D, Buchmiller TL. The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk. J Pediatr Surg 2023; 58:1656-1662. [PMID: 36709093 DOI: 10.1016/j.jpedsurg.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/11/2022] [Accepted: 12/25/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion. METHODS A retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression. RESULTS 102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48-39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20-85) vs. those who did not (median 9 mg/dL, IQR 7-13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737). CONCLUSION We demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, United States.
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA 98105, United States
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States
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11
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Effects of 1.5-T versus 3-T magnetic resonance imaging in fetuses: is there a difference in postnatal neurodevelopmental outcome? Evaluation in a fetal population with left-sided congenital diaphragmatic hernia. Pediatr Radiol 2023; 53:1085-1091. [PMID: 36823375 DOI: 10.1007/s00247-023-05629-2] [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: 10/19/2022] [Revised: 02/04/2023] [Accepted: 02/12/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND The utilization of 3-T magnetic field strength in obstetric imaging is increasingly common. It is important to ensure that magnetic resonance (MR) imaging with higher magnetic field strength is safe for the fetus. Comparison of neurodevelopmental outcome in neonates undergoing prenatal MR imaging with 1.5-T versus 3-T is of interest but has not yet been examined. OBJECTIVE We hypothesized no clinically meaningful difference in neurodevelopmental outcome between fetuses undergoing 1.5-T versus 3-T fetal MR imaging. As imaging a normal fetus for research purposes is illegal in Pennsylvania, this study was conducted in a population of fetuses with left congenital diaphragmatic hernia (left-CDH). MATERIALS AND METHODS A retrospective review of neurodevelopmental outcome of fetuses with left-CDH scanned at 1.5-T (n=75) versus 3-T (n=25) magnetic field strength between July of 2012 and December of 2019 was performed. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant Development, 3rd Edition (BSID-III). RESULTS There were no statistical differences in median age of assessment (1.5-T: 18 [12, 25] versus 3-T: 21 [11, 26], P=0.79), in mean BSID-III cognitive (1.5-T: 91 ± 14 versus 3-T: 90 ± 16, P=0.82), language (1.5-T: 92 ± 20 versus 3-T: 91 ± 20, P=0.91), and motor composite (1.5-T: 89 ± 15 versus 3-T: 87 ± 18, P=0.59) scores, subscales scores (for all, P>0.50), or in risk of abnormal neuromuscular exam (P=0.29) between neonates with left-CDH undergoing a 1.5-T versus 3-T MR imaging during fetal life. Additionally, the distribution of patients with average, mildly delayed, and severely delayed BSID-III scores was similar between the two groups (for all, P>0.50). The overall distribution of the composite scores in this CDH population was similar to the general population independent of exposure to 1.5-T or 3-T fetal MR imaging. Two 3-T patients (8%) and five 1.5-T patients (7%) scored within the significant delayed range for all BSID-III domains. Subjects with lower observed-to-expected fetal lung volume (O/E FLV) and postnatal need for ECMO had lower cognitive, language, motor, and subscales scores (for all, P<0.03) regardless of being imaged at 1.5-T versus 3-T. CONCLUSION This preliminary study suggests that, compared to 1.5-T MR imaging, fetal exposure to 3-T MR imaging does not increase the risk of neurodevelopmental impairment in fetuses with left-CDH. Additional MR imaging studies in larger CDH cohorts and other fetal populations are needed to replicate and extend the present findings.
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12
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Olutoye OO, Mehl SC, Moturu A, Pettit RW, Coleman RD, Vogel AM, Lee TC, Keswani SG, King A. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res 2023; 282:168-173. [PMID: 36306587 PMCID: PMC11132729 DOI: 10.1016/j.jss.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. METHODS A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. RESULTS Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. CONCLUSIONS Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Anoosha Moturu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ryan D Coleman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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13
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Yoneda K, Amari S, Mikami M, Uchida K, Yokoi A, Okawada M, Furukawa T, Toyoshima K, Inamura N, Okazaki T, Yamoto M, Masumoto K, Terui K, Okuyama H, Hayakawa M, Taguchi T, Usui N, Isayama T. Development of mortality prediction models for infants with isolated, left-sided congenital diaphragmatic hernia before and after birth. Pediatr Pulmonol 2023; 58:152-160. [PMID: 36174997 DOI: 10.1002/ppul.26172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/29/2022] [Accepted: 09/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mortality prediction of congenital diaphragmatic hernia (CDH) is essential for developing treatment strategies, including fetal therapy. Several researchers have reported prognostic factors for this rare but life-threatening condition; however, the optimal combination of prognostic factors remains to be elucidated. OBJECTIVES This study aimed to develop the most discriminative prenatal and postnatal models to predict the mortality of infants with an isolated left-sided CDH. METHODS This multi-institutional retrospective cohort study included infants with CDH born at 15 tertiary hospitals of the Japanese CDH Study Group between 2011 and 2016. We developed multivariable logistic models with every possible combination of predictors and identified models with the highest cross-validated area under the receiver operating characteristic curve (AUC) for prenatal and postnatal predictions. RESULTS Among 302 eligible infants, 44 died before discharge. The prenatal mortality prediction model was based on the observed/expected lung area to head circumference ratio (O/E LHR), liver herniation, and stomach herniation (AUC, 0.830). The postnatal mortality prediction model was based on O/E LHR, liver herniation, and the lowest oxygenation index (AUC, 0.944). CONCLUSION Our models can facilitate the prenatal and postnatal mortality prediction of infants with isolated left-sided CDH.
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Affiliation(s)
- Kota Yoneda
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Shoichiro Amari
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Masashi Mikami
- Division of Biostatistics, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University, Faculty of Medicine, Osaka-Sayama, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Fukuoka College of Health Sciences, Fukuoka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
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14
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Hari Gopal S, Toy CL, Hanna M, Furtun BY, Hagan JL, Nassr AA, Fernandes CJ, Keswani S, Gowda SH. Inotropic score and vasoactive inotropic score as predictors of outcomes in congenital diaphragmatic hernia: A single center retrospective study. Front Pediatr 2023; 11:1101546. [PMID: 36816370 PMCID: PMC9929143 DOI: 10.3389/fped.2023.1101546] [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: 11/18/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Neonates with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac dysfunction. These neonates frequently require vasoactive support and are at high risk for mortality and morbidity, including prolonged ventilator support, need for extracorporeal membrane oxygenation (ECMO), prolonged length of stay, and need for tracheostomy. However, identifying which infants are at increased risk can be challenging. In this study, we sought to investigate the utility of the inotropic score (IS) and vasoactive inotropic score (VIS) as tools to predict significant clinical outcomes and overall survival in patients with CDH. Additionally, we evaluated the correlation between IS/VIS and postnatal echocardiographic variables. METHODS This was a retrospective chart review of 57 patients with CDH whose postnatal care was based on a standardized institutional protocol. We calculated the IS/VIS at 6-, 12-, 24-, 48 hours of life (HOL), on the day of CDH repair and 24- and 48 hours after surgical repair. The association of these scores with postnatal echocardiographic markers was analyzed using Pearson's correlation and linear regression, while logistic regression was used for binary outcomes, and Cox proportional hazards regression was used to assess associations with survival. RESULTS We found that every one-unit increase in IS/VIS at 6 HOL was associated with 13% increase in the odds of ECMO (p = 0.034) and 10.1% increase in risk of death (p = 0.021). An increase in IS/VIS at 12-, 24- and 48-HOL was associated with posterior septal bowing in the first postnatal echocardiogram (p < 0.05 for all). Additionally, we noted an inverse relationship between IS (r = -0.281, p = 0.036) and VIS (r = -0.288, p = 0.031) on the day of repair and left ventricle (LV) systolic function in first postnatal echocardiogram. Increase in IS (r = -0.307, p = 0.024) and VIS (r = -0.285, p = 0.037) on the day of repair was associated with decreased LV function on the post-repair echocardiogram. CONCLUSION This retrospective study showed a significant association between IS/VIS obtained at various time points with clinical outcomes and echocardiographic findings in CDH, which could be used to guide prognosis and management in this patient population.
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Affiliation(s)
- Srirupa Hari Gopal
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Cynthia L Toy
- Department of Pharmacy, Texas Children's hospital, Houston, TX, United States
| | - Morcos Hanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Betul Yilmaz Furtun
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Joseph L Hagan
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine/Fetal Intervention Baylor College of Medicine, Houston, TX, United States
| | - Caraciolo J Fernandes
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Sundeep Keswani
- Department of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - Sharada H Gowda
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
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15
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Yang Y, Gowda SH, Hagan JL, Hensch L, Teruya J, Fernandes CJ, Hui SKR. Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support. Vox Sang 2022; 117:1391-1397. [PMID: 36121192 DOI: 10.1111/vox.13363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Blood transfusion is frequently needed to maintain adequate haemostasis and improve oxygenation for patients treated with extracorporeal membrane oxygenation (ECMO). It is more so for neonates with immature coagulation systems who require surgical intervention such as congenital diaphragmatic hernia (CDH) repair. There is growing evidence suggesting an association between blood transfusions and increased mortality. The aim of this study is to evaluate the association of blood transfusions during the peri-operative period of CDH repair, among other clinical parameters, with mortality in neonates undergoing on-ECMO CDH repair. MATERIALS AND METHODS We performed a single centre retrospective chart review of all neonates with CDH undergoing on-ECMO surgical repair from January 2010 to December 2020. Logistic regression was used to investigate associations with survival status. RESULTS Sixty-two patients met the inclusion criteria. Platelet transfusions (odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.06-1.90) in the post-operative period and ECMO duration (OR 1.17, 95% CI: 1.05-1.30) were associated with increased mortality. Major bleeding complications had the strongest association with mortality (OR 10.98, 95% CI: 3.27-36.91). Gestational age, birth weight, Apgar scores, sex, blood type, right versus left CDH, venovenous versus venoarterial ECMO and duration of ECMO before CDH repair and circuit change after adjusting for ECMO duration were not significantly associated with survival. CONCLUSION Platelet transfusion in the post-operative period and major bleeding are associated with increased mortality in CDH neonates with surgical repair. The data suggest a need to develop robust plans for monitoring and preventing coagulation aberrancies during neonatal ECMO support.
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Affiliation(s)
- Yu Yang
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sharada H Gowda
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lisa Hensch
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jun Teruya
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Shiu-Ki R Hui
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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16
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Masahata K, Yamoto M, Umeda S, Nagata K, Terui K, Fujii M, Shiraishi M, Hayakawa M, Amari S, Masumoto K, Okazaki T, Inamura N, Toyoshima K, Koike Y, Furukawa T, Yazaki Y, Yokoi A, Endo M, Tazuke Y, Okuyama H, Usui N. Prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1745-1757. [PMID: 36102982 DOI: 10.1007/s00383-022-05232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to evaluate prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia (CDH). METHODS A systematic literature search was performed to identify relevant observational studies that evaluated the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e-LHR), observed-to-expected total fetal lung volume (o/e-TFLV), lung-to-thorax transverse area ratio (L/T ratio), intrathoracic herniation of the liver and the stomach, and side of diaphragmatic hernia, using a threshold for the prediction of mortality in fetuses with CDH. Study quality was assessed using the QUADAS-2 tool. Hierarchical summary receiver operating characteristic curves were constructed. RESULTS A total of 50 articles were included in this meta-analysis. The QUADAS-2 tool identified a high risk of bias in more than one domain scored in all parameters. Among those parameters, the diagnostic odds ratio of mortality with o/e-LHR < 25%, o/e-TFLV < 25%, and L/T ratio < 0.08 were 11.98 [95% confidence interval (CI) 4.65-30.89], 11.14 (95% CI 5.19-23.89), and 10.28 (95% CI 3.38-31.31), respectively. The predictive values for mortality were similar between the presence of liver herniation and retrocardiac fetal stomach position. CONCLUSIONS This systematic review suggests that o/e-LHR, o/e-TFLV, and L/T ratio are equally good predictors of neonatal mortality in fetuses with isolated CDH.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Fujii
- Department of Health Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Katsuaki Toyoshima
- Departments of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Yokoi
- Departments of Pediatric Surgery, Kobe Children's Medical Center, Kobe, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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Mitchell A, Sekhon S, Gwal K, McGahan J. Multimodality Evaluation of Fetal Congenital Diaphragmatic Hernia and Its Mimics. APPLIED RADIOLOGY 2022. [DOI: 10.37549/ar2854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Ana Mitchell
- Department of Radiology, University of California Davis Health, Radiology
| | - Simran Sekhon
- Department of Radiology, University of California Davis Health, Radiology
| | - Kriti Gwal
- Department of Radiology, University of California Davis Health, Radiology
| | - John McGahan
- Department of Radiology, University of California Davis Health, Radiology
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18
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Perrone EE, Karmakar M, Lally PA, Chung S, Kipfmueller F, Morini F, Phillips R, Van Meurs KP, Harting MT, Mychaliska GB, Lally KP. Image-based prenatal predictors correlate with postnatal survival, extracorporeal life support use, and defect size in left congenital diaphragmatic hernia. J Perinatol 2022; 42:1195-1201. [PMID: 35228684 DOI: 10.1038/s41372-022-01357-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the association between prenatal imaging predictors of patients with left-sided congenital diaphragmatic hernia (LCDH) and postnatal outcomes. STUDY DESIGN CDH study group data were reviewed for LCDH infants born 2015-2019. Prenatal ultrasound (US) and magnetic resonance imaging (MRI) data were collected and correlated with postnatal information including CDHSG defect size (A through D or non-repair (NR)). RESULTS In total, 929 LCDH patients were included. Both US and MRI imaging predictors correlated with postnatal survival (72.2%) and ECLS use (29.6%). Logistic regression models confirmed increased survival and decreased ECLS use with larger values for all predictors. Importantly, all prenatal values evaluated showed no significant difference between defect size D and NR patients. CONCLUSIONS This is the largest cohort of LCDH patients and demonstrates that prenatal imaging factors correlate with postnatal outcomes and confirms that patients in the non-repair group are prenatally similar to type D defects.
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Affiliation(s)
- Erin E Perrone
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA.
| | - Monita Karmakar
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Sukyung Chung
- Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Children's Hospital, University of Bonn, Bonn, Germany
| | - Francesco Morini
- Neonatal Surgical Unit, Ospedale Pediatrico Bambino Gesu, IRCCS, Medical and Surgical Department of the Fetus, Newborn, and Infant, Rome, Italy
| | - Ryan Phillips
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - George B Mychaliska
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
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19
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Takeuchi Y, Inoue S, Odaka A, Muta Y, Beck Y. Anterolateral defect of left congenital diaphragmatic hernia with hepatic herniation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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20
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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21
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Verla MA, Style CC, Lee TC, Menchaca AD, Lau PE, Mehollin-Ray AR, Fernandes CJ, Keswani SG, Olutoye OO. Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair? J Pediatr Surg 2022; 57:637-642. [PMID: 34836640 DOI: 10.1016/j.jpedsurg.2021.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/23/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence. METHODS We conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair. RESULTS We identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07). CONCLUSIONS A dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mariatu A Verla
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Candace C Style
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA.
| | - Timothy C Lee
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alicia D Menchaca
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA
| | - Patricio E Lau
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Houston, TX, USA; Texas Children's Hospital, Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Caraciolo J Fernandes
- Texas Children's Fetal Center, Houston, TX, USA; Texas Children's Hospital, Department of Pediatrics - Newbowrn Section, Baylor College of Medicine, Houston, TX, USA
| | - Sundeep G Keswani
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA
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22
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Mehollin-Ray AR. Prenatal lung volumes in congenital diaphragmatic hernia and their effect on postnatal outcomes. Pediatr Radiol 2022; 52:637-642. [PMID: 34435224 DOI: 10.1007/s00247-021-05153-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/31/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
Lung volume measurement on fetal MRI is a component of the imaging workup for various prenatal conditions, but its use as a prognosticator has been most heavily studied in congenital diaphragmatic hernia (CDH). Pediatric radiologists who perform and interpret fetal MRI must be familiar with the technical aspects of lung volume measurement to guarantee accurate measurement and reporting. Variability in timing and type of measurement at different fetal centers also requires pediatric radiologists to be up-to-date with the literature and aware of their center's internal data. This paper provides both a how-to guide for measuring fetal lung volumes on MRI and a comprehensive review of the CDH outcome literature to serve as a convenient reference for the pediatric radiologist.
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Affiliation(s)
- Amy R Mehollin-Ray
- E. B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
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23
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Tonni G, Grisolia G. Can fetal ultrasound and MRI predict outcome after fetal endoscopic tracheal occlusion for isolated severe congenital diaphragmatic hernia? JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:191-192. [PMID: 35148005 DOI: 10.1002/jcu.23124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Gabriele Tonni
- Department of Obstetrics and Neonatology, Prenatal Diagnostic Center & Researcher, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL di Reggio Emilia, Reggio Emilia, Italy
| | - Gianpaolo Grisolia
- Department of Obstetrics and Gynecology, Carlo Poma Hospital, Mantua, Italy
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24
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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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25
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Ott KC, Bi M, Scorletti F, Ranginwala SA, Marriott WS, Peiro JL, Kline-Fath BM, Alhajjat AM, Shaaban AF. The interplay between prenatal liver growth and lung development in congenital diaphragmatic hernia. Front Pediatr 2022; 10:983492. [PMID: 36225336 PMCID: PMC9548643 DOI: 10.3389/fped.2022.983492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Liver herniation is a known risk factor for increased severity in CDH and is associated with clinically significant pulmonary hypoplasia and pulmonary hypertension. Better studies are needed to understand the growth of the herniated liver compared to the liver that remains in the abdomen and how this liver growth then affects lung development. Serial hi-resolution fetal MRI enables characterization of liver growth throughout gestation and examination of macroscopic features that may regulate liver growth. Here, we hypothesized that the nature of liver herniation affects liver growth and, in turn, affects lung growth. METHODS Clinical data were retrospectively collected from consecutive cases of prenatally diagnosed isolated left-sided or right-sided CDH from June 2006 to August 2021. Only those cases with MRI lung volumetry for both mid-gestation and late-gestation time points were recruited for analysis. Cases with fetal chromosomal abnormalities and other major structural abnormalities were excluded. Fractional liver volume and liver growth was indexed to estimated fetal weight and compared to lung growth. RESULTS Data was collected from 28 fetuses with a left liver-down CDH (LLD), 37 left liver-up CDH (LLU) and 9 right liver-up CDH (RLU). Overall, RLU fetuses had greater overall and fractional (intra-thoracic vs. intra-abdominal) liver growth when compared to LLD and LLU fetuses. Additionally, intra-thoracic liver growth was consistently slower than intra-abdominal liver growth for either right- or left-sided CDH. When the liver was not herniated, a positive correlation was seen between liver growth and lung growth. However, when the liver was herniated above the diaphragm, this positive correlation was lost. CONCLUSION Right-sided CDH fetuses exhibit greater liver growth compared to left-sided CDH. Liver herniation disrupts the normal positive correlation between liver and lung growth that is seen when the liver is entirely within the abdomen.
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Affiliation(s)
- Katherine C Ott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael Bi
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Federico Scorletti
- Neonatal Surgical Unit, Medical and Surgical Department of the Fetus, Newborn and Infant, Bambino Gesù Children's Hospital, Rome, Italy
| | - Saad A Ranginwala
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - William S Marriott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jose L Peiro
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Beth M Kline-Fath
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Amir M Alhajjat
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Aimen F Shaaban
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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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: 7] [Impact Index Per Article: 3.5] [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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27
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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: 8] [Impact Index Per Article: 2.7] [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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Predicting Perinatal Outcomes in Fetuses with Congenital Diaphragmatic Hernia Using Ultrasound and Magnetic Resonance Imaging. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Danzer E, Edgar JC, Eppley E, Goldshore MA, Chotzoglou E, Herkert LM, Oliver ER, Rintoul NE, Panitch H, Adzick NS, Hedrick HL, Victoria T. Predicting neonatal outcomes in infants with giant omphalocele using prenatal magnetic resonance imaging calculated observed-to-expected fetal lung volumes. Prenat Diagn 2021; 41:1439-1448. [PMID: 34473853 DOI: 10.1002/pd.6040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/21/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the association between prenatal magnetic resonance imaging (MRI) based observed/expected total lung volume (O/E TLV) and outcome in neonates with giant omphalocele (GO). METHODS Between 06/2004 and 12/2019, 67 cases with isolated GO underwent prenatal and postnatal care at our institution. MRI-based O/E TLVs were calculated based on normative data from Meyers and from Rypens and correlated with postnatal survival and morbidities. O/E TLV scores were grouped based on severity into <25% (severe), between 25% and 50% (moderate), and >50% (mild) for risk stratification. RESULTS O/E TLV was calculated for all patients according to Meyers nomograms and for 49 patients according to Rypens nomograms. Survival for GO neonates with severe, moderate, and mild pulmonary hypoplasia based on Meyers O/E TLV categories was 60%, 92%, and 96%, respectively (p = 0.04). There was a significant inverse association between Meyers O/E TLV and risk of neonatal morbidities (p < 0.05). A similar trend was observed with Rypens O/E TLV, but associations were less often significant likely related to the smaller sample size. CONCLUSION Neonatal outcomes are related to fetal lung size in isolated GO. Assessment of Meyers O/E TLV allows identification of GO fetuses at greatest risk for complications secondary to pulmonary hypoplasia.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - J Christopher Edgar
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Eppley
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew A Goldshore
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Etze Chotzoglou
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard Panitch
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Teresa Victoria
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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30
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Fetal liver and lung volume index of neonatal survival with congenital diaphragmatic hernia. Pediatr Radiol 2021; 51:1637-1644. [PMID: 33779798 DOI: 10.1007/s00247-021-05049-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assesses pulmonary hypoplasia in fetal congenital diaphragmatic hernia (CDH). Neonatal mortality may occur with CDH. OBJECTIVE To quantify MRI parameters associated with neonatal survival in fetuses with isolated CDH. MATERIALS AND METHODS Fetal MRI for assessing CDH included region of interest (ROI) measurements for total lung volume (TLV), herniated liver volume, herniated other organ volume and predicted lung volume. Ratios of observed lung volume and liver up volume to predicted lung volume (observed to predicted TLV, percentage of the thorax occupied by liver) were calculated and compared to neonatal outcomes. Analyses included Wilcoxon rank sum test, multivariate logistic regression and receiver operating characteristic (ROC) curves. RESULTS Of 61 studies, the median observed to predicted TLV was 0.25 in survivors and 0.16 in non-survivors (P=0.001) with CDH. The median percentage of the thorax occupied by liver was 0.02 in survivors and 0.22 in non-survivors (P<0.001). The association of observed to predicted TLV and percentage of the thorax occupied by liver with survival for gestational age (GA) >28 weeks was greater compared to GA ≤28 weeks. The ROC analysis demonstrated an area under the curve of 0.96 (95% confidence interval 0.91-1.00) for the combined observed to predicted TLV, percentage of the thorax occupied by liver and GA. CONCLUSION The percentage of the thorax occupied by liver and observed to predicted TLV was predictive of neonatal survival in fetuses with CDH.
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Abstract
PURPOSE OF REVIEW Congenital diaphragmatic hernia (CDH) is a structural birth defect that results in significant neonatal morbidity and mortality. CDH occurs in 2-4 per 10 000 pregnancies, and despite meaningful advances in neonatal intensive care, the mortality rate in infants with isolated CDH is still 25-30%. In this review, we will present data on the molecular underpinnings of pathological lung development in CDH, prenatal diagnosis, and prognostication in CDH cases, existing fetal therapy modalities, and future directions. RECENT FINDINGS Developments in the prenatal assessment and in-utero therapy of pregnancies complicated by congenital diaphragmatic hernia are rapidly evolving. Although ultrasound has been the mainstay of prenatal diagnosis, fetal MRI appears to be an increasingly important modality for severity classification. While fetal endoscopic tracheal occlusion (FETO) may have a role in the prenatal management of severe CDH cases, it is possible that future therapeutic paradigms will incorporate adjunct medical interventions with either stem cells or sildenafil in order to address the vascular effects of CDH on the developing lung. SUMMARY Both animal and human data have shown that the pathophysiological underpinnings of CDH are multifactorial, and it appears that future prenatal assessments and therapies will likely be as well.
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Donepudi R, Belfort MA, Shamshirsaz AA, Lee TC, Keswani SG, King A, Ayres NA, Fernandes CJ, Sanz-Cortes M, Nassr AA, Espinoza AF, Style CC, Espinoza J. Fetal endoscopic tracheal occlusion and pulmonary hypertension in moderate congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2021; 35:6967-6972. [PMID: 34096456 DOI: 10.1080/14767058.2021.1932806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmonary hypertension (PH) in fetuses with isolated moderate left-sided diaphragmatic hernia (CDH). METHODS This retrospective study included fetuses with CDH evaluated between February 2004 and July 2017. Using the tracheal occlusion to accelerate lung growth (TOTAL) trial definition, we classified fetuses into moderate left CDH if O/E-LHR (observed/expected-lung head ratio) was 25-34.9% regardless of liver position or O/E-LHR of 35-44.9% if liver was in the chest. Postnatal echocardiograms were used to diagnose PH. Logistic regression analyses were performed to determine the relationship of FETO with study outcomes. RESULTS Of 184 cases with no other major anomalies, 30 (16%) met criteria. There were nine FETO and 21 non-FETO cases. By hospital discharge, a higher proportion of infants in the FETO group had resolution of PH (87.5 (7/8) vs. 40% (8/20); p=.013). FETO was associated with adjusted odds ratio of 17.3 (95% CI: 1.75-171; p=.015) to resolve PH by hospital discharge. No significant differences were noted in need for ECMO or survival to discharge between groups. CONCLUSIONS Infants with moderate left-sided CDH according to O/E-LHR, FETO is associated with resolution of PH by the time of hospital discharge.
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Affiliation(s)
- Roopali Donepudi
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Timothy C Lee
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sundeep G Keswani
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alice King
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nancy A Ayres
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics - Cardiology Section, Baylor College of Medicine, Houston, TX, USA
| | - Caraciolo J Fernandes
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Newborn Section, Baylor College of Medicine, Houston, TX, USA
| | - Magdalena Sanz-Cortes
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed A Nassr
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Andres F Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Candace C Style
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Management of Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: Interim Guidelines Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J 2021; 67:113-120. [PMID: 33512912 DOI: 10.1097/mat.0000000000001338] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.
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Kolbe AB, Ibirogba ER, Thomas KB, Hull NC, Thacker PG, Hathcock M, Sangi-Haghpeykar H, Ruano R. Reproducibility of Lung and Liver Volume Measurements on Fetal Magnetic Resonance Imaging in Left-Sided Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2021; 48:258-264. [PMID: 33756472 DOI: 10.1159/000512491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/22/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) affects 1 in 3,000 live births and is associated with significant morbidity and mortality. METHODS A review of fetal magnetic resonance imaging (MRI) examinations was performed for fetuses with left CDH and normal lung controls. Image review and manual tracings were performed by 4 pediatric radiologists; right and left lung volumes in the coronal and axial planes as well as liver volume above and below the diaphragm in the coronal plane were measured. Intra- and interreviewer reproducibility was assessed using intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS Excellent intra- and interreviewer reproducibility of the right and left lung volume measurements was observed in both axial planes (interreviewer ICC: right lung: 0.97, 95% CI: 0.95-0.99; left lung: 0.97, 95% CI: 0.95-0.98) and coronal planes (interreviewer ICC: right lung: 0.97, 95% CI: 0.95-0.98; left lung: 0.96, 95% CI: 0.93-0.98). Moderate-to-good interreviewer reproducibility was observed for liver volume above the diaphragm (ICC 0.7, 95% CI: 0.59-0.81). Liver volume below the diaphragm had a good-to-excellent interreviewer reproducibility (ICC 0.88, 95% CI: 9.82-0.93). CONCLUSIONS The present study demonstrated an excellent intra- and interreviewer reproducibility of MRI lung volume measurements and good-to-moderate inter- and intrareviewer reproducibility of liver volume measurements after standardization of the methods at our fetal center.
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Affiliation(s)
- Amy B Kolbe
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eniola R Ibirogba
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Kristen B Thomas
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul G Thacker
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Matthew Hathcock
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA,
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Corroenne R, Zhu KH, Johnson R, Mehollin-Ray AR, Shamshirsaz AA, Nassr AA, Belfort MA, Cortes MS, Shetty A, Lee W, Espinoza J. Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia. Eur J Obstet Gynecol Reprod Biol 2021; 260:22-28. [PMID: 33713885 DOI: 10.1016/j.ejogrb.2021.02.025] [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: 10/12/2020] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES (1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO). METHODS Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension. RESULTS The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04). CONCLUSION Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.
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Affiliation(s)
- Romain Corroenne
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Katherine H Zhu
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Rebecca Johnson
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Amy R Mehollin-Ray
- E. B. Singleton Department of Radiology, Texas Children's Hospital & Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Anil Shetty
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA.
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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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37
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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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38
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Coblentz AC, Teixeira SR, Mirsky DM, Johnson AM, Feygin T, Victoria T. How to read a fetal magnetic resonance image 101. Pediatr Radiol 2020; 50:1810-1829. [PMID: 33252751 DOI: 10.1007/s00247-020-04768-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/22/2020] [Accepted: 07/01/2020] [Indexed: 12/18/2022]
Abstract
Accurate antenatal diagnosis is essential for planning appropriate pregnancy management and improving perinatal outcomes. The provision of information vital for prognostication is a crucial component of prenatal imaging, and this can be enhanced by the use of fetal MRI. Image acquisition, interpretation and reporting of a fetal MR study can be daunting to the individual who has encountered few or none of these examinations. This article provides the radiology trainee with a general approach to interpreting a fetal MRI. The authors review the added value of prenatal MRI in the overall assessment of fetal wellbeing, discuss MRI protocols and techniques, and review the normal appearance of maternal and fetal anatomy. The paper concludes with a sample template for structured reporting, to serve as a checklist and guideline for reporting radiologists.
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Affiliation(s)
- Ailish C Coblentz
- Radiology Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 10104, USA
| | - Sara R Teixeira
- Radiology Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 10104, USA
| | - David M Mirsky
- Neuroradiology Department, Children's Hospital of Colorado, Aurora, CO, USA
| | - Ann M Johnson
- Radiology Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 10104, USA
| | - Tamara Feygin
- Radiology Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 10104, USA
| | - Teresa Victoria
- Radiology Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 10104, USA.
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Perrone EE, Abbasi N, Cortes MS, Umar U, Ryan G, Johnson A, Ladino-Torres M, Ruano R. Prenatal assessment of congenital diaphragmatic hernia at north american fetal therapy network centers: A continued plea for standardization. Prenat Diagn 2020; 41:200-206. [PMID: 33125174 DOI: 10.1002/pd.5859] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Prenatal work-up for congenital diaphragmatic hernia (CDH) is important for risk stratification, standardization, counseling, and optimal therapeutic choice. To determine current practice patterns regarding prenatal CDH work-up, including prenatal ultrasound and magnetic resonance imaging (MRI) use, and to identify areas for standardization of such evaluation between fetal centers. METHODS A survey regarding prenatal CDH work-up was sent to each member center of the North American Fetal Therapy Network (NAFTNet) (n = 36). RESULTS All responded. Sonographic measurement of lung-to-head ratio (LHR) was determined by all, 89% (32/36) of which routinely calculate observed-to-expected LHR. The method for measuring LHR varied: 58% (21/36) used a "trace" method, 25% (9/36) used "longest axis," and 17% (6/36) used an "antero-posterior" method. Fetal MRI was routinely used in 78% (28/36) of centers, but there was significant variability in fetal lung volume measurement. Whereas all generated a total fetal lung volume, the planes, methodology and references values varied significantly. All evaluated liver position, 71% (20/28) evaluated stomach position and 54% (15/28) quantified the degree of liver herniation. More consistency in workup was seen between centers offering fetal intervention. CONCLUSION Prenatal CDH work-up and management differs considerably among North American fetal diagnostic centers, highlighting a need for its standardization.
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Affiliation(s)
- Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Uzma Umar
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hospital, University of Texas Health Science Center, Houston, Texas, USA
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo Ruano
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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40
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Ville Y. Should we offer fetal surgery for severe congenital diaphragmatic hernia or bring these cases to trial? Difference between chance and hazard. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:491-492. [PMID: 33001494 DOI: 10.1002/uog.22103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Y Ville
- Fetal Medicine and Surgery Centre, MICADO Consortium (Multidisciplinary Initiative for Congenital and Developmental Anomalies), Université de Paris, Hôpital Necker-Enfants Malades, Paris, France
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41
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Recio Rodríguez M, Andreu-Vázquez C, Thuissard-Vasallo IJ, Cano Alonso R, Bermejo López C, Tamarit Degenhardt I, Martínez Ten P. Real-Life Diagnostic Accuracy of MRI in Prenatal Diagnosis. Radiol Res Pract 2020; 2020:4085349. [PMID: 33062332 PMCID: PMC7542514 DOI: 10.1155/2020/4085349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/17/2022] Open
Abstract
There is some controversy about the value of fetal MRI in prenatal diagnosis, and most of the studies examine its accuracy in central nervous system (CNS) pathology. The objective of this retrospective study was to assess the diagnostic accuracy and usefulness of fetal MRI in the prenatal diagnosis of central nervous system (CNS) pathology and non-CNS pathology. Patients referred to the Radiology Department between 2007 and 2018 for a fetal MRI after detection of an anomaly in the fetal ultrasound, a high-risk pregnancy, or an inconclusive fetal ultrasound (n = 623) were included in the study. Postnatal diagnosis was used to assess the diagnostic accuracy of MRI. Fetal MRI was considered to provide additional information over fetal ultrasound when findings of the fetal MRI were not detected in the fetal ultrasound or when established a pathological condition that was not detected in the fetal ultrasound. Fetal MRI provided useful information for the perinatal management and prognosis over fetal ultrasound when findings of the fetal MRI changed the postnatal prognosis, leaded to the decision to legally terminate the pregnancy, changed prenatal or postnatal follow-up, or helped in the planning of prenatal or postnatal treatment. Fetal MRI offered an accurate diagnosis in 97% of cases (compared to 90.4% of fetal ultrasound; p < 0.001). Concordance between fetal ultrasound and fetal MRI was 92.1%. Fetal MRI provided additional information over fetal ultrasound in 23.1% of cases. In 11.6% of cases, the information was useful for the perinatal management and prognosis. In 45 cases (7.2%), fetal MRI was the only accurate diagnosis. In conclusion, fetal MRI has a superior diagnostic accuracy, especially in CNS pathology, and provides additional useful information in CNS, thoracic, and abdominal pathology.
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Affiliation(s)
- Manuel Recio Rodríguez
- Departamento de Diagnóstico por Imagen, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Cristina Andreu-Vázquez
- Departamento de Medicina, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain
| | | | - Raquel Cano Alonso
- Departamento de Diagnóstico por Imagen, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | | | - Ines Tamarit Degenhardt
- Departamento de Obstetricia y Ginecología, Hospital Universitario Quironsalud Madrid, Madrid, Spain
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42
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Kim AG, Norwitz G, Karmakar M, Ladino-Torres M, Berman DR, Kreutzman J, Treadwell MC, Mychaliska GB, Perrone EE. Discordant prenatal ultrasound and fetal MRI in CDH: wherein lies the truth? J Pediatr Surg 2020; 55:1879-1884. [PMID: 31813580 DOI: 10.1016/j.jpedsurg.2019.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/23/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Prenatal risk assessment of congenital diaphragmatic hernia (CDH) relies on prenatal ultrasound (U/S) and fetal magnetic resonance imaging (MRI). When the modalities differ in prognosis, it is unclear which is more reliable. METHODS Retrospective chart review identified cases of prenatally diagnosed CDH from 4/2010-6/2018 meeting inclusion criteria. Demographic, radiologic, and postnatal outcomes data were collected. Ultrasound- versus MRI-based prognosis (mild, moderate, and severe) was compared with clinical outcomes. Kappa measures compared congruency in disease severity scaling between imaging modalities, while logistic regression and receiver operating characteristics curves compared the ability of each modality to predict outcomes. RESULTS Forty-two patients met criteria. Both U/S- and MRI-based prognosis categories differentiated for survival. MRI categories differentiated for ECMO use, surgical repair, and defect type. O/e TFLV better discriminated for survivors and defect type than o/e LHR. Seventeen (40.5%) had discordant prenatal prognostic categories. In 13/17 (76.5%), o/e TFLV predicted higher severity when compared to o/e LHR, but sample size was insufficient to compare accuracy in cases of discordance. CONCLUSIONS Clinical outcomes suggest fetal MRI may more accurately predict severe pulmonary hypoplasia compared to prenatal ultrasound. Our analysis suggests fetal MRI is a valuable adjunct in the prenatal evaluation of CDH. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Review.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Gabriella Norwitz
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine.
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43
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Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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44
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Pinton A, Boubnova J, Becmeur F, Kuhn P, Senat MV, Stirnemann J, Capelle M, Rosenblatt J, Massardier J, Vaast P, Le Bouar G, Desrumaux A, Connant L, Begue L, Parmentier B, Perrotin F, Diguet A, Benoist G, Muszynski C, Scalabre A, Winer N, Michel JL, Casagrandre-Magne F, Jouannic JM, Gallot D, Coste Mazeau P, Sapin E, Maatouk A, Saliou AH, Sentilhes L, Biquard F, Mottet N, Favre R, Benachi A, Sananès N. Is laterality of congenital diaphragmatic hernia a reliable prognostic factor? French national cohort study. Prenat Diagn 2020; 40:949-957. [PMID: 32279384 DOI: 10.1002/pd.5706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/07/2019] [Accepted: 03/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The objective of this study was to assess whether the laterality of congenital diaphragmatic hernia (CDH) was a prognostic factor for neonatal survival. METHODS This was a cohort study using the French national database of the Reference Center for Diaphragmatic Hernias. The principal endpoint was survival after hospitalization in intensive care. We made a comparative study between right CDH and left CDH by univariate and multivariate analysis. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS A total of 506 CDH were included with 67 (13%) right CDH and 439 left CDH (87%). Rate of survival was 49% for right CDH and 74% for left CDH (P < .01). Multivariate analysis showed two factors significantly associated with mortality: thoracic herniation of liver (OR 2.27; IC 95% [1.07-4.76]; P = .03) and lung-to-head-ratio over under expected (OR 2.99; IC 95% [1.41-6.36]; P < .01). Side of CDH was not significantly associated with mortality (OR 1.87; IC 95% [0.61-5.51], P = .26). CONCLUSION Rate of right CDH mortality is more important than left CDH. Nevertheless after adjusting for lung-to-head-ratio and thoracic herniation of liver, right CDH does not have a higher risk of mortality than left CDH.
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Affiliation(s)
- Anne Pinton
- Department of Obstetrics and Gynecology, Hôpital Trousseau, AP-HP, Paris, France.,Sorbonne Université, boulevard de l'Hôpital, Paris, France
| | - Julia Boubnova
- Department of Obstetrics and Gynecology, Maternité de la Conception, Gynepole, Marseille, France
| | - François Becmeur
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatal Intensive Care Unit, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Institut des Neurosciences Cellulaires et Intégratives, UPR 3212, CNRS et Université de Strasbourg, Strasbourg, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Julien Stirnemann
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Necker-Enfants malades, AP-HP, Paris, France.,EHU7328, Université de Paris and Institut IMAGINE, Paris, France
| | - Marianne Capelle
- Department of Obstetrics and Gynecology, Maternité de la Conception, Gynepole, Marseille, France
| | - Jonathan Rosenblatt
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Universitaire Robert-Debré, AP-HP, Paris, France
| | - Jérôme Massardier
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, University Claude Bernard, Lyon, France
| | - Pascal Vaast
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Gwenaelle Le Bouar
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Rennes, University of Rennes 1, Rennes, France
| | - Amélie Desrumaux
- Department of Pediatrics, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
| | - Laure Connant
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Laetitia Begue
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - Benoit Parmentier
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Tours, François Rabelais University, Tours, France
| | - Alain Diguet
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | - Guillaume Benoist
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Caen, Normandie University, Caen, France
| | - Charles Muszynski
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire d'Amiens, Amiens, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, Centre Hospitalo-Universitaire de Saint Etienne, Saint-Etienne, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Nantes, Nantes, France.,NUN, INRAE, UMR 1280, PhAN, Université de Nantes, CIC Femme enfant adolescent, Nantes, France
| | - Jean-Luc Michel
- Department of Pediatric Surgery, Centre Hospitalo-Universitaire de Félix Guyon, Bellepierre Saint-Denis, Saint-Denis, France
| | | | - Jean-Marie Jouannic
- Department of Obstetrics and Gynecology, Fetal Medicine Department, Hôpital Trousseau AP-HP, Paris, France.,Sorbonne université, boulevard de l'Hôpital, Paris, France
| | - Denis Gallot
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire Estaing, Pole FEE, Clermont-Ferrand, France
| | - Perrine Coste Mazeau
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Limoges, Limoges, France
| | - Emmanuel Sapin
- Department of Pediatric Surgery, François-Mitterrand Teaching Hospital, LE2I UMR CNRS 6306, Arts et Métiers, University of Burgundy, Dijon, France
| | - Alexis Maatouk
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Nancy, Nancy, France
| | - Anne-Hélène Saliou
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Brest, Hôpital Morvan, Brest, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France
| | - Florence Biquard
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire d'Angers, Angers, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Besançon, Université de Franche-Comté, Besançon, France
| | - Romain Favre
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology and Reproductive Medicine, AP-HP, Antoine Béclère Hospital, University Paris Saclay, Clamart, France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,INSERM UMR-S 1121 "Biomatériaux et bioingénierie", Université de Strasbourg, Strasbourg, France
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45
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Snyder E. Current Value of Fetal MRI in Prenatal Diagnosis. J Magn Reson Imaging 2020; 52:1569-1570. [PMID: 32338791 DOI: 10.1002/jmri.27178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 12/31/2022] Open
Affiliation(s)
- Elizabeth Snyder
- Department of Pediatric Radiology, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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46
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Kirby E, Keijzer R. Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up. Pediatr Surg Int 2020; 36:415-429. [PMID: 32072236 DOI: 10.1007/s00383-020-04625-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.
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Affiliation(s)
- Eimear Kirby
- Trinity College Dublin School of Medicine, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - Richard Keijzer
- Thorlakson Chair in Surgical Research, Division of Pediatric Surgery, Department of Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada. .,Department of Pediatrics and Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada. .,Department of Physiology and Pathophysiology and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada.
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47
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Abstract
Because congenital diaphragmatic hernia (CDH) is characterized by a spectrum of severity, risk stratification is an essential component of care. In both the prenatal and postnatal periods, accurate prediction of outcomes may inform clinical decision-making, care planning, and resource allocation. This review examines the history and utility of the most well-established risk prediction tools currently available, and provides recommendations for their optimal use in the management of CDH patients.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap St., Second Floor, Memphis, TN, 38112, USA.
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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48
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Abramov A, Fan W, Hernan R, Zenilman AL, Wynn J, Aspelund G, Khlevner J, Krishnan U, Lim FY, Mychaliska GB, Warner BW, Cusick R, Crombleholme T, Chung D, Danko ME, Wagner AJ, Azarow K, Schindel D, Potoka D, Soffer S, Fisher J, McCulley D, Farkouh-Karoleski C, Chung WK, Duron V. Comparative outcomes of right versus left congenital diaphragmatic hernia: A multicenter analysis. J Pediatr Surg 2020; 55:33-38. [PMID: 31677822 DOI: 10.1016/j.jpedsurg.2019.09.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) occurs in 1 out of 2500-3000 live births. Right-sided CDHs (R-CDHs) comprise 25% of all CDH cases, and data are conflicting on outcomes of these patients. The aim of our study was to compare outcomes in patients with right versus left CDH (L-CDH). METHODS We analyzed a multicenter prospectively enrolled database to compare baseline characteristics and outcomes of neonates enrolled from January 2005 to January 2019 with R-CDH vs. L-CDH. RESULTS A total of 588, 495 L-CDH, and 93 R-CDH patients with CDH were analyzed. L-CDHs were more frequently diagnosed prenatally (p=0.011). Lung-to-head ratio was similar in both cohorts. R-CDHs had a lower frequency of primary repair (p=0.022) and a higher frequency of need for oxygen at discharge (p=0.013). However, in a multivariate analysis, need for oxygen at discharge was no longer significantly different. There were no differences in long-term neurodevelopmental outcomes assessed at two year follow up. There was no difference in mortality, need for ECMO, pulmonary hypertension, or hernia recurrence. CONCLUSION In this large series comparing R to L-CDH patients, we found no significant difference in mortality, use of ECMO, or pulmonary complications. Our study supports prior studies that R-CDHs are relatively larger and more often require a patch or muscle flap for repair. TYPE OF STUDY Prognosis study LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Alexey Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rebecca Hernan
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Ariela L Zenilman
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Gudrun Aspelund
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Julie Khlevner
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Usha Krishnan
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Foong-Yen Lim
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Brad W Warner
- Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert Cusick
- Division of Pediatric Surgery, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA
| | - Timothy Crombleholme
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Dai Chung
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Amy J Wagner
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kenneth Azarow
- Pediatric Surgery Division, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - David Schindel
- Division of Pediatric Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Douglas Potoka
- Division of Pediatric Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Sam Soffer
- Department of Pediatric Surgery, Northwell Health, New York, NY, USA
| | - Jason Fisher
- Division of Pediatric Surgery, New York University Langone Medical Center, New York, NY, USA
| | - David McCulley
- Department of Pediatrics, Meriter-Unity Point Health, Madison, WI, USA
| | | | - Wendy K Chung
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA; Department of Medicine, Columbia University Medical Center, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Vincent Duron
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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49
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Style CC, Olutoye OO, Belfort MA, Ayres NA, Cruz SM, Lau PE, Shamshirsaz AA, Lee TC, Olutoye OA, Fernandes CJ, Cortes MS, Keswani SG, Espinoza J. Fetal endoscopic tracheal occlusion reduces pulmonary hypertension in severe congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:752-758. [PMID: 30640410 DOI: 10.1002/uog.20216] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Fetal endoscopic tracheal occlusion (FETO) is associated with increased perinatal survival and reduced need for extracorporeal membrane oxygenation (ECMO) in fetuses with severe congenital diaphragmatic hernia (CDH). This study evaluates the impact of FETO on the resolution of pulmonary hypertension (PH) in fetuses with isolated CDH. METHODS We reviewed retrospectively the medical records of all fetuses evaluated for CDH between January 2004 and July 2017 at a single institution. Fetuses with additional major structural or chromosomal abnormalities were excluded. CDH cases were classified retrospectively into mild, moderate and severe groups based on prenatal magnetic resonance imaging indices (observed-to-expected total fetal lung volume and percentage of intrathoracic liver herniation). Presence of PH was determined based on postnatal echocardiograms. Logistic regression analyses were performed to evaluate the relationship between FETO and resolution of PH by 1 year of age while controlling for side of the CDH, use of ECMO, gestational age at diagnosis, gestational age at delivery, fetal gender, sildenafil use at discharge and CDH severity. Resolution of PH by 1 year of age was compared between a cohort of fetuses with severe CDH that underwent FETO and a cohort that did not have the procedure (non-FETO). A subanalysis was performed restricting the analysis to isolated left CDH. Parametric and non-parametric tests were used for comparisons. RESULTS Of 257 CDH cases evaluated, 72% (n = 184) had no major structural or chromosomal anomalies of which 58% (n = 107) met the study inclusion criteria. The FETO cohort consisted of 19 CDH cases and the non-FETO cohort (n = 88) consisted of 31 (35%) mild, 32 (36%) moderate and 25 (28%) severe CDH cases. All infants with severe CDH, regardless of whether they underwent FETO, had evidence of neonatal PH. FETO (OR, 3.57; 95% CI, 1.05-12.10; P = 0.041) and ECMO (OR, 5.01; 95% CI, 2.10-11.96; P < 0.001) were independent predictors of resolution of PH by 1 year of age. A higher proportion of infants with severe CDH that underwent FETO had resolution of PH by 1 year after birth compared with infants with severe CDH in the non-FETO cohort (69% (11/16) vs 28% (7/25); P = 0.017). Similar results were observed when the analysis was restricted to cases with left-sided CDH (PH resolution in 69% (11/16) vs 28% (5/18); P = 0.032). CONCLUSION In infants with severe CDH, FETO and ECMO are independently associated with increased resolution of PH by 1 year of age. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C C Style
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - O O Olutoye
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - N A Ayres
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Cardiology Section, Baylor College of Medicine, Houston, TX, USA
| | - S M Cruz
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - P E Lau
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - A A Shamshirsaz
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - T C Lee
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - O A Olutoye
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - C J Fernandes
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Newborn Section, Baylor College of Medicine, Houston, TX, USA
| | - M Sanz Cortes
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - S G Keswani
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - J Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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Verla MA, Style CC, Mehollin-Ray AR, Fallon SC, Vogel AM, Fernandes CJ, Ikedionwu CA, Lee TC, Keswani SG, Olutoye OO. Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2019; 47:252-260. [PMID: 31434077 DOI: 10.1159/000501555] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate. RESULTS We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05). CONCLUSION Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.
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Affiliation(s)
- Mariatu A Verla
- Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Candace C Style
- Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Texas Children's Hospital and Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Sara C Fallon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Texas Children's Fetal Center, Texas Children's Hospital and Department of Pediatrics - Newborn Section, Baylor College of Medicine, Houston, Texas, USA
| | - Chioma A Ikedionwu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Timothy C Lee
- Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sundeep G Keswani
- Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA,
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