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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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Bouchghoul H, Dumery G, Russo FM, Cordier AG, Le Sache N, Debeer A, Decaluwe H, Fouquet V, Senat MV, Deprest J, Benachi A. Optimal gestational age at delivery in isolated left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:968-973. [PMID: 32610372 DOI: 10.1002/uog.22133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/25/2020] [Accepted: 06/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the morbidity and mortality of neonates with left-sided isolated congenital diaphragmatic hernia (CDH) according to gestational age at delivery. METHODS This was a retrospective study of fetuses diagnosed prenatally with isolated left-sided CDH that were delivered in the University Hospitals of Antoine Béclère-Bicêtre and Leuven between 1 January 2010 and 31 December 2018. The Kaplan-Meier method was used to calculate cumulative survival at 28 days after birth according to gestational age at delivery. The association between gestational age at delivery, as a continuous variable, and survival at 28 days was modeled using a fractional polynomial. Adjustment for position of the liver, management center and mode of delivery was performed. The association was also evaluated according to the severity of CDH, as defined by the observed-to-expected lung-to-head ratio (o/e-LHR), which was classified as severe (o/e-LHR < 25%), moderate (o/e-LHR between 25% and 45%) or mild (o/e-LHR > 45%). RESULTS We included 213 fetuses with isolated left-sided CDH, with a median gestational age at delivery of 38 + 2 weeks (interquartile range, 37 + 0 to 39 + 1 weeks). The survival rates at 28 days and at 6 months were 66.7% (142/213) and 64.3% (137/213), respectively. Kaplan-Meier analysis showed a higher survival rate at 28 days for babies delivered between 37 + 0 and 38 + 6 weeks than for those delivered at or after 39 + 0 weeks (log-rank test, P < 0.001). In the subgroup of moderate CDH, the 28-day survival rate was significantly higher in newborns delivered between 37 + 0 and 38 + 6 weeks than in those delivered at or after 39 + 0 weeks (81.5% vs 61.5%; P = 0.03), and this was also the case for survival rate at 6 months. In the subgroup with moderate CDH, 28-day survival significantly increased with advancing gestational age at birth up to about 38-39 weeks (P = 0.005), and significantly decreased from 39 weeks onwards. CONCLUSION Delivery between 37 + 0 and 38 + 6 weeks' gestation is associated with a higher survival rate at 28 days in neonates with isolated left-sided CDH and moderate lung hypoplasia, independently of intrathoracic liver, management center and mode of delivery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H Bouchghoul
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
| | - G Dumery
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France
| | - F M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - A G Cordier
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Antoine Béclère Hospital, University Paris-Saclay, Clamart, France
| | - N Le Sache
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Neonatology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France
| | - A Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - H Decaluwe
- Department of Pediatric Surgery, University Hospitals Leuven, Leuven, Belgium
| | - V Fouquet
- Department of Pediatric Surgery, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, University Paris-Saclay, Le Kremlin-Bicêtre, France
| | - M V Senat
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
| | - J Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - A Benachi
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Antoine Béclère Hospital, University Paris-Saclay, Clamart, France
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Gien J, Meyers ML, Kinsella JP. Assessment of Carina Position Antenatally and Postnatally in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2018; 192:93-98.e1. [PMID: 29246364 PMCID: PMC5737713 DOI: 10.1016/j.jpeds.2017.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/05/2017] [Accepted: 09/20/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine whether endotracheal tube (ETT) insertion depth should be modified in infants with congenital diaphragmatic hernia (CDH) to reduce the risk of main-stem intubation. STUDY DESIGN The distance from the thoracic inlet to the carina was measured antenatally by fetal magnetic resonance imaging (MRI) between 20-28 weeks' (early) and 30-34 weeks' (late) gestation in 30 infants with CDH and compared with 12 early and 36 late MRIs in control infants without CDH. Postnatal tube position was assessed by chest radiograph in the same 30 infants with CDH and compared with 20 control infants with postnatal birth depression. RESULTS The carina position was displaced upward in fetuses and newborns with CDH. Distance from the thoracic inlet to the carina compared with controls was 1.04 ± 0.1 cm vs 1.42 ± 0.07 cm on early MRI (P < .05), 1.43 ± 0.14 cm vs 1.9 ± 0.04 cm on late MRI (P < .01), and 2.36 ± 0.07 cm vs 3.28 ± 0.05 cm on postnatal radiographs (P < .01). Adjusting the ETT depth by 1 cm resulted in a median distance of 1.27 cm from the tip of the ETT to the carina. CONCLUSION Cephalad displacement of the carina in infants with CDH may predispose them to right main-stem intubation and subsequent development of pneumothorax. We speculate that modifying the ETT insertion depth to 5.5 cm + weight in newborns born at term may prevent pneumothoraces and improve outcomes for infants with CDH.
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MESH Headings
- Case-Control Studies
- Female
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Infant, Newborn
- Intubation, Intratracheal/methods
- Magnetic Resonance Imaging
- Male
- Pregnancy
- Prenatal Diagnosis
- Trachea/abnormalities
- Trachea/diagnostic imaging
- Trachea/embryology
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Affiliation(s)
- Jason Gien
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Mariana L Meyers
- Department of Radiology, Pediatric Section, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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Kadir D, Lilja HE. Risk factors for postoperative mortality in congenital diaphragmatic hernia: a single-centre observational study. Pediatr Surg Int 2017; 33:317-323. [PMID: 27986977 PMCID: PMC5310566 DOI: 10.1007/s00383-016-4032-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The management of congenital diaphragmatic hernia (CDH) is a major challenge. The mortality is dependent on associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension and iatrogenic lung injury associated with aggressive mechanical ventilation. The aims of the study were to investigate the mortality over time in a single paediatric surgical centre, to compare the results with recent reports and to define the risk factors for mortality. METHODS The medical records of infants with CDH from two time periods: 1995-2005 and 2006-2016 were reviewed. Cox regression was used for statistical analysis. RESULTS The study included 113 infants. The mortality rate was significantly decreased in the later time period, compared to the earlier, 4.4 and 17.9%, respectively. At the early time period five patients (7.5%) were treated with ECMO and in the later time period ECMO was used in three patients (6.5%). The mortality in ECMO-treated patients was 50% in both time periods. Prenatal diagnosis, intrathoracic liver, low Apgar score and low birth weight were defined as independent risk factors for mortality. CONCLUSION Despite no significant differences in the incidence of independent risk factors and the use of ECMO between the two time periods, mortality decreased over time. The mortality was lower than previously reported. The results indicate that there are many important factors involved in a successful outcome after CDH repair. Large multicentre studies are necessary to define those critical factors and to determine optimal treatment strategies.
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Affiliation(s)
- Darya Kadir
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden.
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden.
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Outcomes of Congenital Diaphragmatic Hernia: An 8-Year Experience. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.9144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Akinkuotu AC, Cruz SM, Abbas PI, Lee TC, Welty SE, Olutoye OO, Cassady CI, Mehollin-Ray AR, Ruano R, Belfort MA, Cass DL. Risk-stratification of severity for infants with CDH: Prenatal versus postnatal predictors of outcome. J Pediatr Surg 2016; 51:44-8. [PMID: 26563530 DOI: 10.1016/j.jpedsurg.2015.10.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 10/06/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to compare the predication accuracy of a newly described postnatally-based clinical prediction model to fetal imaging-based predictors of mortality for infants with CDH. METHODS We performed a retrospective review of all CDH patients treated at a comprehensive fetal care center from January 2004 to January 2014. Prenatal data reviewed included lung-to-head ratio (LHR), observed/expected-total fetal lung volume (O/E-TFLV), and percent liver herniation (%LH). Based on the postnatal prediction model, neonates were categorized as low, intermediate, and high risk of death. The primary outcome was 6-month mortality. RESULTS Of 176 CDH patients, 58 had a major cardiac anomaly, and 28 had a genetic anomaly. Patients with O/E-TFLV <35% and %LH >20% were at increased risk for mortality (44% and 36%, respectively). There was a significant difference in mortality between low, intermediate, and high-risk groups (4% vs. 22% vs. 51%; p<0.001). On multivariate regression, the O/E-TFLV and postnatal-based mortality risk score were the two independent predictors of 6-month mortality. CONCLUSION The CDH Study Group postnatal predictive model provides good discrimination among three risk groups in our patient cohort. The prenatal MRI-based O/E-TFLV is the strongest prenatal predictor of 6-month mortality in infants with CDH and will help guide prenatal counseling and discussions regarding fetal intervention and perinatal management.
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Affiliation(s)
- Adesola C Akinkuotu
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Stephanie M Cruz
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Paulette I Abbas
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Stephen E Welty
- Texas Children's Fetal Center, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Christopher I Cassady
- Texas Children's Fetal Center, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Rodrigo Ruano
- Texas Children's Fetal Center, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.
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Park HW, Lee BS, Lim G, Choi YS, Kim EAR, Kim KS. A simplified formula using early blood gas analysis can predict survival outcomes and the requirements for extracorporeal membrane oxygenation in congenital diaphragmatic hernia. J Korean Med Sci 2013; 28:924-8. [PMID: 23772159 PMCID: PMC3678011 DOI: 10.3346/jkms.2013.28.6.924] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 04/08/2013] [Indexed: 11/20/2022] Open
Abstract
The aims of this study were to investigate whether early arterial blood gas analysis (ABGA) could define the severity of disease in infants with congenital diaphragmatic hernia (CDH). We conducted a retrospective study over a 21-yr period of infants diagnosed with CDH. Outcomes were defined as death before discharge, and extracorporeal membrane oxygenation requirements (ECMO) or death. A total 114 infants were included in this study. We investigated whether simplified prediction formula [PO2-PCO2] values at 0, 4, 8, and 12 hr after birth were associated with mortality, and ECMO or death. The area under curve (AUC) of receiver operating characteristic curve was used to determine the optimum ABGA values for predicting outcomes. The value of [PO2-PCO2] at birth was the best predictor of mortality (AUC 0.803, P < 0.001) and at 4 hr after birth was the most reliable predictor of ECMO or death (AUC 0.777, P < 0.001). The value of [PO2-PCO2] from ABGA early period after birth can reliably predict outcomes in infants with CDH.
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Affiliation(s)
- Hye Won Park
- Department of Pediatrics, Division of Neonatology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gina Lim
- Department of Pediatrics, Division of Neonatology, Ulsan University Hospital, Ulsan, Korea
| | - Yong-Sung Choi
- Department of Pediatrics, Division of Neonatology, Kyung Hee University Medical Center, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Guner YS, Khemani RG, Qureshi FG, Wee CP, Austin MT, Dorey F, Rycus PT, Ford HR, Friedlich P, Stein JE. Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation. J Pediatr Surg 2009; 44:1691-701. [PMID: 19735810 DOI: 10.1016/j.jpedsurg.2009.01.017] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 01/15/2009] [Accepted: 01/15/2009] [Indexed: 11/18/2022]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation (ECMO) (VA) is used more commonly in neonates with congenital diaphragmatic hernia (CDH) than venovenous ECMO (VV). We hypothesized that VV may result in comparable outcomes in infants with CDH requiring ECMO. METHODS We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) database (1991-2006). Multivariate logistic regression analyses were used to compare VV- and VA-associated mortality. RESULTS Four thousand one hundred fifteen neonates required ECMO, with an overall mortality rate of 49.6%. Venoarterial ECMO was used in 82% and VV in 18% of neonates. Pre-ECMO inotrope use and complications were equivalent between VA and VV. The mortality rate for VA and VV was 50% and 46%, respectively. After adjusting for birth weight, gestational age, prenatal diagnosis, ethnicity, Apgar scores, pH less than 7.20, Paco(2) greater than 50, requiring high-frequency ventilation, and year of ECMO, there was no difference in mortality between VV vs VA. Renal complications and on-ECMO inotrope use were more common with VV, whereas neurologic complications were more common with VA. The conversion rate from VV to VA was 18%; conversion was associated with a 56% mortality rate. CONCLUSION The short-term outcomes of VV and VA are comparable. Patients with CDH who fail VV may be predisposed to a worse outcome. Nevertheless, VV offers equal benefit to patients with CDH requiring ECMO while preserving the native carotid.
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Affiliation(s)
- Yigit S Guner
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
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Haricharan RN, Barnhart DC, Cheng H, Delzell E. Identifying neonates at a very high risk for mortality among children with congenital diaphragmatic hernia managed with extracorporeal membrane oxygenation. J Pediatr Surg 2009; 44:87-93. [PMID: 19159723 DOI: 10.1016/j.jpedsurg.2008.10.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to identify mortality risk factors in children with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) and generate a prediction score for those at a very high risk for mortality. METHODS Data on first ECMO runs of all neonates with CDH, between January 1997 and June 2007, were obtained from the Extracorporeal Life Support Organization registry (N = 2678). The data were split into "training data (TD)" (n = 2006) and "validation data" (n = 672). The primary outcome analyzed was in-hospital mortality. Modified Poisson regression was used for analyses. RESULTS Overall in-hospital mortality among 2678 neonates (males, 57%; median age at ECMO, 1 day) was 52%. The univariate and multivariable analyses were performed using TD. An empirically weighted mortality prediction score was generated with possible scores ranging from 0 to 35 points. Of 69 who scored 14 or higher in the TD, 62 died (positive predictive value [PPV], 90%), of 37 with 15 or higher, 35 died (PPV, 95%), of 23 with 16 or higher, 22 died (PPV, 96%). A cut-off point of 15 was chosen and was tested using the separate validation dataset. In validation data, the cut-off point 15 had a PPV of 96% (23 died of 24). CONCLUSION Scoring 15 or higher on the prediction score identifies neonates with CDH at a very high risk for mortality among those managed with ECMO and could be used in surgical decision making and counseling.
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