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Basurto D, Watananirun K, Cordier AG, Otaño J, Carriere D, Scuglia M, de Luna Freire Vargas AM, Prat J, Russo FM, Debeer A, Peralta CFA, De Coppi P, Gratacós E, Benachi A, Deprest J. Tracheomalacia and tracheomegaly in infants and children with congenital diaphragmatic hernia managed with and without fetoscopic endoluminal tracheal occlusion (FETO): a multicentre, retrospective cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:580-588. [PMID: 38914091 DOI: 10.1016/s2352-4642(24)00109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Temporary fetoscopic endoluminal tracheal occlusion (FETO) promotes lung growth and increases survival in selected fetuses with congenital diaphragmatic hernia (CDH). FETO is performed percutaneously by inserting into the trachea a balloon designed for vascular occlusion. However, reports on the potential postnatal side-effects of the balloon are scarce. This study aimed to evaluate the prevalence of tracheomalacia in infants with CDH managed with and without FETO and other consequences related to the use of the balloon. METHODS In this multicentre, retrospective cohort study, we included infants who were live born with CDH, either with FETO or without, who were managed postnatally at four centres (UZ Leuven, Leuven, Belgium; Antoine Béclère, Clamart, France; BCNatal, Barcelona, Spain; and HCor-Heart Hospital, São Paulo, Brazil) between April 5, 2002, and June 2, 2021. We primarily assessed the prevalence of all (symptomatic and asymptomatic) tracheomalacia as reported in medical records among infants with and without FETO. Secondarily we assessed the prevalence of symptomatic tracheomalacia and its resolution as reported in medical records, and compared tracheal diameters as measured on postnatal x-rays. Crude and adjusted risk ratios (aRRs) and 95% CIs were calculated via modified Poisson regression models with robust error variances for potential association between FETO and tracheomalacia. Variables included in the adjusted model were the side of the hernia, observed-to-expected lung-to-head ratio, and gestational age at birth. Crude and adjusted mean differences and 95% CIs were calculated via linear regression models to assess the presence and magnitude of association between FETO and tracheal diameters. In infants who had undergone FETO we also assessed the localisation of balloon remnants on x-rays, and the methods used for reversal of occlusion and potential complications associated with balloon remnants as documented in clinical records. Finally we investigated whether the presence of balloon remnants was influenced by the interval between balloon removal and delivery. FINDINGS 505 neonates were included in the study, of whom 287 had undergone FETO and 218 had not. Tracheomalacia was reported in 18 (6%) infants who had undergone FETO and in three (1%) who had not (aRR 6·17 [95% CI 1·83-20·75]; p=0·0030). Tracheomalacia was first reported in the FETO group at a median of 5·0 months (IQR 0·8-13·0). Symptomatic tracheomalacia was reported in 13 (5%) infants who had undergone FETO, which resolved in ten (77%) children by 55·0 months (IQR 14·0-83·0). On average, infants who had undergone FETO had a 31·3% wider trachea (with FETO tracheal diameter 7·43 mm [SD 1·24], without FETO tracheal diameter 5·10 mm [SD 0·84]; crude mean difference 2·32 [95% CI 2·11-2·54]; p<0·0001; adjusted mean difference 2·62 [95% CI 2·35-2·89]; p<0·0001). At birth, the metallic component was visible within the body in 75 (37%) of 205 infants with available thoraco-abdominal x-rays: it was located in the gastrointestinal tract in 60 (80%) and in the lung in 15 (20%). No side-effects were reported for any of the infants during follow-up. The metallic component was more likely to be in the lung than either outside the body or the gastrointestinal tract when the interval between occlusion reversal and birth was less than 24 h. INTERPRETATION Although FETO was associated with an increased tracheal diameter and an increased probability of tracheomalacia, symptomatic tracheomalacia typically resolved over time. There is a higher risk of retention of metallic balloon components if reversal of the occlusion occurs less than 24 h before delivery. Finally, there were no reported side-effects of the metallic component of the balloon persisting in the body during follow-up. Longer-term follow-up is needed to ensure that no tracheal problems arise later in life. FUNDING None.
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Affiliation(s)
- David Basurto
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Department of Maternal Fetal Medicine, Instituto Nacional de Perinatología, Mexico City, Mexico
| | - Kanokwaroon Watananirun
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anne-Gael Cordier
- Obstetrics and Gynecology Department, Antoine Béclère Hospital-AP-HP, Paris Saclay University, Clamart, France; Centre de Référence Maladie Rare: Hernie de Couple Diaphragmatique, Paris Saclay University, Clamart, France
| | - Juan Otaño
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Diane Carriere
- Pediatric and Neonatal Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France
| | - Marianna Scuglia
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; NIHR BRC Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Anna Moraes de Luna Freire Vargas
- Department of Maternal Fetal Medicine, HCor-Heart Hospital, São Paulo, Brazil Fetal medicine Unit, HCor-Heart Hospital, São Paulo, Brazil
| | - Jordi Prat
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Francesca Maria Russo
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Cleisson Fábio Andrioli Peralta
- Department of Maternal Fetal Medicine, HCor-Heart Hospital, São Paulo, Brazil Fetal medicine Unit, HCor-Heart Hospital, São Paulo, Brazil
| | - Paolo De Coppi
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; NIHR BRC Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Eduard Gratacós
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Alexandra Benachi
- Obstetrics and Gynecology Department, Antoine Béclère Hospital-AP-HP, Paris Saclay University, Clamart, France; Centre de Référence Maladie Rare: Hernie de Couple Diaphragmatique, Paris Saclay University, Clamart, France
| | - Jan Deprest
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.
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Manfroi A, Bernardes LS, de Oliveira LMC, Peres SV, de Carvalho WB, Tannuri ACA, da Silva MM, Del Bigio JZ, de Amorim Filho AG, de Carvalho MHB, de Francisco RPV, Carvalho MA. Congenital diaphragmatic hernia treated via fetal endoscopic tracheal occlusion improves outcome in a middle-income country. J Perinat Med 2024; 0:jpm-2024-0070. [PMID: 38926929 DOI: 10.1515/jpm-2024-0070] [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: 02/23/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES A recent European randomized trial - Tracheal Occlusion To Accelerate Lung Growth - demonstrated that fetoscopic endoluminal tracheal occlusion (FETO) is associated with increased postnatal survival among infants with severe congenital diaphragmatic hernia (CDH). However, this differs in middle-income countries such as Brazil, where abortion is illegal and neonatal intensive care is inadequate. This study evaluated the effects of FETO on improving the survival of infants with moderate-to-severe CDH in isolated and non-isolated cases. METHODS This retrospective cohort study selected 49 fetuses with CDH, a normal karyotype, and a lung-to-head ratio (LHR) of <1 from a single national referral center for fetal surgery in São Paulo, Brazil, between January 2016 and November 2019. FETO was performed between 26 and 29 weeks of gestation. The primary outcomes were infant survival until discharge from the neonatal intensive care unit and survival until six months of age. RESULTS Forty-six women with singleton fetuses having severe CDH underwent prenatal intervention with FETO. Infant survival rates until discharge and at six months of age were both 38 %. The observed-to-expected LHR increased by 25 % after FETO in neonates who survived until discharge. Spontaneous intrauterine death occurred in four growth-restricted fetuses after FETO. Preterm birth in <37 weeks and preterm rupture of membranes in <34 weeks occurred in 56.5 % (26) and 26 % (12) cases, respectively. CONCLUSIONS FETO may increase neonatal survival in fetuses with severe CDH, particularly in countries with limited neonatal intensive care.
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Affiliation(s)
- Amanda Manfroi
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Lisandra S Bernardes
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
- Research and Development, North Denmark Regional Hospital Centre for Clinical Research, Hjoerring, Denmark
- Department of Gynecology and Obstetrics, North Denmark Regional Hospital, Hjørring, Denmark
| | - Luiza M C de Oliveira
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Stela V Peres
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Werther B de Carvalho
- Disciplina de Pediatria Neonatal e Cuidados Intensivos, Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ana C A Tannuri
- Disciplina de Cirurgia Pediatrica e Transplante Hepatico, Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcos M da Silva
- Disciplina de Cirurgia Pediatrica e Transplante Hepatico, Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Juliana Z Del Bigio
- Disciplina de Pediatria Neonatal e Cuidados Intensivos, Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Antonio G de Amorim Filho
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | - Mariana A Carvalho
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Teillet B, Manœuvrier F, Rougraff C, Besengez C, Bernard L, Wojtanowski A, Ghesquieres L, Storme L, Mur S, Sharma D, Le Duc K. Intact cord resuscitation in newborns with congenital diaphragmatic hernia: insights from a lamb model. Front Pediatr 2023; 11:1236556. [PMID: 37744447 PMCID: PMC10516551 DOI: 10.3389/fped.2023.1236556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) is a rare condition characterized by pulmonary hypoplasia, vascular dystrophy, and pulmonary hypertension at birth. Validation of the lamb model as an accurate representation of human CDH is essential to translating research findings into clinical practice and understanding disease mechanisms. This article emphasizes the importance of validating the lamb model to study CDH pathogenesis and develop innovative therapeutics. Material and methods At 78 days of gestation, the fetal lamb's left forelimb was exposed through a midline laparotomy and hysterotomy, and a supra diaphragmatic thoracotomy was performed to allow the digestive organs to ascend into the thoracic cavity. At 138 ± 3 days of gestation, lambs were delivered via a cesarean section; then, with umbilical cord intact during 1 hour, the lambs were mechanically ventilated with gentle ventilation in a pressure-controlled mode for 2 h. Results CDH lambs exhibited a lower left lung-to-body weight ratio of 5.3 (2.03), p < 0.05, and right lung-to-body weight ratio of 8.2 (3.1), p < 0.05. They reached lower Vt/kg (tidal volume per kg) during the course of the resuscitation period with 1.2 (0.7) ml/kg at 10 min and 3 (1.65) ml/kg at 60 min (p < 0.05). Compliance of the respiratory system was lower in CDH lambs with 0.5 (0.3) ml/cmH2O at 60 min (p < 0.05) and 0.9 (0.26) ml/cmH2O at 120 min (p < 0.05). Differences between pre- and postductal SpO2 were higher with 15.1% (21.4%) at 20 min and 6.7% (14.5%) at 80 min (p < 0.05). CDH lambs had lower differences between inspired and expired oxygen fractions with 4.55% (6.84%) at 20 min and 6.72% (8.57%) at 60 min (p < 0.05). CDH lamb had lower left ventricle [2.73 (0.5) g/kg, p < 0.05] and lower right ventricle [0.69 (0.8), p < 0.05] to left ventricle ratio. Discussion CDH lambs had significantly lower tidal volume than control lambs due to lower compliance of the respiratory system and higher airway resistance. These respiratory changes are characteristic of CDH infants and are associated with higher mortality rates. CDH lambs also exhibited pulmonary hypertension, pulmonary hypoplasia, and left ventricle hypoplasia, consistent with observations in human newborns. To conclude, our lamb model successfully provides a reliable representation of CDH and can be used to study its pathophysiology and potential interventions.
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Affiliation(s)
- Baptiste Teillet
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Florian Manœuvrier
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatry, Centre Hospitalier Universitaire d’Amiens, Lille, France
| | - Céline Rougraff
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Capucine Besengez
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laure Bernard
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Wojtanowski
- INSERM CIC-IT 1403, Maison Régionale de la Recherche Clinique, CHRU de, Lille, France
| | - Louise Ghesquieres
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Obstetrics, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Laurent Storme
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sébastien Mur
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Dyuti Sharma
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Department of Pediatric Surgery, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Kévin Le Duc
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Axe Environnement Périnatal et Santé, Centre Hospitalier Universitaire de Lille, Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia with the Support of Rare Disease Foundation (Fondation Maladies Rares), Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
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Janssen J, van Drongelen J, Daamen WF, Grutters JPC. Plugging membranes after fetoscopy in congenital diaphragmatic hernia: early cost-effectiveness analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:710-718. [PMID: 36647616 DOI: 10.1002/uog.26163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/02/2022] [Accepted: 01/09/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Fetal endoscopic tracheal occlusion (FETO) improves neonatal survival of fetuses with congenital diaphragmatic hernia (CDH). However, FETO also increases the risk of preterm prelabor rupture of membranes (PPROM) and preterm delivery (PTD), as fetal membrane defects after fetoscopy do not heal. To solve this issue, an advanced sealing plug for closing the membrane defect is being developed. Using early-stage health economic modeling, we aimed to estimate the potential value of this innovative plug in terms of costs and effects, and to determine the properties required for it to become cost-effective. METHODS Early-stage health economic modeling was applied to the case of performing FETO in women with a singleton pregnancy whose fetus is diagnosed prenatally with CDH. We simulated a cohort of patients using a state-transition model over a 45-year time horizon. In our best-case-scenario analysis, we compared the current-care strategy with the perfect-plug strategy, which reduces the risk of PPROM and PTD by 100%, to determine the maximum quality-adjusted life years (QALYs) gained and costs saved. Using threshold analysis, we determined the minimum percentage reduction in the risk of PPROM and PTD required for the plug to be considered cost-effective. The impact of model parameters on outcome was investigated using a sensitivity analysis. RESULTS Our model indicated that a perfect-plug strategy would yield on average an additional 1.94 QALYs at a cost decrease of €2554 per patient. These values were influenced strongly by the percentage of cases with early PTD (27-34 weeks). Threshold analysis showed that, for €500 per plug, the plug strategy needs a minimum percentage reduction of 1.83% in the risk of PPROM and PTD (i.e. reduction in the risk from 47.50% to 46.63% for PPROM and from 71.50% to 70.19% for PTD) to be cost-effective. CONCLUSIONS Our model-based approach showed clear potential of the plug strategy when applied in the context of FETO for CDH fetuses, as only a minor reduction in the risk of PPROM and PTD is needed for the plug to be cost-effective. Its value is expected to be even higher when used in conditions associated with a higher rate of early PTD. Continued investment in research and development of the plug strategy appears to provide value for money. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Janssen
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - J van Drongelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - W F Daamen
- Department of Biochemistry, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - J P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
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Simulation training for urgent postnatal fetal tracheal balloon removal: Two learning methods. Eur J Obstet Gynecol Reprod Biol 2023; 281:92-98. [PMID: 36586211 DOI: 10.1016/j.ejogrb.2022.12.027] [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: 07/24/2022] [Revised: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE In fetuses with severe congenital diaphragmatic hernia, fetal endoluminal tracheal occlusion (FETO) with balloon increases survival and reduces morbidity. Balloon removal is often scheduled electively. In urgent cases, in-utero removal is impossible and removal immediately after delivery has to occur, posing risk of death from airway obstruction. Medical staff need training in urgent removal. Ideal training method is unclear; thus, we compared the performance of two groups trained by different methods. METHODS 24 medical students were randomly assigned to two different learning methods for removal: Group 1 (in-person lecture) and Group 2 (online video). Both methods presented the same information: endoscopic instrument set-up, anatomical landmarks for intubation, and balloon removal. All participants were evaluated using the same instruments and high-fidelity simulator, comparing time for instrument set-up and simulate balloon removal (including removal attempts). RESULTS Group 1 took significantly less time for instrument set-up compared to Group 2 [62 (30-92) secs vs 81 (57-108) secs; p < 0.01)]; no difference in time to intubate and locate the balloon [75 (50-173) secs vs 92 (32-232) secs; p 0.42], or number of attempts. CONCLUSION There was no difference between video training and in-person training with regards to the time taken to locate the FETO balloon in the trachea and to simulate its removal.
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Gonçalves AN, Moura RS, Correia-Pinto J, Nogueira-Silva C. Intraluminal chloride regulates lung branching morphogenesis: involvement of PIEZO1/PIEZO2. Respir Res 2023; 24:42. [PMID: 36740669 PMCID: PMC9901166 DOI: 10.1186/s12931-023-02328-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 01/13/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinical and experimental evidence shows lung fluid volume as a modulator of fetal lung growth with important value in treating fetal lung hypoplasia. Thus, understanding the mechanisms underlying these morphological dynamics has been the topic of multiple investigations with, however, limited results, partially due to the difficulty of capturing or recapitulating these movements in the lab. In this sense, this study aims to establish an ex vivo model allowing the study of lung fluid function in branching morphogenesis and identify the subsequent molecular/ cellular mechanisms. METHODS Ex vivo lung explant culture was selected as a model to study branching morphogenesis, and intraluminal injections were performed to change the composition of lung fluid. Distinct chloride (Cl-) concentrations (5.8, 29, 143, and 715 mM) or Cl- channels inhibitors [antracene-9-carboxylic acid (A9C), cystic fibrosis transmembrane conductance regulator inhibitor172 (CFTRinh), and calcium-dependent Cl- channel inhibitorA01 (CaCCinh)] were injected into lung lumen at two timepoints, day0 (D0) and D2. At D4, morphological and molecular analyses were performed in terms of branching morphogenesis, spatial distribution (immunofluorescence), and protein quantification (western blot) of mechanoreceptors (PIEZO1 and PIEZO2), neuroendocrine (bombesin, ghrelin, and PGP9.5) and smooth muscle [alpha-smooth muscle actin (α-SMA) and myosin light chain 2 (MLC2)] markers. RESULTS For the first time, we described effective intraluminal injections at D0 and D2 and demonstrated intraluminal movements at D4 in ex vivo lung explant cultures. Through immunofluorescence assay in in vivo and ex vivo branching morphogenesis, we show that PGP9.5 colocalizes with PIEZO1 and PIEZO2 receptors. Fetal lung growth is increased at higher [Cl-], 715 mM Cl-, through the overexpression of PIEZO1, PIEZO2, ghrelin, bombesin, MLC2, and α-SMA. In contrast, intraluminal injection of CFTRinh or CaCCinh decreases fetal lung growth and the expression of PIEZO1, PIEZO2, ghrelin, bombesin, MLC2, and α-SMA. Finally, the inhibition of PIEZO1/PIEZO2 by GsMTx4 decreases branching morphogenesis and ghrelin, bombesin, MLC2, and α-SMA expression in an intraluminal injection-independent manner. CONCLUSIONS Our results identify PIEZO1/PIEZO2 expressed in neuroendocrine cells as a regulator of fetal lung growth induced by lung fluid.
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Affiliation(s)
- Ana N. Gonçalves
- grid.10328.380000 0001 2159 175XSchool of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Campus de Gualtar, Gualtar, 4710-057 Braga, Portugal ,grid.10328.380000 0001 2159 175XLife and Health Sciences Research Institute/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Rute S. Moura
- grid.10328.380000 0001 2159 175XSchool of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Campus de Gualtar, Gualtar, 4710-057 Braga, Portugal ,grid.10328.380000 0001 2159 175XLife and Health Sciences Research Institute/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Correia-Pinto
- grid.10328.380000 0001 2159 175XSchool of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Campus de Gualtar, Gualtar, 4710-057 Braga, Portugal ,grid.10328.380000 0001 2159 175XLife and Health Sciences Research Institute/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal ,Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
| | - Cristina Nogueira-Silva
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Campus de Gualtar, Gualtar, 4710-057, Braga, Portugal. .,Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal. .,Department of Obstetrics and Gynecology, Hospital de Braga, Braga, Portugal.
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Lifesaving Treatments for the Tiniest Patients-A Narrative Description of Old and New Minimally Invasive Approaches in the Arena of Fetal Surgery. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010067. [PMID: 36670618 PMCID: PMC9856479 DOI: 10.3390/children10010067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel procedures by both patients and health care providers. From his vast personal experience of more than 20 years as one of the pioneers at the forefront of clinical minimally invasive fetal surgery, the author describes and comments on old and new minimally invasive approaches, highlighting their lifesaving or quality-of-life-improving potential. He provides easy-to-use practical information on how to perform partial amniotic carbon dioxide insufflation (PACI), how to assess lung function in fetuses with pulmonary hypoplasia, how to deal with giant CPAMS, how to insert shunts into fetuses with LUTO and hydrothorax when conventional devices are not available, and how to resuscitate a fetus during fetal cardiac intervention. Furthermore, the author proposes a curriculum for future fetal surgeons, solicits for the centralization of patients, for adequate maternal counseling, for adequate pain management and adequate hygienic conditions during interventions, and last but not least for starting the process of academic recognition of the matured field as an independent specialty. These steps will allow more affected expectant women and their unborn children to gain access to modern minimally invasive fetal surgery and therapy. The opportunity to treat more patients at dedicated centers will also result in more opportunities for the research of rare diseases and conditions, promising even better pre- and postnatal care in the future.
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9
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Danzer E, Rintoul NE, van Meurs KP, Deprest J. Prenatal management of congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101406. [PMID: 36456433 DOI: 10.1016/j.siny.2022.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, two randomized controlled, prospective trials, the Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trials, reported the outcomes on fetal endoluminal tracheal occlusion (FETO) for isolated left congenital diaphragmatic hernia (CDH). FETO significantly improved outcomes for severe hypoplasia. The effect in moderate cases, where the balloon was inserted later in pregnancy, did not reach significance. In a pooled analysis investigating the effect of the heterogeneity of the treatment effect by the time point of occlusion and severity, the difference may be explained by a difference in the duration of occlusion. Nevertheless, FETO carries a significant risk of preterm birth. The primary objective of this review is to provide an overview of the rationale for fetal intervention in CDH and the results of the randomized trials. The secondary objective is to discuss the technical aspects of FETO. Finally, recent developments of potential alternative fetal approaches will be highlighted.
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Affiliation(s)
- Enrico Danzer
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA; Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
| | - Natalie E Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment and Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krisa P van Meurs
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium; Institute of Women's Health, University College London Hospitals, London, United Kingdom
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Baschat AA, Blackwell SB, Chatterjee D, Cummings JJ, Emery SP, Hirose S, Hollier LM, Johnson A, Kilpatrick SJ, Luks FI, Menard MK, McCullough LB, Moldenhauer JS, Moon-Grady AJ, Mychaliska GB, Narvey M, Norton ME, Rollins MD, Skarsgard ED, Tsao K, Warner BB, Wilpers A, Ryan G. Care Levels for Fetal Therapy Centers. Obstet Gynecol 2022; 139:1027-1042. [PMID: 35675600 PMCID: PMC9202072 DOI: 10.1097/aog.0000000000004793] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/03/2022] [Indexed: 01/05/2023]
Abstract
Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity, with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level I fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture but that would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level II center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level III therapy center should offer the full range of fetal interventions (including open fetal surgery) and be able manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.
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Affiliation(s)
- Ahmet A. Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology &Obstetrics, Johns Hopkins University
| | - Sean B Blackwell
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | - Debnath Chatterjee
- Department of Anesthesiology, Children’s Hospital Colorado/Colorado Fetal Care Center, University of Colorado School of Medicine
| | | | - Stephen P. Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine
| | - Shinjiro Hirose
- Division of Pediatric, General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center
| | - Lisa M. Hollier
- Division of Maternal-Fetal; Medicine, Department of Obstetrics & Gynecology, Baylor College of Medicine
| | - Anthony Johnson
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | | | - Francois I Luks
- Department of Surgery, Alpert Medical School of Brown University and Hasbro Children’s Hospital
| | - M. Kathryn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill
| | | | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Anita J. Moon-Grady
- Division of Pediatric Cardiology, Department of Clinical Pediatrics, University of California, San Francisco
| | - George B. Mychaliska
- Department of Pediatric Surgery, C.S. Mott Children’s Hospital, University of Michigan
| | - Michael Narvey
- Division of Neonatology, Department of Pediatrics, University of Manitoba
| | - Mary E. Norton
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | | | - Eric D. Skarsgard
- Centre for Surgical Research, Department of Surgery, BC Children’s Hospital, University of British Columbia
| | - KuoJen Tsao
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Texas, Mc Govern Medical School
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine
| | | | - Greg Ryan
- Ontario Fetal Care Centre, Mount Sinai Hospital, University of Toronto
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Van Calster B, Benachi A, Nicolaides KH, Gratacos E, Berg C, Persico N, Gardener GJ, Belfort M, Ville Y, Ryan G, Johnson A, Sago H, Kosiński P, Bagolan P, Van Mieghem T, DeKoninck PLJ, Russo FM, Hooper SB, Deprest JA. The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data. Am J Obstet Gynecol 2022; 226:560.e1-560.e24. [PMID: 34808130 DOI: 10.1016/j.ajog.2021.11.1351] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Two randomized controlled trials compared the neonatal and infant outcomes after fetoscopic endoluminal tracheal occlusion with expectant prenatal management in fetuses with severe and moderate isolated congenital diaphragmatic hernia, respectively. Fetoscopic endoluminal tracheal occlusion was carried out at 27+0 to 29+6 weeks' gestation (referred to as "early") for severe and at 30+0 to 31+6 weeks ("late") for moderate hypoplasia. The reported absolute increase in the survival to discharge was 13% (95% confidence interval, -1 to 28; P=.059) and 25% (95% confidence interval, 6-46; P=.0091) for moderate and severe hypoplasia. OBJECTIVE Data from the 2 trials were pooled to study the heterogeneity of the treatment effect by observed over expected lung-to-head ratio and explore the effect of gestational age at balloon insertion. STUDY DESIGN Individual participant data from the 2 trials were reanalyzed. Women were assessed between 2008 and 2020 at 14 experienced fetoscopic endoluminal tracheal occlusion centers and were randomized in a 1:1 ratio to either expectant management or fetoscopic endoluminal tracheal occlusion. All received standardized postnatal management. The combined data involved 287 patients (196 with moderate hypoplasia and 91 with severe hypoplasia). The primary endpoint was survival to discharge from the neonatal intensive care unit. The secondary endpoints were survival to 6 months of age, survival to 6 months without oxygen supplementation, and gestational age at live birth. Penalized regression was used with the following covariates: intervention (fetoscopic endoluminal tracheal occlusion vs expectant), early balloon insertion (yes vs no), observed over expected lung-to-head ratio, liver herniation (yes vs no), and trial (severe vs moderate). The interaction between intervention and the observed over expected lung-to-head ratio was evaluated to study treatment effect heterogeneity. RESULTS For survival to discharge, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion was 1.78 (95% confidence interval, 1.05-3.01; P=.031). The additional effect of early balloon insertion was highly uncertain (adjusted odds ratio, 1.53; 95% confidence interval, 0.60-3.91; P=.370). When combining these 2 effects, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion with early balloon insertion was 2.73 (95% confidence interval, 1.15-6.49). The results for survival to 6 months and survival to 6 months without oxygen dependence were comparable. The gestational age at delivery was on average 1.7 weeks earlier (95% confidence interval, 1.1-2.3) following fetoscopic endoluminal tracheal occlusion with late insertion and 3.2 weeks earlier (95% confidence interval, 2.3-4.1) following fetoscopic endoluminal tracheal occlusion with early insertion compared with expectant management. There was no evidence that the effect of fetoscopic endoluminal tracheal occlusion depended on the observed over expected lung-to-head ratio for any of the endpoints. CONCLUSION This analysis suggests that fetoscopic endoluminal tracheal occlusion increases survival for both moderate and severe lung hypoplasia. The difference between the results for the Tracheal Occlusion To Accelerate Lung growth trials, when considered apart, may be because of the difference in the time point of balloon insertion. However, the effect of the time point of balloon insertion could not be robustly assessed because of a small sample size and the confounding effect of disease severity. Fetoscopic endoluminal tracheal occlusion with early balloon insertion in particular strongly increases the risk for preterm delivery.
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Affiliation(s)
- Ben Van Calster
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands; EPI-center, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology of the Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | | | | | - Nicola Persico
- Hospital Maggiore Policlinico IRCCS, University of Milan, Milan, Italy
| | | | - Michael Belfort
- Texas Children's Hospital, Baylor College of Medicine Houston, TX
| | | | - Greg Ryan
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Haruhiko Sago
- National Center for Child Health and Development, Tokyo, Japan
| | - Przemysław Kosiński
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Pietro Bagolan
- Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Tim Van Mieghem
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philip L J DeKoninck
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesca M Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Jan A Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Institute for Women's Health, University College London Hospital, London, United Kingdom.
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12
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Russo F, Benachi A, Gratacos E, Zani A, Keijzer R, Partridge E, Sananes N, De Coppi P, Aertsen M, Nicolaides KH, Deprest J. Antenatal Management of Congenital Diaphragmatic Hernia: what's next ? Prenat Diagn 2022; 42:291-300. [PMID: 35199368 DOI: 10.1002/pd.6120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/19/2022] [Accepted: 02/20/2022] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be diagnosed in the prenatal period and its severity can be measured by fetal imaging. There is now level I evidence that, in selected cases, Fetoscopic Endoluminal Tracheal Occlusion (FETO) increases survival to discharge from the neonatal unit as well as the risk for prematurity. Both effects are dependent on the time point of tracheal occlusion. FETO may also lead to iatrogenic death when done in unexperienced centres. The implementation of the findings from our clinical studies, may also vary based on local conditions. These may be different in terms of available skill set, access to fetal therapy, as well as outcome based on local neonatal management. We encourage prior benchmarking of local outcomes with optimal postnatal management, based on large enough numbers and using identical criteria as in the recent trials. We propose to work further on prenatal prediction methods, and the improvement of fetal intervention. In this manuscript, we describe a research agenda from a fetal medicine perspective. This research should be in parallel with innovation in neonatal and pediatric (surgical) management of this condition. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Partridge
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Nicolas Sananes
- Department Obstetrics and Gynaecology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Michael Aertsen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, United Kingdom
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13
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Deprest J, Flake A. How should fetal surgery for congenital diaphragmatic hernia be implemented in the post-TOTAL trial era: a discussion . Prenat Diagn 2022; 42:301-309. [PMID: 35032132 DOI: 10.1002/pd.6091] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/07/2022]
Abstract
Following prenatal diagnosis of congenital diaphragmatic hernia, severity can be predicted based on the presence of associated abnormalities, and in isolated cases, on lung size and position of the liver. Severe hypoplasia is defined by a contralateral lung size < 25% on ultrasound; moderate hypoplasia is when that lung measures between 25 and 45% of the normal. In fetuses with predicted poor postnatal outcome a procedure that reverses pulmonary hypoplasia may be considered. In uncontrolled studies, fetoscopic endoluminal tracheal occlusion (FETO) improved neonatal outcome. Recently, two randomized controlled trials compared the neonatal and infant outcomes in fetuses with isolated CDH (www.totaltrial.eu). In severe cases, FETO was carried out at 27+0 -29+6 weeks' gestation (referred to as "early") and in moderate at 30+0 -31+6 weeks ("late"). Survival to discharge from the neonatal intensive care unit increased by 25% (95%-CI:+6 - +46; P=.0091) and 13% (-1 - +28; P=.059), in fetuses with severe and moderate cases, respectively. Following FETO gestational age at delivery was on average 3.2 (2.3-4.1) weeks earlier following early and 1.7 (1.1 - 2.3) following late FETO. Here the strengths and weaknesses of the TOTAL trials and their translation to the clinic are debated. Discussants are the lead for the trial (JD) and a colleague (AF) not involved. The discussant notes that the observed survival, both in treated and expectantly managed fetuses, was overall less than what is reported by some high volume centers, particularly in North America. Additional criticisms are the potential effects of prematurity on the long term, the inclusion of low-volume centers, and the potential of FETO for severe iatrogenic complications. Therefore results may not be generalizable. The discussants concluded that although FETO may have its value it remains a procedure with a high risk for prematurity and it can be lethal when the balloon cannot be removed prior to delivery. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alan Flake
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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14
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Deprest JA, Benachi A, Gratacos E, Nicolaides KH, Berg C, Persico N, Belfort M, Gardener GJ, Ville Y, Johnson A, Morini F, Wielgoś M, Van Calster B, DeKoninck PLJ. Randomized Trial of Fetal Surgery for Moderate Left Diaphragmatic Hernia. N Engl J Med 2021; 385:119-129. [PMID: 34106555 PMCID: PMC7613454 DOI: 10.1056/nejmoa2026983] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetoscopic endoluminal tracheal occlusion (FETO) has been associated with increased postnatal survival among infants with severe pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, but data are lacking to inform its effects in infants with moderate disease. METHODS In this open-label trial conducted at many centers with experience in FETO and other types of prenatal surgery, we randomly assigned, in a 1:1 ratio, women carrying singleton fetuses with a moderate isolated congenital diaphragmatic hernia on the left side to FETO at 30 to 32 weeks of gestation or expectant care. Both treatments were followed by standardized postnatal care. The primary outcomes were infant survival to discharge from a neonatal intensive care unit (NICU) and survival without oxygen supplementation at 6 months of age. RESULTS In an intention-to-treat analysis involving 196 women, 62 of 98 infants in the FETO group (63%) and 49 of 98 infants in the expectant care group (50%) survived to discharge (relative risk , 1.27; 95% confidence interval [CI], 0.99 to 1.63; two-sided P = 0.06). At 6 months of age, 53 of 98 infants (54%) in the FETO group and 43 of 98 infants (44%) in the expectant care group were alive without oxygen supplementation (relative risk, 1.23; 95% CI, 0.93 to 1.65). The incidence of preterm, prelabor rupture of membranes was higher among women in the FETO group than among those in the expectant care group (44% vs. 12%; relative risk, 3.79; 95% CI, 2.13 to 6.91), as was the incidence of preterm birth (64% vs. 22%, respectively; relative risk, 2.86; 95% CI, 1.94 to 4.34), but FETO was not associated with any other serious maternal complications. There were two spontaneous fetal deaths (one in each group) without obvious cause and one neonatal death that was associated with balloon removal. CONCLUSIONS This trial involving fetuses with moderate congenital diaphragmatic hernia on the left side did not show a significant benefit of FETO performed at 30 to 32 weeks of gestation over expectant care with respect to survival to discharge or the need for oxygen supplementation at 6 months. FETO increased the risks of preterm, prelabor rupture of membranes and preterm birth. (Funded by the European Commission and others; TOTAL ClinicalTrials.gov number, NCT00763737.).
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Affiliation(s)
- Jan A Deprest
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Alexandra Benachi
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Eduard Gratacos
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Kypros H Nicolaides
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Christoph Berg
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Nicola Persico
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Michael Belfort
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Glenn J Gardener
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Yves Ville
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Anthony Johnson
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Francesco Morini
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Mirosław Wielgoś
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Ben Van Calster
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
| | - Philip L J DeKoninck
- From the Department of Obstetrics and Gynecology, University Hospitals KU Leuven (J.A.D., P.L.J.D.) and Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium (J.A.D., B.V.C., P.L.J.D.); Hospital Antoine-Béclère, Université Paris-Saclay, Clamart (A.B.), and Necker-Enfants Malades Hospital, Paris (Y.V.) - both in France; Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Institute for Women's Health, University College London Hospital (J.A.D.) and King's College Hospital(K.H.N.) - both in London; the University Hospital Bonn, Bonn, Germany (C.B.); Hospital Maggiore Policlinico, Milan (N.P.), and Bambino Gesù Children's Hospital, Rome (F.M.) - both in Italy; Baylor College of Medicine and Texas Children's Hospital (M.B.) and Children's Memorial Hermann Hospital (A.J.) - all in Houston; Mater Mothers' Hospital, Brisbane, QLD, Australia (G.J.G.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (P.L.J.D.)
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Deprest JA, Nicolaides KH, Benachi A, Gratacos E, Ryan G, Persico N, Sago H, Johnson A, Wielgoś M, Berg C, Van Calster B, Russo FM. Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia. N Engl J Med 2021; 385:107-118. [PMID: 34106556 PMCID: PMC7613453 DOI: 10.1056/nejmoa2027030] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational studies have shown that fetoscopic endoluminal tracheal occlusion (FETO) has been associated with increased survival among infants with severe pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, but data from randomized trials are lacking. METHODS In this open-label trial conducted at centers with experience in FETO and other types of prenatal surgery, we randomly assigned, in a 1:1 ratio, women carrying singleton fetuses with severe isolated congenital diaphragmatic hernia on the left side to FETO at 27 to 29 weeks of gestation or expectant care. Both treatments were followed by standardized postnatal care. The primary outcome was infant survival to discharge from the neonatal intensive care unit. We used a group-sequential design with five prespecified interim analyses for superiority, with a maximum sample size of 116 women. RESULTS The trial was stopped early for efficacy after the third interim analysis. In an intention-to-treat analysis that included 80 women, 40% of infants (16 of 40) in the FETO group survived to discharge, as compared with 15% (6 of 40) in the expectant care group (relative risk, 2.67; 95% confidence interval [CI], 1.22 to 6.11; two-sided P = 0.009). Survival to 6 months of age was identical to the survival to discharge (relative risk, 2.67; 95% CI, 1.22 to 6.11). The incidence of preterm, prelabor rupture of membranes was higher among women in the FETO group than among those in the expectant care group (47% vs. 11%; relative risk, 4.51; 95% CI, 1.83 to 11.9), as was the incidence of preterm birth (75% vs. 29%; relative risk, 2.59; 95% CI, 1.59 to 4.52). One neonatal death occurred after emergency delivery for placental laceration from fetoscopic balloon removal, and one neonatal death occurred because of failed balloon removal. In an analysis that included 11 additional participants with data that were available after the trial was stopped, survival to discharge was 36% among infants in the FETO group and 14% among those in the expectant care group (relative risk, 2.65; 95% CI, 1.21 to 6.09). CONCLUSIONS In fetuses with isolated severe congenital diaphragmatic hernia on the left side, FETO performed at 27 to 29 weeks of gestation resulted in a significant benefit over expectant care with respect to survival to discharge, and this benefit was sustained to 6 months of age. FETO increased the risks of preterm, prelabor rupture of membranes and preterm birth. (Funded by the European Commission and others; TOTAL ClinicalTrials.gov number, NCT01240057.).
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Affiliation(s)
- Jan A Deprest
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Kypros H Nicolaides
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Alexandra Benachi
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Eduard Gratacos
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Greg Ryan
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Nicola Persico
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Haruhiko Sago
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Anthony Johnson
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Mirosław Wielgoś
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Christoph Berg
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Ben Van Calster
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
| | - Francesca M Russo
- From the Department of Obstetrics and Gynecology, KU Leuven (J.A.D., F.M.R.) and Academic Department of Development and Regeneration, Biomedical Sciences, University Hospitals KU Leuven, Leuven, Belgium (J.A.D., B.V.C., F.M.R.); King's College Hospital (K.H.N.) and the Institute for Women's Health, University College London Hospital (J.A.D.) - both in London; Hospital Antoine-Béclère, Université Paris-Saclay, Clamart, France (A.B.); Hospital Clinic and Sant Joan de Déu, Barcelona (E.G.); Mount Sinai Hospital, Toronto (G.R.); Hospital Maggiore Policlinico, Milan (N.P.); the National Center for Child Health and Development, Tokyo (H.S.); Children's Memorial Hermann Hospital, Houston (A.J.); the Medical University of Warsaw, Warsaw, Poland (M.W.); and University Hospital Bonn, Bonn, Germany (C.B.)
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Cruz-Martínez R, Shazly S, Martínez-Rodríguez M, Gámez-Varela A, Luna-García J, Juárez-Martínez I, López-Briones H, Coronel-Cruz F, Villalobos-Gómez R, Ibarra-Rios D, Ordorica-Flores R, Nieto-Zermeño J. Impact of fetal endoscopic tracheal occlusion in fetuses with congenital diaphragmatic hernia and moderate lung hypoplasia. Prenat Diagn 2021; 42:310-317. [PMID: 34132402 DOI: 10.1002/pd.5988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 03/29/2021] [Accepted: 05/29/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the effect of Fetal Endoscopic Tracheal Occlusion (FETO) on neonatal survival in fetuses with left congenital diaphragmatic hernia (CDH) and moderate lung hypoplasia. STUDY DESIGN CDH fetuses with moderate pulmonary hypoplasia (observed/expected lung area to head ratio between 26% and 35%, or between 36% and 45% with liver herniation) were prospectively recruited. Included patients were matched to a control group who were ineligible for FETO. Primary outcomes were survival at 28 days, at discharge, and at 6 months of age, respectively. RESULTS 58 cases were recruited, 29 treated with FETO and 29 matched controls. Median gestational age (GA) at balloon placement and removal were 29.6 and 33.6 weeks, respectively. FETO group showed significantly lower GA at delivery (35.2 vs. 37.1 weeks, respectively, p < 0.01), higher survival at 28 days (51.7 vs. 24.1%, respectively, p = 0.03), at discharge (48.3 vs. 24.1%, respectively, p = 0.06), and at six months of age (41.4 vs. 24.1%, respectively, p = 0.16), and significantly lower length of ventilatory support (17.8 vs. 32.3 days, p = 0.01) and NICU stay (34.2 vs. 58.3 days, p = <0.01) compared to controls. CONCLUSION FETO was associated with a non-significant increase in survival and significantly lower neonatal respiratory morbidity among CDH fetuses with moderate lung hypoplasia.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico.,Instituto de Ciencias en Salud (ICSA), Universidad Autónoma del Estado de Hidalgo (UAEH), Hidalgo, Mexico
| | - Sherif Shazly
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Miguel Martínez-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Alma Gámez-Varela
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Jonahtan Luna-García
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Israel Juárez-Martínez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Hugo López-Briones
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Fausto Coronel-Cruz
- Department of Maternal-Fetal Medicine, Hospital General de México, Mexico City, Mexico
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico
| | - Daniel Ibarra-Rios
- Department of Neonatology, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Ricardo Ordorica-Flores
- Department of Pediatric Surgery, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Jaime Nieto-Zermeño
- Department of Pediatric Surgery, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
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Perrone EE, Deprest JA. Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: a narrative review of the history, current practice, and future directions. Transl Pediatr 2021; 10:1448-1460. [PMID: 34189104 PMCID: PMC8192998 DOI: 10.21037/tp-20-130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Fetal intervention for fetuses with congenital diaphragmatic hernia (CDH) has been investigated for over 30 years and is summarized in this manuscript. The review begins with a discussion of the history of fetal intervention for this severe congenital anomaly beginning with open fetal surgery with repair of the anatomical defect, shifting towards tracheal occlusion via open surgery techniques, and finally fetoscopic endoluminal balloon tracheal occlusion using a percutaneous approach. The current technique of fetal endoscopic tracheal occlusion (FETO) is described in detail with steps of the procedure and complementary figures. The main outcomes of single-institutional studies and multiple systematic reviews are examined and discussed. Despite these studies, the fetal community agrees that FETO remains investigational at this time as there is insufficient evidence to recommend it as the standard of care for CDH. A randomized controlled trial, The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial, has been designed to attempt to answer this question in an elaborate, international, multi-institutional study and is described in the text. Finally, future directions of fetal intervention for antenatally diagnosed CDH are discussed, including options for non-isolated CDH, the Smart-TO balloon for nonoperative reversal of occlusion, and transplacental sildenafil for treatment of pulmonary hypertension prior to birth.
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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, MI, USA
| | - Jan A Deprest
- Clinical Department of Obstetrics and Gynecology, Academic Department of Development and Regeneration, Woman and Child, Leuven, Belgium.,Institute of Women's Health, University College London, London, UK
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18
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Russo FM, Cordier AG, Basurto D, Salazar L, Litwinska E, Gomez O, Debeer A, Nevoux J, Patel S, Lewi L, Pertierra A, Aertsen M, Gratacos E, Nicolaides KH, Benachi A, Deprest J. Fetal endoscopic tracheal occlusion reverses the natural history of right-sided congenital diaphragmatic hernia: European multicenter experience. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:378-385. [PMID: 32924187 DOI: 10.1002/uog.23115] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the neonatal outcome of fetuses with isolated right-sided congenital diaphragmatic hernia (iRCDH) based on prenatal severity indicators and antenatal management. METHODS This was a retrospective review of prospectively collected data on consecutive cases diagnosed with iRCDH before 30 weeks' gestation in four fetal therapy centers, between January 2008 and December 2018. Data on prenatal severity assessment, antenatal management and perinatal outcome were retrieved. Univariate and multivariate logistic regression analysis were used to identify predictors of survival at discharge and early neonatal morbidity. RESULTS Of 265 patients assessed during the study period, we excluded 40 (15%) who underwent termination of pregnancy, two cases of unexplained fetal death, two that were lost to follow-up, one for which antenatal assessment of lung hypoplasia was not available and six cases which were found to have major associated anomalies or syndromes after birth. Of the 214 fetuses with iRCDH included in the neonatal outcome analysis, 86 were managed expectantly during pregnancy and 128 underwent fetal endoscopic tracheal occlusion (FETO) with a balloon. In the expectant-management group, lung size measured by ultrasound or by magnetic resonance imaging was the only independent predictor of survival (observed-to-expected lung-to-head ratio (o/e-LHR) odds ratio (OR), 1.06 (95% CI, 1.02-1.11); P = 0.003). Until now, stratification for severe lung hypoplasia has been based on an o/e-LHR cut-off of 45%. In cases managed expectantly, the survival rate was 15% (4/27) in those with o/e-LHR ≤ 45% and 61% (36/59) for o/e-LHR > 45% (P = 0.001). However, the best o/e-LHR cut-off for the prediction of survival at discharge was 50%, with a sensitivity of 78% and specificity of 72%. In the expectantly managed group, survivors with severe pulmonary hypoplasia stayed longer in the neonatal intensive care unit than did those with mildly hypoplastic lungs. In fetuses with an o/e-LHR ≤ 45% treated with FETO, survival rate was higher than in those with similar lung size managed expectantly (49/120 (41%) vs 4/27 (15%); P = 0.014), despite higher prematurity rates (gestational age at birth: 34.4 ± 2.7 weeks vs 36.8 ± 3.0 weeks; P < 0.0001). In fetuses treated with FETO, gestational age at birth was the only predictor of survival (OR, 1.25 (95% CI, 1.04-1.50); P = 0.02). CONCLUSIONS Antenatal measurement of lung size can predict survival in iRCDH. In fetuses with severe lung hypoplasia, FETO was associated with a significant increase in survival without an associated increase in neonatal morbidity. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F M Russo
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - A-G Cordier
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
- Centre for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - D Basurto
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Salazar
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - E Litwinska
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - O Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - A Debeer
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - J Nevoux
- ENT Department, AP-HP, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - S Patel
- Department of Paediatric Surgery, Kings' College Hospital, London, UK
| | - L Lewi
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - A Pertierra
- Clinical Department of Neonatology, Sant Joan de Déu University Hospital, Barcelona, Spain
| | - M Aertsen
- Clinical Department of Radiology, Unit Pediatric Radiology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Imaging and Pathology, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Gratacos
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal i+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Barcelona, Spain
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Benachi
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
- Centre for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - J Deprest
- Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
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19
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Basurto D, Sananès N, Bleeser T, Valenzuela I, De Leon N, Joyeux L, Verbeken E, Vergote S, Van Der Veeken L, Russo FM, Deprest J. Safety and efficacy of smart tracheal occlusion device in diaphragmatic hernia lamb model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:105-112. [PMID: 33012007 PMCID: PMC7613565 DOI: 10.1002/uog.23135] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH). METHODS DH was created in fetal lambs on gestational day 70 (term, 145 days). Fetuses were allocated to either pregnancy continuation until term (DH group) or fetoscopic endoluminal tracheal occlusion (TO), performed using the Smart-TO balloon on gestational day 97 (DH + TO group). On gestational day 116, the presence of the balloon was confirmed on ultrasound, then the ewe was walked around a 3.0-Tesla magnetic resonance scanner for balloon deflation, which was confirmed by ultrasound immediately afterwards. At term, euthanasia was performed and the fetus retrieved. Efficacy of occlusion was assessed by the lung-to-body-weight ratio (LBWR) and lung morphometry. Safety parameters included tracheal side effects assessed by morphometry and balloon location after deflation. The unoccluded DH lambs served as a comparator. RESULTS Six fetuses were included in the DH group and seven in the DH + TO group. All balloons deflated successfully and were expelled spontaneously from the airways. In the DH + TO group, in comparison to controls, the LBWR at birth was significantly higher (1.90 (interquartile range (IQR), 1.43-2.55) vs 1.07 (IQR, 0.93-1.46); P = 0.005), while on lung morphometry, the alveolar size was significantly increased (mean linear intercept, 47.5 (IQR, 45.6-48.1) vs 41.9 (IQR, 38.8-46.1) μm; P = 0.03); whereas airway complexity was lower (mean terminal bronchiolar density, 1.56 (IQR, 1.0-1.81) vs 2.23 (IQR, 2.14-2.40) br/mm2 ; P = 0.005). Tracheal changes on histology were minimal in both groups, but more noticeable in fetal lambs that underwent TO than in unoccluded lambs (tracheal score, 2 (IQR, 1-3) vs 0 (0-1); P = 0.03). CONCLUSIONS In fetal lambs with DH, TO using the Smart-TO balloon is effective and safe. Occlusion can be reversed non-invasively and the deflated intact balloon expelled spontaneously from the fetal upper airways. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D. Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. Sananès
- INSERM 1121 Biomaterials and Bioengineering, Strasbourg University, Strasbourg, France
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - T. Bleeser
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I. Valenzuela
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. De Leon
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L. Joyeux
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E. Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - S. Vergote
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - L. Van Der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - F. M. Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J. Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women’s Health, University College London, London, UK
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20
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Abstract
Congenital diaphragmatic hernia (CDH) is a potentially severe anomaly that should be referred to a fetal care center with expertise in multidisciplinary evaluation and management. The pediatric radiologist plays an important role in the evaluation of CDH, both in terms of anatomical description of the anomaly and in providing detailed prognostic information for use in caring for the fetus and pregnant mother as well as planning for delivery and postnatal care. This article reviews the types of hernias, including distinguishing features and imaging clues. The most common methods of predicting severity are covered, and current fetal and postnatal therapies are explained. The author of this paper provides a handy reference for pediatric radiologists presented with a case of CDH as part of their daily practice.
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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22
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Deprest J. Prenatal treatment of severe congenital diaphragmatic hernia: there is still medical equipoise. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:493-497. [PMID: 33001496 DOI: 10.1002/uog.22182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 06/11/2023]
Affiliation(s)
- J Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Woman's Health, University College London, London, UK
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23
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Basurto D, Sananès N, Verbeken E, Sharma D, Corno E, Valenzuela I, Van der Veeken L, Favre R, Russo FM, Deprest J. New device permitting non-invasive reversal of fetal endoscopic tracheal occlusion: ex-vivo and in-vivo study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:522-531. [PMID: 32602968 DOI: 10.1002/uog.22132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/05/2020] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE One of the drawbacks of fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to re-establish airway patency. The 'Smart-TO' device is a new balloon for FETO that deflates spontaneously when placed in a strong magnetic field, therefore overcoming the need for a second procedure. The safety and efficacy of this device have not yet been demonstrated. The aim of this study was to investigate the reversibility, local side effects and occlusiveness of the Smart-TO balloon, both in a simulated in-utero environment and in the fetal lamb model. METHODS First, the reversibility of tracheal occlusion by the Smart-TO balloon was tested in a high-fidelity simulator. Following videoscopic tracheoscopic balloon insertion, the fetal mannequin was placed within a 1-L water-filled balloon to mimic the amniotic cavity. This was held by an operator in front of their abdomen, and different fetal and maternal positions were simulated to mimic the most common clinical scenarios. Following exposure to the magnetic field generated by a 1.5-T magnetic resonance (MR) machine, deflation of the Smart-TO balloon was assessed by tracheoscopy. In cases of failed deflation, the mannequin was reinserted into a water-filled balloon for additional MR exposure, up to a maximum of three times. Secondly, reversibility, occlusiveness and local effects of the Smart-TO balloon were tested in vivo in fetal lambs. Tracheal occlusion was performed in fetal lambs on gestational day 95 (term, 145 days), either using the balloon currently used in clinical practice (Goldbal2) (n = 5) or the Smart-TO balloon (n = 5). On gestational day 116, the presence of the balloon was assessed by tracheoscopy. Deflation was performed by puncture (Goldbal2) or MR exposure (Smart-TO). Six unoccluded fetal lambs served as controls. Following euthanasia, the lung-to-body-weight ratio (LBWR), lung morphometry and tracheal circumference were assessed. Local tracheal changes were measured using a hierarchical histologic scoring system. RESULTS Ex vivo, Smart-TO balloon deflation occurred after a single MR exposure in 100% of cases in a maternal standing position with the mannequin at a height of 95 cm (n = 32), 55 cm (n = 8) or 125 cm (n = 8), as well as when the maternal position was 'lying on a stretcher' (n = 8). Three out of eight (37.5%) balloons failed to deflate at first exposure when the maternal position was 'sitting in a wheelchair'. Of these, two balloons deflated after a second MR exposure, but one balloon remained inflated after a third exposure. In vivo, all Smart-TO balloons deflated successfully. The LBWR in fetal lambs with tracheal occlusion by a Smart-TO balloon was significantly higher than that in unoccluded controls, and was comparable with that in the Goldbal2 group. There were no differences in lung morphometry and tracheal circumference between the two balloon types. Tracheal histology showed minimal changes for both balloons. CONCLUSIONS In a simulated in-utero environment, the Smart-TO balloon was effectively deflated by exposure of the fetus in different positions to the magnetic field of a 1.5-T MR system. There was only one failure, which occurred when the mother was sitting in a wheelchair. In healthy fetal lambs, the Smart-TO balloon is as occlusive as the clinical standard Goldbal2 system and has only limited local side effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Basurto
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N Sananès
- INSERM 1121 'Biomaterials and Bioengineering', Strasbourg University, Strasbourg, France
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - E Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - D Sharma
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Corno
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I Valenzuela
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - R Favre
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - F M Russo
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J Deprest
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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Congenital lung overinflation secondary to a unilateral obstructing mediastinal bronchogenic cyst. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia. Ann Surg 2020; 275:e586-e595. [PMID: 33055583 DOI: 10.1097/sla.0000000000003943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effect of combining antenatal sildenafil with fetal tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). BACKGROUND Although antenatal sildenafil administration rescues vascular abnormalities in lungs of fetal rabbits with CDH, it only partially improves airway morphometry. We hypothesized that we could additionally stimulate lung growth by combining this medical treatment with fetal TO. METHODS CDH was created on gestational day (GD)23 (n=54). Does were randomized to receive either sildenafil 10 mg/kg/d or placebo by subcutaneous injection from GD24 to GD30. On GD28, fetuses were randomly assigned to TO or sham neck dissection. At term (GD30) fetuses were delivered, ventilated, and finally harvested for histological and molecular analyses. Unoperated littermates served as controls. RESULTS The lung-to-body-weight ratio was significantly reduced in sham-CDH fetuses either (1.2 ± 0.3% vs 2.3 ± 0.3% in controls, P=0.0003). Sildenafil had no effect on this parameter, while CDH fetuses undergoing TO had a lung-to-body-weight ratio comparable to that of controls (2.5 ± 0.8%, P<0.0001). Sildenafil alone induced an improvement in the mean terminal bronchiolar density (2.5 ± 0.8 br/mm vs 3.5 ± 0.9 br/mm, P=0.043) and lung mechanics (static elastance 61 ± 36 cmH2O /mL vs 113 ± 40 cmH2O/mL, P=0.008), but both effects were more pronounced in fetuses undergoing additional TO (2.1 ± 0.8 br/mm, P=0.001 and 31 ± 9 cmH2O/mL, P<0.0001 respectively). Both CDH-sham and CDH-TO fetuses treated with placebo had an increased medial wall thickness of peripheral pulmonary vessels (41.9 ± 2.9% and 41.8 ± 3.2%, vs 24.0 ± 2.9% in controls, P<0.0001). CDH fetuses treated with sildenafil, either with or without TO, had a medial thickness in the normal range (29.4% ± 2.6%). Finally, TO reduced gene expression of vascular endothelial growth factor and surfactant protein A and B, but this effect was counteracted by sildenafil. CONCLUSION In the rabbit model for CDH, the combination of maternal sildenafil and TO has a complementary effect on vascular and parenchymal lung development.
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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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Abstract
Congenital diaphragmatic hernia (CDH) remains one of the most elusive birth defects to treat. Despite greater knowledge of disease and advances in technology, approximately one-third of CDH children born today still die. Consequently, clinicians and researchers have struggled to find the optimal treatment strategies for CDH. Without further innovations in postnatal treatment, many have focused an antenatal approach to improve pulmonary function. Fetoscopic Endoluminal Tracheal Occlusion (FETO) for CDH has evolved to the bedside after decades of research. While still under clinical investigation, FETO remains a promising adjunct to the treatment of CDH.
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Affiliation(s)
- KuoJen Tsao
- Departments of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
| | - Anthony Johnson
- Departments Obstetrics, Gynecology & Reproductive Sciences and Pediatric Surgery, Division of Maternal-Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
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Anesthesia for predelivery procedures: ex-utero intrapartum treatment/intrauterine transfusion/surgery of the fetus. Curr Opin Anaesthesiol 2019; 32:291-297. [PMID: 31045636 DOI: 10.1097/aco.0000000000000718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the current literature on anesthesia for predelivery procedures and to summarize recent findings on anesthesiological methods used. RECENT FINDINGS Ex-utero intrapartum treatment (EXIT)-procedures are performed to secure the newborn's oxygenation in case of severe airway obstruction due to multiple conditions. A key feature of EXIT is continued intactness of the maternofetal circulation by uterine relaxation achieved by general anesthesia with high doses of anesthetic gases. A dose reduction may be achieved by combining inhaled anesthesia with propofol. After intrauterine transfusion the anesthesia team needs to be prepared for a potential need of emergency cesarean section. Temporary fetal endoluminal tracheal occlusion and laser coagulation for twin-to-twin transfusion syndrome may be either performed in monitored anesthesia care or neuraxial anesthesia. Neuraxial anesthesia also is a method of choice for fetal valvuloplasty and amniotic band release. Fetal myelomenigocele repair requires general anesthesia with tocolysis. SUMMARY Predelivery procedures require a differentiated anesthesia approach depending on the invasiveness of the intervention. Anesthesia ranges from monitored care to neuraxial anesthesia and general anesthesia. Depending on the procedure uterine relaxation and fetal immobilization are crucial for technical success. Interdisciplinary consultation optimizes the anesthesia plan for complex procedures.
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Abstract
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
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Affiliation(s)
- Mark L Kovler
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States
| | - Eric B Jelin
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States.
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Sananès N, Regnard P, Mottet N, Miry C, Fellmann L, Haelewyn L, Delaine M, Schneider A, Debry C, Favre R. Evaluation of a new balloon for fetal endoscopic tracheal occlusion in the nonhuman primate model. Prenat Diagn 2019; 39:403-408. [PMID: 30861154 DOI: 10.1002/pd.5445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/17/2019] [Accepted: 02/23/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We developed a new balloon called "Smart-TO," which allows noninvasive and easy unplugging, thanks to a magnetic valve actuated by the magnetic fringe field of a magnetic resonance imaging (MRI) scanner. The objective of this feasibility study was to evaluate the operation of this new balloon in a nonhuman primate model. METHODS Four pregnant rhesus monkeys underwent fetal endoscopic tracheal occlusion using the "Smart-TO" balloon. The pregnant monkeys were simply carried around the perimeter of an MRI scanner a few days later. Study outcomes were feasibility of fetal tracheal occlusion using the "Smart-TO" balloon, persistence of the balloon in the fetal trachea, and deflation of the balloon when subjected to the magnetic fringe field of an MRI. RESULTS At the time of the unplug procedure, in all cases, the balloon was still in a correct position, and its shape did not change based on their ultrasound appearance. After bringing the pregnant monkeys into the fringe field of the MRI scanner, the balloon deflated in all cases. CONCLUSION The balloon we developed allows noninvasive, easily triggered, and externally controlled reversal occlusion, based on the nonhuman primate model. Further tests evaluating occlusiveness and potential adverse effects are necessary.
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Affiliation(s)
- Nicolas Sananès
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France.,INSERM, UMR-S 1121, "Biomatériaux et Bioingénierie", Strasbourg University, Strasbourg, France
| | | | - Nicolas Mottet
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Claire Miry
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | | | | | - Maïa Delaine
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Anne Schneider
- Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Christian Debry
- INSERM, UMR-S 1121, "Biomatériaux et Bioingénierie", Strasbourg University, Strasbourg, France.,Department of Ear, Nose and Throat Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Romain Favre
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Basurto D, Russo FM, Van der Veeken L, Van der Merwe J, Hooper S, Benachi A, De Bie F, Gomez O, Deprest J. Prenatal diagnosis and management of congenital diaphragmatic hernia. Best Pract Res Clin Obstet Gynaecol 2019; 58:93-106. [PMID: 30772144 DOI: 10.1016/j.bpobgyn.2018.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
Congenital diaphragmatic hernia is characterized by failed closure of the diaphragm, thereby allowing abdominal viscera to herniate into the thoracic cavity and subsequently interfering with normal lung development. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension (PHT), that is lethal in up to 32% of patients. In isolated cases, the outcome may be predicted prenatally by medical imaging and advanced genetic testing. In those fetuses with a predicted poor outcome, fetoscopic endoluminal tracheal occlusion may be offered. This procedure is currently being evaluated in a global randomized clinical trial (www.TOTALtrial.eu). We are currently investigating alternative strategies including transplacental sildenafil administration to reduce the occurrence of persistent PHT.
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Affiliation(s)
- David Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Francesca Maria Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Lennart Van der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Johannes Van der Merwe
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Alexandra Benachi
- Obstetrics and Gynaecology Department, Centre de Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Université Paris Sud, AP-HP, Clamart, France; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA"
| | - Felix De Bie
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Olga Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal I+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia I Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Spain
| | - Jan Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA".
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Clohse K, Rayyan M, Deprest J, Decaluwe H, Gewillig M, Debeer A. Application of a postnatal prediction model of survival in CDH in the era of fetal therapy. J Matern Fetal Neonatal Med 2019; 33:1818-1823. [PMID: 30606098 DOI: 10.1080/14767058.2018.1530755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The disease severity in patients with a congenital diaphragmatic hernia (CDH) is highly variable. To compare patient outcomes, set up clinical trials and come to severity-based treatment guidelines, a performant prediction tool early in neonatal life is needed.Objective: The primary purpose of this study was to validate the CDH study group (SG) prediction model for survival in neonates with CDH, including patients who had fetal therapy. Secondary, we aimed to assess its predictive value for early morbidity.Methods: This is a retrospective single-center study at the University Hospitals Leuven on all infants with a diagnosis of CDH live-born between April 2002 and December 2016. The prediction model of the CDHSG was applied to evaluate its performance in determining mortality risk. Besides, we examined its predictive value for early morbidity parameters, including duration of ventilation, respiratory support on day 30, time to full enteral feeding and length of hospital stay.Results: The CDHSG prediction model predicted survival well, with an area under the curve of 0.796 (CI: 0.720-0.871). It had poor value in predicting infants who needed respiratory support on day 30 (area under the curve (AUC) 0.606; CI: 0.493-0.719), and correlated poorly with duration of ventilation, time to full enteral feeding and length of hospital stay.Conclusion: The CDHSG prediction model was in our hands also a useful tool in predicting mortality in neonates with CDH in the fetal treatment era. Correlation with early morbidity was poor.RationaleObjectives: (1) Validation of the CDHSG prediction model for survival in a cohort of neonates with CDH, in whom fetal endoscopic tracheal occlusion was applied according to the severity of lung hypoplasia. (2) Evaluation of performance of the model in the prediction of early morbidity.Main results: (1) Confirmation of the predictive value of the model for survival in neonates with CDH in the era of fetal therapy. (2) No correlation of the model with early morbidity parameters.
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Affiliation(s)
- K Clohse
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - M Rayyan
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - J Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, Maternal Fetal Medicine, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - H Decaluwe
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M Gewillig
- Department of Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - A Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
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Stirnemann J, Maltret A, Haydar A, Stos B, Bonnet D, Ville Y. Successful in utero transesophageal pacing for severe drug-resistant tachyarrhythmia. Am J Obstet Gynecol 2018; 219:320-325. [PMID: 30055126 DOI: 10.1016/j.ajog.2018.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/11/2018] [Accepted: 07/19/2018] [Indexed: 01/08/2023]
Abstract
Sustained fetal tachyarrhythmia can evolve into a life-threatening condition in 40% of cases when hydrops develops, with a 27% risk of perinatal death. Several antiarrhythmic drugs can be given solely or in combination to the mother to achieve therapeutic transplacental concentrations. Therapeutic failure could lead to progressive cardiac insufficiency and restrict therapeutic options to either elective delivery or direct fetal administration of antiarrhythmic drugs, which may increase the risk of death. We report for the first time successful fetal transesophageal pacing to treat a hydropic fetus with drug-resistant tachyarrhythmia.
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Antenatal sildenafil administration to prevent pulmonary hypertension in congenital diaphragmatic hernia (SToP-PH): study protocol for a phase I/IIb placenta transfer and safety study. Trials 2018; 19:524. [PMID: 30261903 PMCID: PMC6161420 DOI: 10.1186/s13063-018-2897-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/31/2018] [Indexed: 01/28/2023] Open
Abstract
Background Congenital diaphragmatic hernia is an orphan disease with high neonatal mortality and significant morbidity. An important cause for this is pulmonary hypertension, for which no effective postnatal therapy is available to date. An innovative strategy aiming at treating or preventing pulmonary hypertension more effectively is urgently needed. Prenatal sildenafil administration to expectant mothers prevented fetal and neonatal vascular changes leading to pulmonary hypertension in several animal models, and is, therefore, a promising approach. Before transferring this antenatal medical approach to the clinic, more information is needed on transplacental transfer and safety of sildenafil in humans. Methods This is a randomized, investigator-blinded, double-armed, parallel-group, phase I/IIb study with as a primary objective to measure the in-vivo transplacental transfer of sildenafil in women in the second and early third trimester of pregnancy (sub-study 1; weeks: 20.0–32.6) and at term (sub-study 2; weeks: 36.6–40). Participants will be randomized to two different sildenafil doses: 25 or 75 mg. In sub-study 1, a single dose of the investigational product will be administered to women undergoing termination of pregnancy, and maternal and fetal blood samples will be collected for determination of sildenafil concentrations. In sub-study 2, sildenafil will be administered three times daily from 3 days before planned delivery until actual delivery, following which maternal and umbilical cord samples will be collected. Proxies of maternal and fetal tolerance as well as markers of fetal pulmonary vasodilation will also be measured. Discussion This is the first study evaluating in-vivo transplacental passage of sildenafil in humans. Trial registration EU Clinical Trials Register 2016–002619-17, validated on 12 August 2016. Trial sponsor: UZ Leuven, Herestraat 49, 3000 Leuven. Electronic supplementary material The online version of this article (10.1186/s13063-018-2897-8) contains supplementary material, which is available to authorized users.
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Ruano R, Klinkner DB, Balakrishnan K, Novoa Y Novoa VA, Davies N, Potter DD, Carey WA, Colby CE, Kolbe AB, Arendt KW, Segura L, Sviggum HP, Lemens MA, Famuyide A, Terzic A. Fetoscopic Therapy for Severe Pulmonary Hypoplasia in Congenital Diaphragmatic Hernia: A First in Prenatal Regenerative Medicine at Mayo Clinic. Mayo Clin Proc 2018; 93:693-700. [PMID: 29803315 DOI: 10.1016/j.mayocp.2018.02.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/23/2018] [Accepted: 02/28/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To introduce the prenatal regenerative medicine service at Mayo Clinic for fetal endoscopic tracheal occlusion (FETO) care for severe congenital diaphragmatic hernia (CDH). PATIENTS AND METHODS Two cases of prenatal management of severe CDH with FETO between January and August 2017 are reported. Per protocol, FETO was offered for life-threatening severe CDH at between 26 and 29 weeks' gestation. Regenerative outcome end point was fetal lung growth. Gestational age at procedure and maternal and perinatal outcomes were additional monitored parameters. RESULTS Diagnosis by ultrasonography of severe CDH was based on extremely reduced lung size (observed-to-expected lung area to head circumference ratio [o/e-LHR], eg, o/e-LHR of 20.3% for fetus 1 and 23.0% for fetus 2) along with greater than one-third of the liver herniated into the chest in both fetuses. Both patients underwent successful FETO at 28 weeks. At the time of intervention, no maternal or fetal complications were observed. Postintervention, fetal lung growth was observed in both fetuses, reaching an o/e-LHR of 62.7% at 36 weeks in fetus 1 and 52.4% at 32 weeks in fetus 2. The balloons were removed successfully at 35 weeks and 4 days by ultrasound-guided puncture in the first patient and at 32 weeks and 3 days by ex utero intrapartum therapy-to-airway procedure in the second patient. Postnatal management followed standard of care with patch CDH therapy. At discharge, one patient was breathing normally, whereas the other required minimal nasal cannula oxygen support. CONCLUSION The successful launch of the first fetoscopic therapy for CDH at Mayo Clinic reveals its feasibility and safety, with early signs of benefit documented by fetal lung growth and reversal of severe pulmonary hypoplasia. TRIAL REGISTRATION clinicaltrials.gov Identifier: G170062.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Center for Regenerative Medicine, Mayo Clinic, Rochester, MN.
| | - Denise B Klinkner
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Victoria A Novoa Y Novoa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Norman Davies
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Dean D Potter
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - William A Carey
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Christopher E Colby
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Amy B Kolbe
- Department of Radiology, Mayo Clinic, Rochester, MN
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Leal Segura
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Hans P Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Maureen A Lemens
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Abimbola Famuyide
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Andre Terzic
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN
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Van der Veeken L, Russo FM, De Catte L, Gratacos E, Benachi A, Ville Y, Nicolaides K, Berg C, Gardener G, Persico N, Bagolan P, Ryan G, Belfort MA, Deprest J. Fetoscopic endoluminal tracheal occlusion and reestablishment of fetal airways for congenital diaphragmatic hernia. ACTA ACUST UNITED AC 2018; 15:9. [PMID: 29770109 PMCID: PMC5940711 DOI: 10.1186/s10397-018-1041-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/12/2018] [Indexed: 11/10/2022]
Abstract
Background Congenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and morbidity mainly due to pulmonary hypoplasia and hypertension. Temporary fetal tracheal occlusion to promote prenatal lung growth may improve survival. Entrapment of lung fluid stretches the airways, leading to lung growth. Methods Fetal endoluminal tracheal occlusion (FETO) is performed by percutaneous sono-endoscopic insertion of a balloon developed for interventional radiology. Reversal of the occlusion to induce lung maturation can be performed by fetoscopy, transabdominal puncture, tracheoscopy, or by postnatal removal if all else fails. Results FETO and balloon removal have been shown safe in experienced hands. This paper deals with the technical aspects of balloon insertion and removal. While FETO is invasive, it has minimal maternal risks yet can cause preterm birth potentially offsetting its beneficial effects. Conclusion For left-sided severe and moderate CDH, the procedure is considered investigational and is currently being evaluated in a global randomized clinical trial (https://www.totaltrial.eu/). The procedure can be clinically offered to fetuses with severe right-sided CDH.
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Affiliation(s)
- Lennart Van der Veeken
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Francesca Maria Russo
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Luc De Catte
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Eduard Gratacos
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,3BCNatal - Barcelona Center for MaternaleFetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Alexandra Benachi
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,4Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine-Béclère, University Paris Sud, Clamart, France.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
| | - Yves Ville
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,5Fetal Medicine Unit, Obstetrics and Fetal Medicine Department, Necker-Enfants Malades Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Kypros Nicolaides
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,6Harris Birthright Centre, King's College Hospital, London, UK
| | - Christoph Berg
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,7Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany.,8Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - Glenn Gardener
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,9Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Nicola Persico
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,10Department of Obstetrics and Gynecology, "L. Mangiagalli," Fondazione IRCCS "Ca' Granda" - Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Bagolan
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,11Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165 Rome, Italy.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
| | - Greg Ryan
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,12Fetal Medicine Unit, Mt Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michael A Belfort
- TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,13Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas USA
| | - Jan Deprest
- 1Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,TOTAL (Tracheal Occlusion To Accelerate Lung Growth Trial) Consortium, Leuven, Belgium.,European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA", Rotterdam, The Netherlands
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In case you missed it: The Prenatal Diagnosis
editors bring you the most significant advances of 2017. Prenat Diagn 2018; 38:83-90. [DOI: 10.1002/pd.5210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 12/14/2022]
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Current and future antenatal management of isolated congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2017; 22:383-390. [PMID: 29169875 DOI: 10.1016/j.siny.2017.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Congenital diaphragmatic hernia is surgically correctable, yet the poor lung development determines mortality and morbidity. In isolated cases the outcome may be predicted prenatally by medical imaging. Cases with a poor prognosis could be treated before birth. However, prenatal modulation of lung development remains experimental. Fetoscopic endoluminal tracheal occlusion triggers lung growth and is currently being evaluated in a global clinical trial. Prenatal transplacental sildenafil administration may in due course be a therapeutic approach, reducing the occurrence of persistent pulmonary hypertension, either alone or in combination with fetal surgery.
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