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Fraga MV, Hedrick HL, Rintoul NE, Wang Y, Ash D, Flohr SJ, Mathew L, Reynolds T, Engelman JL, Avitabile CM. Congenital Diaphragmatic Hernia Patients with Left Heart Hypoplasia and Left Ventricular Dysfunction Have Highest Odds of Mortality. J Pediatr 2024; 271:114061. [PMID: 38636784 PMCID: PMC11239301 DOI: 10.1016/j.jpeds.2024.114061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/18/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES To describe the scope of left ventricular (LV) dysfunction and left heart hypoplasia (LHH) in infants with congenital diaphragmatic hernia (CDH), to determine associations with CDH severity, and to evaluate the odds of extracorporeal membrane oxygenation (ECMO) and death with categories of left heart disease. STUDY DESIGN Demographic and clinical variables were collected from a single-center, retrospective cohort of patients with CDH from January 2017 through May 2022. Quantitative measures of LV function and LHH were prospectively performed on initial echocardiograms. LHH was defined as ≥2 of the following: z score ≤ -2 of any left heart structure or LV end-diastolic volume <3 mL. LV dysfunction was defined as shortening fraction <28%, ejection fraction <60%, or global longitudinal strain <20%. The exposure was operationalized as a 4-group categorical variable (LV dysfunction +/-, LHH +/-). Logistic regression models evaluated associations with ECMO and death, adjusting for CDH severity. RESULTS One hundred eight-two patients (80.8% left CDH, 63.2% liver herniation, 23.6% ECMO, 12.1% mortality) were included. Twenty percent demonstrated normal LV function and no LHH (LV dysfunction-/LHH-), 37% normal LV function with LHH (LV dysfunction-/LHH+), 14% LV dysfunction without LHH (LV dysfunction+/LHH-), and 28% both LV dysfunction and LHH (LV dysfunction+/LHH+). There was a dose-response effect between increasing severity of left heart disease, ECMO use, and mortality. LV dysfunction+/LHH + infants had the highest odds of ECMO use and death, after adjustment for CDH severity [OR (95% CI); 1.76 (1.20, 2.62) for ECMO, 2.76 (1.63, 5.17) for death]. CONCLUSIONS In our large single-center cohort, patients with CDH with LV dysfunction+/LHH + had the highest risk of ECMO use and death.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA.
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Devon Ash
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Sabrina J Flohr
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jenny L Engelman
- Center for Fetal Diagnosis and Treatment, Department of Pediatric General Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Catherine M Avitabile
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA; Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
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Surak A, Mahgoub L, Ting JY. Hemodynamic management of congenital diaphragmatic hernia: the role of targeted neonatal echocardiography. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000790. [PMID: 38737963 PMCID: PMC11086387 DOI: 10.1136/wjps-2024-000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/17/2024] [Indexed: 05/14/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a major congenital anomaly, resulting from the herniation of abdominal contents into the thoracic cavity, thereby impeding the proper development of the lungs and pulmonary vasculature. CDH severity correlates with a spectrum of pulmonary hypoplasia, pulmonary hypertension (PHT), and cardiac dysfunction, constituting the pathophysiological triad of this complex condition. The accurate diagnosis and effective management of PHT and cardiac dysfunction is pivotal to optimizing patient outcomes. Targeted neonatal echocardiography is instrumental in delivering real-time data crucial for the bespoke, pathophysiology-targeted hemodynamic management of CDH-associated PHT.
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Affiliation(s)
- Aimann Surak
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Linda Mahgoub
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Bergh E, Baschat AA, Cortes MS, Hedrick HL, Ryan G, Lim FY, Zaretsky MV, Schenone MH, Crombleholme TM, Ruano R, Gosnell KA, Johnson A. Fetoscopic Endoluminal Tracheal Occlusion for Severe, Left-Sided Congenital Diaphragmatic Hernia: The North American Fetal Therapy Network Fetoscopic Endoluminal Tracheal Occlusion Consortium Experience. Obstet Gynecol 2024; 143:440-448. [PMID: 38128107 PMCID: PMC10863657 DOI: 10.1097/aog.0000000000005491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed. METHODS We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients. RESULTS Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014). CONCLUSION In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%).
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Affiliation(s)
- Eric Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth Houston, the University of Texas McGovern Medical School, and the Fetal Center at Children's Memorial Hermann Hospital, and the Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Texas Children's Hospital Fetal Center, Baylor College of Medicine, Houston, Texas; the Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; the Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; the Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; the Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado; the Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, Minnesota; the Fetal Care Center Dallas, Dallas, Texas; and the Fetal Treatment Center, University of California, San Francisco, San Francisco, California
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Maddaloni C, De Rose DU, Ronci S, Pugnaloni F, Martini L, Caoci S, Bersani I, Conforti A, Campi F, Lombardi R, Capolupo I, Tomà P, Dotta A, Calzolari F. The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia. Pediatr Res 2024; 95:901-911. [PMID: 37978315 DOI: 10.1038/s41390-023-02889-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
In the last few years, current evidence has supported the use of point-of-care ultrasound (POCUS) for a number of diagnostic and procedural applications. Considering the valuable information that POCUS can give, we propose a standardized protocol for the management of neonates with a congenital diaphragmatic hernia (CDH-POCUS protocol) in the neonatal intensive care unit. Indeed, POCUS could be a valid tool for the neonatologist through the evaluation of 1) cardiac function and pulmonary hypertension; 2) lung volumes, postoperative pleural effusion or pneumothorax; 3) splanchnic and renal perfusion, malrotations, and/or signs of necrotizing enterocolitis; 4) cerebral perfusion and eventual brain lesions that could contribute to neurodevelopmental impairment. In this article, we discuss the state-of-the-art in neonatal POCUS for which concerns congenital diaphragmatic hernia (CDH), and we provide suggestions to improve its use. IMPACT: This review shows how point-of-care ultrasound (POCUS) could be a valid tool for managing neonates with congenital diaphragmatic hernia (CDH) after birth. Our manuscript underscores the importance of standardized protocols in neonates with CDH. Beyond the well-known role of echocardiography, ultrasound of lungs, splanchnic organs, and brain can be useful. The use of POCUS should be encouraged to improve ventilation strategies, systemic perfusion, and enteral feeding, and to intercept any early signs related to future neurodevelopmental impairment.
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Affiliation(s)
- Chiara Maddaloni
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
- PhD course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome "Tor Vergata", Rome, Italy.
| | - Sara Ronci
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Flaminia Pugnaloni
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Stefano Caoci
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Iliana Bersani
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Roberta Lombardi
- Department of Imaging, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Paolo Tomà
- Department of Imaging, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Flaminia Calzolari
- Neonatal Intensive Care Unit - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
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Stewart LA, Hernan RR, Mardy C, Hahn E, Chung WK, Bacha EA, Krishnamurthy G, Duron VP, Krishnan US. Congenital Heart Disease with Congenital Diaphragmatic Hernia: Surgical Decision Making and Outcomes. J Pediatr 2023; 260:113530. [PMID: 37268035 PMCID: PMC10527207 DOI: 10.1016/j.jpeds.2023.113530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe the types of congenital heart disease (CHD) in a congenital diaphragmatic hernia (CDH) cohort in a large volume center and evaluate surgical decision making and outcomes based on complexity of CHD and associated conditions. STUDY DESIGN A retrospective review of patients with CHD and CDH diagnosed by echocardiogram between 01/01/2005 and 07/31/2021. The cohort was divided into 2 groups based on survival at discharge. RESULTS Clinically important CHD was diagnosed in 19% (62/326) of CDH patients. There was 90% (18/20) survival in children undergoing surgery for both CHD and CDH as neonates, and 87.5 (22/24) in those undergoing repair initially for CDH alone. A genetic anomaly identified on clinical testing was noted in 16% with no significant association with survival. A higher frequency of other organ system anomalies was noted in nonsurvivors compared with survivors. Nonsurvivors were more likely to have unrepaired CDH (69% vs 0%, P < .001) and unrepaired CHD (88% vs 54%, P < .05), reflecting a decision not to offer surgery. CONCLUSIONS Survival was excellent in patients who underwent repair of both CHD and CDH. Patients with univentricular physiology have poor survival and this finding should be incorporated into pre and postnatal counseling about eligibility for surgery. In contrast, patients with other complex lesions including transposition of the great arteries have excellent outcomes and survival at 5 years follow-up at a large pediatric and cardiothoracic surgical center.
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Affiliation(s)
- Latoya A Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Rebecca R Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Christopher Mardy
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Eunice Hahn
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Vincent P Duron
- Division of Pediatric Surgery, Columbia University Irving Medical Center, New York, NY
| | - Usha S Krishnan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY; Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY.
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Sferra SR, Guo M, Gonzalez Salazar AJ, Penikis AB, Engwall-Gill AJ, Ebanks A, Harting MT, Collaco JM, Kunisaki SM. Sex-Specific Differences in Congenital Diaphragmatic Hernia Mortality. J Pediatr 2023; 259:113481. [PMID: 37196780 DOI: 10.1016/j.jpeds.2023.113481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To compare disease severity and mortality differences between female and male patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN We queried the CDH Study Group (CDHSG) database for CDH neonates managed between 2007 and 2018. Female and males were compared in statistical analyses using t tests, χ² tests, and Cox regression, as appropriate (P ≤ .05). RESULTS There were 7288 CDH patients, of which 3048 (41.8%) were female. Females weighed less on average at birth than males (2.84 kg vs 2.97 kg, P < .001) despite comparable gestational age. Females had similar rates of extracorporeal life support (ECLS) utilization (27.8% vs 27.3%, P = .65). Although both cohorts had equivalent defect size and rates of patch repair, female patients had increased rates of intrathoracic liver herniation (49.2% vs 45.9%, P = .01) and pulmonary hypertension (PH) (86.6% vs 81.1%, P < .001). Females had lower survival rates at 30-days (77.3% vs 80.1%, P = .003) and overall lower survival to discharge (70.2% vs 74.2%, P < .001). Subgroup analysis revealed that increased mortality was significant among those who underwent repair but were never supported on ECLS (P = .005). On Cox regression analysis, female sex was independently associated with mortality (adjusted hazard ratio 1.32, P = .02). CONCLUSION After controlling for the established prenatal and postnatal predictors of mortality, female sex remains independently associated with a higher risk of mortality in CDH. Further study into the underlying causes for sex-specific disparities in CDH outcomes is warranted.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andres J Gonzalez Salazar
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abigail J Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashley Ebanks
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Gavotto A, Amedro P, Cambonie G. Think out of the box: association of left congenital diaphragmatic hernia and abnormal origin of the right pulmonary artery : A train can hide another. BMC Pediatr 2023; 23:349. [PMID: 37434143 DOI: 10.1186/s12887-023-04164-1] [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: 03/29/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND We report the occurrence of a severe pulmonary hypertension (PH) in a neonate affected by a left congenital diaphragmatic hernia (CDH). PH in this patient was associated with an abnormal origin of the right pulmonary artery from the right brachiocephalic artery. This malformation, sometimes named hemitruncus arteriosus, has to the best of our knowledge never been reported in association with a CDH. CASE PRESENTATION A male newborn was hospitalized from birth in the neonatal intensive care unit after prenatal diagnosis of a left CDH. Ultrasound examination at 34 weeks of gestational age evaluated the observed-to-expected lung-to-head ratio at 49%. Birth occurred at 38+ 5 weeks of gestational age. Soon after admission, severe hypoxemia, i.e., preductal pulse oximetry oxygen saturation (SpO2) < 80%, prompted therapeutic escalation including the use of high frequency oscillatory ventilation with fraction of inspired oxygen (FiO2) 100% and inhaled nitric oxide (iNO). Echocardiography assessment revealed signs of severe PH and normal right ventricle function. Despite administration of epoprostenolol, milrinone, norepinephrine, and fluid loadings with albumin and 0.9% saline, hypoxemia remained severe, preductal SpO2 inconsistently greater than or equal to 80-85% and post ductal SpO2 lower on average by 15 points. This clinical status remained unchanged during the first 7 days of life. The infant's clinical instability was incompatible with surgical intervention, while chest X-ray showed a relatively preserved lung volume, especially on the right side. This prompted an additional echocardiography, aimed at searching an explanation of this unusual evolution and found an abnormal origin of the right pulmonary artery, which was confirmed on computed tomography angiography subsequently. A change in the medical strategy was decided, with the suspension of pulmonary vasodilator treatments, the administration of diuretics, and the decrease in norepinephrine dose to decrease the systemic-to-pulmonary shunt. Progressive improvement in the infant respiratory and hemodynamic status enabled to perform CDH surgical repair 2 weeks after birth. CONCLUSIONS This case recalls the interest of systematic analysis of all potential causes of PH in a neonate with CDH, a condition frequently associated with various congenital malformations.
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Affiliation(s)
- Arthur Gavotto
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 371 Avenue du Doyen Giraud, 34295, Montpellier, France.
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France.
| | - Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France
- IHU Liryc, INSERM 1045, Bordeaux University, Bordeaux, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 371 Avenue du Doyen Giraud, 34295, Montpellier, France
- Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
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Nam CPBM, Campos CV, Leal GN, Tannuri U, Ceccon MEJR, Carvalho WBD. Post-natal prognostic factors in CDH: experience of 11 years in a referral center in Brazil. Clinics (Sao Paulo) 2023; 78:100217. [PMID: 37247561 DOI: 10.1016/j.clinsp.2023.100217] [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: 12/28/2022] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE To describe post-natal risk factors associated with death in Newborns (NB) with Congenital Diaphragmatic Hernia (CDH) in a Brazilian reference center. METHODS In this retrospective cohort study, post-natal clinical factors of all NB diagnosed with CDH were reviewed in an 11-year period (2007‒2018). The primary outcome was death. Secondary outcomes included clinical features, prognostic indexes, type of mechanical ventilation, complications during hospitalization and surgical repair. RESULTS After applying the exclusion criteria, the authors analyzed 137 charts. Overall mortality was 59% (81/137), and the highest rates were observed for low-birth-weight NB (87%), syndromic phenotype (92%), and those with major malformations (100%). Prognostic indexes such as Apgar, SNAPPE-II and 24hOI (best oxygenation index in 24 hours) were all associated with poor evolution. In a multivariate analysis, only birth weight and 24hOI were statistically significant risk factors for mortality, with a reduction in mortality risk of 17.1% (OR = 0.829, 95% IC 0.72‒0.955, p = 0.009) for each additional 100g at birth and an increase by 26.5% (OR = 1.265, 95% IC 1.113‒1.436, p = 0.0003) for each unitary increase at the 24hOI. CONCLUSION Prognostic indexes are an important tool for predicting outcomes and improving resource allocation. Post-natal risk factors may be more suitable for settings where antenatal diagnosis is not universal. Classical risk factors, such as prematurity, low birth weight, higher need for supportive care, and poorer prognostic indexes were associated with mortality in our CDH population.
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Affiliation(s)
- Camila Pinho Brasileiro Martins Nam
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Carolina Vieira Campos
- Pediatric Cardiology Department, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gabriela Nunes Leal
- Echocardiography Laboratory of Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Esther Jurfest Rivero Ceccon
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Antounians L, Zani A. Beyond the diaphragm and the lung: a multisystem approach to understanding congenital diaphragmatic hernia. Pediatr Surg Int 2023; 39:194. [PMID: 37160490 DOI: 10.1007/s00383-023-05471-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a birth defect characterized by the incomplete closure of the diaphragm and herniation of abdominal organs into the chest during gestation. This invariably leads to an impairment in fetal lung development (pulmonary hypoplasia) that involves the pulmonary vessels (vascular remodeling) leading to postnatal pulmonary hypertension. Moreover, approximately 60% of CDH survivors have long-term comorbidities, including critical cardiac anomalies, neurodevelopmental impairment, gastroesophageal reflux, and musculoskeletal malformations. While the pathophysiology of the diaphragmatic defect and pulmonary hypoplasia have been studied in detail over the decades, less is known about the other organs affected in CDH. In this review, we searched the literature for reports on other organs beyond the lung and diaphragm in human and experimental models of CDH. We found studies reporting gross morphometric changes and alterations to biological pathways in the heart, brain, liver, kidney, gastrointestinal tract, and musculoskeletal system. Given the paucity of literature and the importance that these comorbidities play in the life of patients with CDH, further studies are needed to comprehensively uncover the pathophysiology of the changes observed in these other organs.
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Affiliation(s)
- Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Department of Surgery, University of Toronto, Toronto, M5T 1P5, Canada.
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Gupta VS, Popp EC, Ebanks AH, Greenleaf CE, Annavajjhala V, Patel N, Robie DK, LaPar DJ, Lally KP, Harting MT. Isolated aortic arch anomalies are associated with defect severity and outcome in patients with congenital diaphragmatic hernia. Pediatr Surg Int 2022; 39:69. [PMID: 36580203 DOI: 10.1007/s00383-022-05354-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) patients often have suspected isolated aortic arch anomalies (IAAA) on imaging. The purpose of this work was to describe the incidence and outcomes of CDH + IAAA patients. METHODS Cardiovascular data were collected for infants from the CDH Study Group born between 2007 and 2019. IAAA were defined as coarctation of aorta, hypoplastic aortic arch, interrupted aortic arch, and aortic aneurysmal disease on early, postnatal echocardiography. Patients with major cardiac malformations and/or chromosomal abnormalities were excluded. Primary outcomes included the rate of aortic intervention, rates of extracorporeal life support (ECLS) utilization, and mortality. RESULTS Of 6357 CDH infants, 432 (7%) were diagnosed with a thoracic aortic anomaly. Of these, 165 were diagnosed with IAAA, most commonly coarctation of the aorta (n = 106; 64%) or hypoplastic aortic arch (n = 58; 35%). CDH + IAAA patients had lower birthweights (3 kg vs. 2.9 kg) and Apgar scores (7 vs. 6) than patients without IAAA (both χ2 p < 0.001). CDH + IAAA were less likely to undergo diaphragm repair (72 vs. 87%, p < 0.001), and overall mortality was higher for CDH + IAAA infants (58 vs. 24%, p < 0.001). When controlling for defect size, birth weight, and Apgar, IAAA were significantly associated with mortality (OR 3.3, 95% CI 2.2-5.0; p < 0.01) but not associated with ECLS (OR 0.98, 95% CI 0.65-1.50; p = 0.90). Only 17% (n = 28) of CDH + IAAA patients underwent aortic intervention. CONCLUSIONS IAAA in CDH are associated with increased mortality. This often simply reflects severity of the defect and thoracic anatomic derangement, as opposed to unique aortic pathology, given few CDH + IAAA patients undergo aortic intervention.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Elizabeth C Popp
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Christopher E Greenleaf
- Division of Pediatric and Congenital Heart Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Vidhya Annavajjhala
- Department of Pediatrics, Division of Pediatric Cardiology, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children Glasgow, Glasgow, Scotland
| | | | - Damien J LaPar
- Division of Pediatric and Congenital Heart Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA.
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11
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Gil LA, Asti L, Apfeld JC, Sebastião YV, Deans KJ, Minneci PC. Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies. J Pediatr Surg 2022; 57:755-762. [PMID: 35985848 DOI: 10.1016/j.jpedsurg.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches. METHODS The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes. RESULTS 12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5). CONCLUSIONS MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes. MINI-ABSTRACT In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Yuri V Sebastião
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Division of Global Women's Health, School of Medicine, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA.
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12
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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13
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Long term outcomes in CDH: Cardiopulmonary outcomes and health related quality of life. J Pediatr Surg 2022; 57:501-509. [PMID: 35508437 DOI: 10.1016/j.jpedsurg.2022.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/27/2022] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND With improvements in clinical management and an increase in CDH survivorship there is a crucial need for better understanding of long-term health outcomes in CDH. AIM To investigate the prevalence of cardiopulmonary health morbidity and health related quality of life (HRQoL) in CDH survivors. METHODS We included all studies (n = 65) investigating long-term cardiopulmonary outcomes in CDH patients more than 2 years published in the last 30 years. The Newcastle-Ottawa Scale and the CASP checklist for cohort studies were utilized to assess study quality. Results were reported descriptively and collated by age group where possible. RESULTS The incidence of pulmonary hypertension was highly variable (4.5-38%), though rates (%) appeared to diminish after 5 years of age. Lung function indices and radiological outcomes were frequently abnormal, and Health Related Quality of Life (HRQoL) reduced also. Long term diseases notably emphysema and COPD are not yet fully described in the contemporary literature. CONCLUSION This study underscores cardiopulmonary health morbidity and a reduced HRQoL among CDH survivors. Where not already available dedicated multidisciplinary follow-up clinics should be established to support these vulnerable patients transition safely into adulthood. Future research is therefore needed to investigate the risk factors for cardiopulmonary ill health and morbidity in CDH survivors. TYPE OF STUDY Systematic review of case control and cohort studies.
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14
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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15
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Amodeo I, Borzani I, Raffaeli G, Persico N, Amelio GS, Gulden S, Colnaghi M, Villamor E, Mosca F, Cavallaro G. The role of magnetic resonance imaging in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:3243-3257. [PMID: 35794403 PMCID: PMC9395465 DOI: 10.1007/s00431-022-04540-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
UNLABELLED In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity. CONCLUSION Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment. WHAT IS KNOWN • MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling. WHAT IS NEW • Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Irene Borzani
- grid.414818.00000 0004 1757 8749Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Persico
- grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Simeone Amelio
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Silvia Gulden
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Mariarosa Colnaghi
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Eduardo Villamor
- grid.412966.e0000 0004 0480 1382Department of Pediatrics, School for Oncology and Reproduction (GROW), Maastricht University Medical Center, University of Maastricht, MUMC+), Maastricht, the Netherlands
| | - Fabio Mosca
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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16
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Patel N, Massolo AC, Kraemer US, Kipfmueller F. The heart in congenital diaphragmatic hernia: Knowns, unknowns, and future priorities. Front Pediatr 2022; 10:890422. [PMID: 36052357 PMCID: PMC9424541 DOI: 10.3389/fped.2022.890422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
There is growing recognition that the heart is a key contributor to the pathophysiology of congenital diaphragmatic hernia (CDH), in conjunction with developmental abnormalities of the lung and pulmonary vasculature. Investigations to date have demonstrated altered fetal cardiac morphology, notably relative hypoplasia of the fetal left heart, as well as early postnatal right and left ventricular dysfunction which appears to be independently associated with adverse outcomes. However, many more unknowns remain, not least an understanding of the genetic and cellular basis for cardiac dysplasia and dysfunction in CDH, the relationship between fetal, postnatal and long-term cardiac function, and the impact on other parts of the body especially the developing brain. Consensus on how to measure and classify cardiac function and pulmonary hypertension in CDH is also required, potentially using both non-invasive imaging and biomarkers. This may allow routine assessment of the relative contribution of cardiac dysfunction to individual patient pathophysiological phenotype and enable better, individualized therapeutic strategies incorporating targeted use of fetal therapies, cardiac pharmacotherapies, and extra-corporeal membrane oxygenation (ECMO). Collaborative, multi-model approaches are now required to explore these unknowns and fully appreciate the role of the heart in CDH.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | | | - Ulrike S Kraemer
- Intensive Care Unit, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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17
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Qiao L, Xu L, Yu L, Wynn J, Hernan R, Zhou X, Farkouh-Karoleski C, Krishnan US, Khlevner J, De A, Zygmunt A, Crombleholme T, Lim FY, Needelman H, Cusick RA, Mychaliska GB, Warner BW, Wagner AJ, Danko ME, Chung D, Potoka D, Kosiński P, McCulley DJ, Elfiky M, Azarow K, Fialkowski E, Schindel D, Soffer SZ, Lyon JB, Zalieckas JM, Vardarajan BN, Aspelund G, Duron VP, High FA, Sun X, Donahoe PK, Shen Y, Chung WK. Rare and de novo variants in 827 congenital diaphragmatic hernia probands implicate LONP1 as candidate risk gene. Am J Hum Genet 2021; 108:1964-1980. [PMID: 34547244 PMCID: PMC8546037 DOI: 10.1016/j.ajhg.2021.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/25/2021] [Indexed: 12/21/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly that is often accompanied by other anomalies. Although the role of genetics in the pathogenesis of CDH has been established, only a small number of disease-associated genes have been identified. To further investigate the genetics of CDH, we analyzed de novo coding variants in 827 proband-parent trios and confirmed an overall significant enrichment of damaging de novo variants, especially in constrained genes. We identified LONP1 (lon peptidase 1, mitochondrial) and ALYREF (Aly/REF export factor) as candidate CDH-associated genes on the basis of de novo variants at a false discovery rate below 0.05. We also performed ultra-rare variant association analyses in 748 affected individuals and 11,220 ancestry-matched population control individuals and identified LONP1 as a risk gene contributing to CDH through both de novo and ultra-rare inherited largely heterozygous variants clustered in the core of the domains and segregating with CDH in affected familial individuals. Approximately 3% of our CDH cohort who are heterozygous with ultra-rare predicted damaging variants in LONP1 have a range of clinical phenotypes, including other anomalies in some individuals and higher mortality and requirement for extracorporeal membrane oxygenation. Mice with lung epithelium-specific deletion of Lonp1 die immediately after birth, most likely because of the observed severe reduction of lung growth, a known contributor to the high mortality in humans. Our findings of both de novo and inherited rare variants in the same gene may have implications in the design and analysis for other genetic studies of congenital anomalies.
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Affiliation(s)
- Lu Qiao
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Le Xu
- Department of Pediatrics, University of California, San Diego Medical School, San Diego, CA 92093, USA
| | - Lan Yu
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Xueya Zhou
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | | | - Usha S Krishnan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Julie Khlevner
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Aliva De
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Annette Zygmunt
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | | | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Howard Needelman
- University of Nebraska Medical Center College of Medicine, Omaha, NE 68114, USA
| | - Robert A Cusick
- University of Nebraska Medical Center College of Medicine, Omaha, NE 68114, USA
| | | | - Brad W Warner
- Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Melissa E Danko
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
| | - Dai Chung
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
| | | | | | - David J McCulley
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 52726, USA
| | | | - Kenneth Azarow
- Oregon Health & Science University, Portland, OR 97239, USA
| | | | | | | | - Jane B Lyon
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Badri N Vardarajan
- Department of Neurology, Taub Institute for Research on Alzheimer Disease and the Aging Brain and the Gertrude H. Sergievsky Center, Columbia University, New York, NY 10032, USA
| | - Gudrun Aspelund
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Vincent P Duron
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Frances A High
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA; Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Xin Sun
- Department of Pediatrics, University of California, San Diego Medical School, San Diego, CA 92093, USA
| | - Patricia K Donahoe
- Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Yufeng Shen
- Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY 10032, USA; JP Sulzberger Columbia Genome Center, Columbia University Irving Medical Center, New York, NY 10032, USA.
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA.
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18
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Congenital Diaphragmatic Hernia Management: A Systematic Review and Care Pathway Description Including Volume-Targeted Ventilation. Adv Neonatal Care 2021; 21:E138-E143. [PMID: 33843783 DOI: 10.1097/anc.0000000000000863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although it is well established that standardized treatment protocols improve outcomes for infants with congenital diaphragmatic hernia (CDH), there remains variance between existing protocols. PURPOSE The purpose of this article was to review current literature on protocols for CDH management in the preoperative period and to describe a care pathway integrating best practice elements from existing literature with volume-targeted ventilation strategies previously in place at a major tertiary care center in the Pacific Northwestern United States. METHODS/SEARCH STRATEGY A systematic review of literature was performed according to PRISMA guidelines to identify current publications on CDH protocols and examine them for similarities and differences, particularly regarding ventilation strategies. FINDINGS/RESULTS Although existing protocols from multiple regions worldwide shared common goals of reducing barotrauma and delaying surgery until a period of clinical stabilization was achieved, their strategies varied. None included volume-targeted ventilation with pressure limitation as a method of avoiding ventilation-induced lung injury (VILI). IMPLICATIONS FOR PRACTICE Institutions that routinely manage infants with CDH should have a standardized treatment protocol in place, as this is shown to improve outcomes. This may include volume-targeted ventilation with pressure limitation as a successful VILI-limiting strategy. IMPLICATIONS FOR RESEARCH While standardized protocols have been shown to increase survival rate for infants with CDH, more research is needed to determine what these protocols should include. Specifically, there is a need for future study on the most appropriate ventilation mode for this population.
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Kotecha MK, Choo JTL, Sundararaghavan S. Saline contrast echocardiography complements cardiac interventions in neonates with transposition of great arteries and abnormal ductus venosus anatomy. BMJ Case Rep 2021; 14:e244023. [PMID: 34479892 PMCID: PMC8420688 DOI: 10.1136/bcr-2021-244023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 11/03/2022] Open
Abstract
We present a rare case of premature low birthweight neonate with right diaphragmatic hernia and transposition of great vessels requiring balloon atrial septostomy. Congenital diaphragmatic hernia poses a unique challenge to umbilical venous catheterisation. Based on the radiographic position of umbilical vein catheter, umbilical venous cannulation was attempted; however, the catheter could not be navigated to the right atrium. Saline contrast echocardiography was used to delineate the abnormal umbilical and ductus venosus drainage. Eventually, the procedure was successfully completed via the femoral venous approach. We emphasise the importance of defining ductus venosus anatomy and umbilical venous drainage using a simple tool like saline contrast echocardiography before performing catheterisation using the umbilical venous access in such cases.
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Risk factors for mortality in infants with congenital diaphragmatic hernia: a single center experience. Wien Klin Wochenschr 2021; 133:674-679. [PMID: 33783619 PMCID: PMC8008339 DOI: 10.1007/s00508-021-01843-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 02/27/2021] [Indexed: 11/14/2022]
Abstract
Background Despite current progress in research of congenital diaphragmatic hernia, its management remains challenging, requiring an interdisciplinary team for optimal treatment. Objective Aim of the present study was to evaluate potential risk factors for mortality of infants with congenital diaphragmatic hernia. Methods A single-center chart review of all patients treated with congenital diaphragmatic hernia over a period of 16 years, at the Medical University of Vienna, was performed. A comparison of medical parameters between survivors and non-survivors, as well as to published literature was conducted. Results During the observational period 66 patients were diagnosed with congenital diaphragmatic hernia. Overall survival was 84.6%. Left-sided hernia occurred in 51 patients (78.5%) with a mortality of 7.8%. In comparison, right-sided hernia occurred less frequently (n = 12) but showed a higher mortality (33.3%, p = 0.000). Critically instable patients were provided with venoarterial extracorporeal membrane oxygenation (ECMO, 32.3%, n = 21). Survival rate among these patients was 66.7%. Right-sided hernia, treatment with inhaled nitric oxide (iNO) over 15 days and the use of ECMO over 10 days were significant risk factors for mortality. Conclusion The survival rate in this cohort is comparable to the current literature. Parameters such as the side of the diaphragmatic defect, duration of ECMO and inhaled nitric oxide were assessed as mortality risk factors. This analysis of patients with congenital diaphragmatic hernia enhances understanding of risk factors for mortality, helping to improve management and enabling further evaluation in prospective clinical trials.
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Wu SJ, Fan YF, Wang NL, Chen MR. Substantial growth of atretic pulmonary artery after repair of total anomalous pulmonary venous connection and congenital diaphragmatic hernia. Asian J Surg 2021; 44:678-679. [PMID: 33581942 DOI: 10.1016/j.asjsur.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Shye-Jao Wu
- Division of Cardiovascular Surgery, Department of Surgery, MacKay Memorial Hospital, Taiwan.
| | - Ya-Fen Fan
- Division of Cardiovascular Surgery, Department of Surgery, MacKay Memorial Hospital, Taiwan
| | - Nien-Lu Wang
- Division of Pediatric Surgery, Department of Surgery, MacKay Memorial Hospital, Taiwan
| | - Ming-Ren Chen
- Division of Pediatric Cardiology, Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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Paoletti M, Raffler G, Gaffi MS, Antounians L, Lauriti G, Zani A. Prevalence and risk factors for congenital diaphragmatic hernia: A global view. J Pediatr Surg 2020; 55:2297-2307. [PMID: 32690291 DOI: 10.1016/j.jpedsurg.2020.06.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/06/2020] [Accepted: 06/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the global prevalence for congenital diaphragmatic hernia (CDH) and identify CDH-related risk factors. METHODS Using a defined strategy, a systematic review of the literature was conducted according to PRISMA guidelines, searching for population-based epidemiological studies to evaluate the prevalence of CDH globally and per country. Studies containing overlapping populations or timeframes were excluded. CDH-related risk factors were calculated by meta-analysis using RevMan5.3 and expressed as risk ratio and 95% confidence interval. RESULTS Prevalence: Of 8230 abstracts screened, 30 full-text articles published between 1980 and 2019 were included. The overall prevalence of CDH was 2.3 in 10,000 births (16,710 CDH babies in 73,663,758 livebirths). RISK FACTORS From 9 studies we found that male sex [RR 1.38 (1.05-1.80), p=0.02] and maternal age >35 years [RR 1.69 (1.26-2.25), p=0.0004] were associated with CDH. Conversely, maternal black ethnicity resulted as a protective factor [RR 0.82 (0.77-0.89, p<0.00001]. CONCLUSION This study reveals that there is a worldwide paucity of population-based studies, and those studies that report on prevalence and risk factors come from a small number of countries. The prevalence of CDH varies within and across geographical world regions. The main risk factors for CDH identified are male sex and older maternal age. More epidemiological studies, involving more world regions, are needed to identify possible strategies to help strengthen our understanding of the risk factors, provide clinicians with the tools necessary for prenatal and postnatal counseling, and inform policy makers on how to strategize CDH care in different parts of the world. TYPE OF STUDY Systematic review and meta-analysis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Monica Paoletti
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gabriele Raffler
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Maria Sole Gaffi
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Giuseppe Lauriti
- Department of Pediatric Surgery, "Spirito Santo" Hospital, Pescara, and Department of Medicine and Aging Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Wagner R, Montalva L, Zani A, Keijzer R. Basic and translational science advances in congenital diaphragmatic hernia. Semin Perinatol 2020; 44:151170. [PMID: 31427115 DOI: 10.1053/j.semperi.2019.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Congenital Diaphragmatic Hernia (CDH) is a birth defect that is characterized by lung hypoplasia, pulmonary hypertension and a diaphragmatic defect that allows herniation of abdominal organs into the thoracic cavity. Although widely unknown to the public, it occurs as frequently as cystic fibrosis (1:2500). There is no monogenetic cause, but different animal models revealed various biological processes and epigenetic factors involved in the pathogenesis. However, the pathobiology of CDH is not sufficiently understood and its mortality still ranges between 30 and 50%. Future collaborative initiatives are required to improve our basic knowledge and advance novel strategies to (prenatally) treat the abnormal lung development. This review focusses on the genetic, epigenetic and protein background and the latest advances in basic and translational aspects of CDH research.
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Affiliation(s)
- Richard Wagner
- Departments of Surgery, Division of Pediatric Surgery, Pediatrics & Child Health and Physiology & Pathophysiology (Adjunct), University of Manitoba and Children's Hospital Research Institute of Manitoba, Biology of Breathing Theme, Winnipeg, Manitoba, Canada; Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Louise Montalva
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada and Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada; Department of Pediatric Surgery, Hospital Robert Debré, Paris, France
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada and Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Richard Keijzer
- Departments of Surgery, Division of Pediatric Surgery, Pediatrics & Child Health and Physiology & Pathophysiology (Adjunct), University of Manitoba and Children's Hospital Research Institute of Manitoba, Biology of Breathing Theme, Winnipeg, Manitoba, Canada.
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