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Matsuo S, Yokoi A, Yoshida K, Kitagawa M, Asano‐Inami E, Miura M, Yasui T, Tano S, Ushida T, Imai K, Kajiyama H, Kotani T. Amniotic fluid-derived small extracellular vesicles for predicting postnatal severe outcome of congenital diaphragmatic hernia. JOURNAL OF EXTRACELLULAR BIOLOGY 2024; 3:e160. [PMID: 38947173 PMCID: PMC11212330 DOI: 10.1002/jex2.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/18/2024] [Indexed: 07/02/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening condition with high morbidity and mortality rates. The survival rate of neonates with severe CDH is reportedly only 10%-15%. However, prenatal prediction of severe cases is difficult, and the discovery of new predictive markers is an urgent issue. In this study, we focused on microRNAs (miRNAs) in amniotic fluid-derived small EVs (AF-sEVs). We identified four miRNAs (hsa-miR-127-3p, hsa-miR-363-3p, hsa-miR-493-5p, and hsa-miR-615-3p) with AUC > 0.8 to classify good prognosis group and poor prognosis group in human study. The AUC for hsa-miR-127-3p and hsa-miR-615-3p, for predicting the poor prognosis, were 0.93 and 0.91, respectively. In addition, in the in vivo study, the miRNA profiles of the lung tissues of CDH rats were different from those of control rats. Additionally, two elevated miRNAs (rno-miR-215-5p and rno-miR-148a-3p) in the lung tissues of CDH rats were increased in the AF-sEVs of CDH rats. Our results suggest that severe CDH neonates can be predicted prenatally with high accuracy using miRNAs contained in AF-sEVs. Furthermore, miRNA profile changes in AF-sEVs reflected the lung status in CDH. Our findings may contribute to the development of advanced perinatal care for patients with CDH.
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Affiliation(s)
- Seiko Matsuo
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Akira Yokoi
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
- Nagoya University Institute for Advanced ResearchNagoyaJapan
- Japan Science and Technology Agency (JST)FORESTKawaguchiJapan
| | - Kosuke Yoshida
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
- Nagoya University Institute for Advanced ResearchNagoyaJapan
| | - Masami Kitagawa
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Eri Asano‐Inami
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Mayo Miura
- Department of Obstetrics and GynecologyTokoname Municipal HospitalTokonameJapan
| | - Takao Yasui
- Department of Life Science and TechnologyTokyo Institute of TechnologyYokohamaJapan
- Institute of Nano‐Life Systems, Institutes of Innovation for Future SocietyNagoya UniversityNagoyaJapan
- Department of Biomolecular Engineering, Graduate School of EngineeringNagoya UniversityNagoyaJapan
| | - Sho Tano
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Takafumi Ushida
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
- Division of Reproduction and Perinatology, Center for Maternal‐Neonatal CareNagoya University HospitalNagoyaJapan
| | - Kenji Imai
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Hiroaki Kajiyama
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Tomomi Kotani
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
- Division of Reproduction and Perinatology, Center for Maternal‐Neonatal CareNagoya University HospitalNagoyaJapan
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Vandewalle RJ, Greiten LE. Diaphragmatic Defects in Infants: Acute Management and Repair. Thorac Surg Clin 2024; 34:133-145. [PMID: 38705661 DOI: 10.1016/j.thorsurg.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.
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Affiliation(s)
- Robert J Vandewalle
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 844, Little Rock, AR 72202, USA.
| | - Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 677, Little Rock, AR 72202, USA
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Horn-Oudshoorn EJJ, Vermeulen MJ, Knol R, Bout-Rebel R, Te Pas AB, Hooper SB, Otter SCMCD, Wijnen RMH, Crossley KJ, Rafat N, Schaible T, de Boode WP, Debeer A, Urlesberger B, Roberts CT, Kipfmueller F, Capolupo I, Burgos CM, Hansen BE, Reiss IKM, DeKoninck PLJ. Multicentre, randomised controlled trial of physiological-based cord clamping versus immediate cord clamping in infants with a congenital diaphragmatic hernia (PinC): statistical analysis plan. Trials 2024; 25:198. [PMID: 38509614 PMCID: PMC10953116 DOI: 10.1186/s13063-024-08027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Infants born with congenital diaphragmatic hernia (CDH) are at high risk of respiratory insufficiency and pulmonary hypertension. Routine practice includes immediate clamping of the umbilical cord and endotracheal intubation. Experimental animal studies suggest that clamping the umbilical cord guided by physiological changes and after the lungs have been aerated, named physiological-based cord clamping (PBCC), could enhance the fetal-to-neonatal transition in CDH. We describe the statistical analysis plan for the clinical trial evaluating the effects of PBCC versus immediate cord clamping on pulmonary hypertension in infants with CDH (PinC trial). DESIGN The PinC trial is a multicentre, randomised controlled trial in infants with isolated left-sided CDH, born ≥ 35.0 weeks of gestation. The primary outcome is the incidence of pulmonary hypertension in the first 24 h after birth. Maternal outcomes include estimated maternal blood loss. Neonatal secondary outcomes include mortality before discharge, extracorporeal membrane oxygenation therapy, and number of days of mechanical ventilation. Infants are 1:1 randomised to either PBCC or immediate cord clamping using variable random permutated block sizes (4-8), stratified by treatment centre and estimated severity of pulmonary hypoplasia (i.e. mild/moderate/severe). At least 140 infants are needed to detect a relative reduction in pulmonary hypertension by one third, with 80% power and 0.05 significance level. A chi-square test will be used to evaluate the hypothesis that PBCC decreases the occurrence of pulmonary hypertension. This plan is written and submitted without knowledge of the collected data. The trial has been ethically approved. TRIAL REGISTRATION ClinicalTrials.gov NCT04373902 (registered April 2020).
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rebekka Bout-Rebel
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victory, Australia
| | - Suzan C M Cochius-den Otter
- Division of Paediatric Intensive Care, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rene M H Wijnen
- Division of Paediatric Intensive Care, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victory, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboudumc University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Intensive Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesu Children's Hospital, IRCCS, Rome, Italy
| | - Carmen M Burgos
- Department of Paediatric Surgery, Karolinska University Hospital, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Bettina E Hansen
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Irwin K M Reiss
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Philip L J DeKoninck
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victory, Australia.
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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Chimenea A, Domínguez-Moreno M, Barrera-Talavera M, García-Díaz L, Antiñolo G. Maternal and Neonatal Outcomes After Ex-Utero Intrapartum Treatment for Congenital Diaphragmatic Hernia: A Case Series. Eur J Pediatr Surg 2023. [PMID: 37473779 DOI: 10.1055/a-2133-8380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition. MATERIAL AND METHODS We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery. RESULTS A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful. CONCLUSIONS In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.
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Affiliation(s)
- Angel Chimenea
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | - Marta Domínguez-Moreno
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - María Barrera-Talavera
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain
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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Pertierra Cortada A, Clotet Caba J, Hadley S, Sabrià Bach J, Iriondo Sanz M, Camprubí Camprubí M. Do FETO CDH survivors need the same follow-up program as non-FETO patients? Eur J Pediatr 2023:10.1007/s00431-023-04977-3. [PMID: 37145216 DOI: 10.1007/s00431-023-04977-3] [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: 01/10/2023] [Revised: 03/16/2023] [Accepted: 04/08/2023] [Indexed: 05/06/2023]
Abstract
Congenital diaphragmatic hernia (CDH) survivors are at risk of developing significant chronic health conditions and disabilities. The main purpose of this study was to compare the outcomes of CDH infants at 2 years of age (2y) according to whether the infants had undergone fetoscopic tracheal occlusion (FETO) during the prenatal period and characterize the relationship between morbidity at 2y and perinatal characteristics. Retrospective cohort single center study. Eleven years of clinical follow-up data (from 2006 to 2017) were collected. Prenatal and neonatal factors as well as growth, respiratory, and neurological evaluations at 2y were analyzed. One hundred and fourteen CDH survivors were evaluated. Failure to thrive (FTT) was present in 24.6% of patients, gastroesophageal reflux disease (GERD) in 22.8%, 28.9% developed respiratory problems, and 22% had neurodevelopment disabilities. Prematurity and birth weight < 2500 g were related to FTT and respiratory morbidity. Time to reach full enteral nutrition and prenatal severity markers seemed to influence all outcomes, but FETO therapy itself only had an effect on respiratory morbidity. Some variables related to postnatal severity (ECMO, patch closure, days on mechanic ventilation, and vasodilator treatment) were associated with almost all outcomes. Conclusion: CDH patients have specific morbidities at 2y, most of them related to lung hypoplasia severity. Only respiratory problems were related to FETO therapy itself. The implementation of a specific multidisciplinary follow-up program for CDH patients is essential to provide them the best standard of care, but, more severe patients, regardless of whether they received prenatal therapy, need a more intensive follow-up. What is Known: • Antenatal fetoscopic endoluminal tracheal occlusion (FETO) increases survival in more severe congenital diaphragmatic hernia patients. • Congenital diaphragmatic hernia survivors are at risk of developing significant chronic health conditions and disabilities. Very limited data are available about the follow-up in patients with congenital diaphragmatic hernia and FETO therapy. What is New: • CDH patients have specific morbidities at 2 years of age, most of them related to lung hypoplasia severity. • FETO patients present more respiratory problems at 2 years of age but they don't have an increased incidence of other morbidities. More severe patients, regardless of whether they received prenatal therapy, need a more intensive follow-up.
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Affiliation(s)
- Africa Pertierra Cortada
- Neonatology Department, BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine Hospital Sant Joan de Déu and Hospital Clínic, Institut de Recerca Sant Joan de Déu University of Barcelona, Passeig Sant Joan de Déu, 2. 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Jordi Clotet Caba
- Neonatology Department, BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine Hospital Sant Joan de Déu and Hospital Clínic, Institut de Recerca Sant Joan de Déu University of Barcelona, Passeig Sant Joan de Déu, 2. 08950, Esplugues de Llobregat, Barcelona, Spain
| | | | - Joan Sabrià Bach
- Fetal Medicine Unit, BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine Hospital Sant Joan de Déu and Hospital Clínic, University of Barcelona, Barcelona, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Martin Iriondo Sanz
- Neonatology Department, BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine Hospital Sant Joan de Déu and Hospital Clínic, Institut de Recerca Sant Joan de Déu University of Barcelona, Passeig Sant Joan de Déu, 2. 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Marta Camprubí Camprubí
- Neonatology Department, BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine Hospital Sant Joan de Déu and Hospital Clínic, Institut de Recerca Sant Joan de Déu University of Barcelona, Passeig Sant Joan de Déu, 2. 08950, Esplugues de Llobregat, Barcelona, Spain
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Scottoline B, Jordan BK, Parkhotyuk K, Schilling D, McEvoy CT. Perioperative Improvement in Pulmonary Function in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2023; 253:173-180.e2. [PMID: 36181873 DOI: 10.1016/j.jpeds.2022.09.037] [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: 05/01/2022] [Revised: 08/26/2022] [Accepted: 09/23/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to compare serial changes in pulmonary function in contemporary infants with congenital diaphragmatic hernia managed with a gentle ventilation approach. STUDY DESIGN Observational cohort, single-center study of infants ≥350/7 weeks gestation at delivery with congenital diaphragmatic hernia. Functional residual capacity (FRC), passive respiratory compliance, and passive respiratory resistance were measured presurgical and postsurgical repair and within 2 weeks of discharge. A 1-way analysis of variance for repeated measures was used to evaluate the change in FRC, passive respiratory compliance, and passive respiratory resistance over these repeated measures. RESULTS Twenty-eight infants were included in the analysis with a mean gestational age of 38.3 weeks and birth weight of 3139 g. We found a significant increase in FRC across the 3 time points (mean in mL/kg [SD]: 10.9 [3.6] to 18.5 [5.2] to 24.2 [4.4]; P < .0001). There was also a significant increase in passive respiratory compliance and decrease in passive respiratory resistance. In contrast to a previous report, there were survivors in the current cohort with a preoperative FRC of <9 mL/kg. The mean FRC measured at discharge was in the range considered within normal limits. Sixteen infants had prenatal measurements of the lung-to-head ratio, but there was no relationship between the lung-to-head ratio and preoperative or postoperative FRC measurements. CONCLUSIONS Infants with congenital diaphragmatic hernia demonstrate significant increases in FRC and improvements in respiratory mechanics measured preoperatively and postoperatively and at discharge. We speculate these improvements are due to the surgical resolution of the mechanical obstruction to lung recruitment and that after achieving preoperative stability, repair should not be delayed given these demonstrable postoperative improvements.
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Affiliation(s)
- Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR.
| | - Brian K Jordan
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Kseniya Parkhotyuk
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Diane Schilling
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Cindy T McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
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The metabolic and lipidomic profiling of the effects of tracheal occlusion in a rabbit model of congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:971-980. [PMID: 36801071 DOI: 10.1016/j.jpedsurg.2023.01.040] [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: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE Fetal tracheal occlusion (TO) reverses the pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH), but its mechanism of action remains poorly understood. 'Omic' readouts capture metabolic and lipid processing function, which aid in understanding CDH and TO metabolic mechanisms. METHODS CDH was created in fetal rabbits at 23 days, TO at 28 days and lung collection at 31 days (Term ∼32 days). Lung-body weight ratio (LBWR) and mean terminal bronchiole density (MTBD) were determined. In a cohort, left and right lungs were collected, weighed, and samples homogenized, and extracts collected for non-targeted metabolomic and lipidomic profiling via LC-MS and LC-MS/MS, respectively. RESULTS LBWR was significantly lower in CDH while CDH + TO was similar to controls (p = 0.003). MTBD was significantly higher in CDH fetuses and restored to control and sham levels in CDH + TO (p < 0.001). CDH and CDH + TO resulted in significant differences in metabolome and lipidome profiles compared to sham controls. A significant number of altered metabolites and lipids between the controls and CDH groups and the CDH and CDH + TO fetuses were identified. Significant changes in the ubiquinone and other terpenoid-quinone biosynthesis pathway and the tyrosine metabolism pathway were observed in CDH + TO. CONCLUSION CDH + TO reverses pulmonary hypoplasia in the CDH rabbit, in association with a specific metabolic and lipid signature. A synergistic untargeted 'omics' approach provides a global signature for CDH and CDH + TO, highlighting cellular mechanisms among lipids and other metabolites, enabling comprehensive network analysis to identify critical metabolic drivers in disease pathology and recovery. TYPE OF STUDY Basic Science, Prospective. LEVEL OF EVIDENCE II.
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9
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Horn-Oudshoorn EJJ, Peters NCJ, Franx A, Eggink AJ, Cochius-den Otter SCM, Reiss IKM, DeKoninck PLJ. Termination of pregnancy after a prenatal diagnosis of congenital diaphragmatic hernia: Factors influencing the parental decision process. Prenat Diagn 2023; 43:95-101. [PMID: 36443507 PMCID: PMC10107614 DOI: 10.1002/pd.6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). STUDY DESIGN Single-centre retrospective cohort includes all prenatally detected CDH cases born between January 2009 and December 2021. Parental factors, such as parity, and fetal characteristics, such as disease severity, were collected. Descriptive statistics were used to present the data. Differences between terminated and continued pregnancies were analysed. RESULTS The study population consisted of 278 prenatally detected CDH cases of which 80% detected <24 weeks of gestation. The TOP rate was 28% in cases that were detected <24 weeks of gestation. Twenty continued pregnancies resulted in either intrauterine fetal demise (n = 6), preterm birth <24 weeks (n = 2), or comfort care after birth (n = 12). The survival rate was 70% in the remaining 195 live born cases. Factors associated with the decision for TOP were additional fetal genetic or anatomical abnormalities (p < 0.0001) and expected severity of pulmonary hypoplasia in left-sided CDH (p = 0.0456). CONCLUSION The decision to terminate a pregnancy complicated by fetal CDH depends on the severity of pulmonary hypoplasia and the presence of additional abnormalities. This emphasises the importance of early referral to expertise centres for detailed evaluation and multidisciplinary counselling.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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10
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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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11
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Dahl MJ, Lavizzari A, Davis JW, Noble PB, Dellacà R, Pillow JJ. Impact of fetal treatments for congenital diaphragmatic hernia on lung development. Anat Rec (Hoboken) 2022. [PMID: 36065499 DOI: 10.1002/ar.25059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022]
Abstract
The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.
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Affiliation(s)
- Mar Janna Dahl
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Anna Lavizzari
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jonathan W Davis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Peter B Noble
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Raffaele Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - J Jane Pillow
- School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Western Australia, Australia
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12
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Perrone EE, Karmakar M, Lally PA, Chung S, Kipfmueller F, Morini F, Phillips R, Van Meurs KP, Harting MT, Mychaliska GB, Lally KP. Image-based prenatal predictors correlate with postnatal survival, extracorporeal life support use, and defect size in left congenital diaphragmatic hernia. J Perinatol 2022; 42:1195-1201. [PMID: 35228684 DOI: 10.1038/s41372-022-01357-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the association between prenatal imaging predictors of patients with left-sided congenital diaphragmatic hernia (LCDH) and postnatal outcomes. STUDY DESIGN CDH study group data were reviewed for LCDH infants born 2015-2019. Prenatal ultrasound (US) and magnetic resonance imaging (MRI) data were collected and correlated with postnatal information including CDHSG defect size (A through D or non-repair (NR)). RESULTS In total, 929 LCDH patients were included. Both US and MRI imaging predictors correlated with postnatal survival (72.2%) and ECLS use (29.6%). Logistic regression models confirmed increased survival and decreased ECLS use with larger values for all predictors. Importantly, all prenatal values evaluated showed no significant difference between defect size D and NR patients. CONCLUSIONS This is the largest cohort of LCDH patients and demonstrates that prenatal imaging factors correlate with postnatal outcomes and confirms that patients in the non-repair group are prenatally similar to type D defects.
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Affiliation(s)
- Erin E Perrone
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA.
| | - Monita Karmakar
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Sukyung Chung
- Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Children's Hospital, University of Bonn, Bonn, Germany
| | - Francesco Morini
- Neonatal Surgical Unit, Ospedale Pediatrico Bambino Gesu, IRCCS, Medical and Surgical Department of the Fetus, Newborn, and Infant, Rome, Italy
| | - Ryan Phillips
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - George B Mychaliska
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
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13
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Godden B, Keir A. EBNEO commentary: Foetal surgery for severe left diaphragmatic hernia. Acta Paediatr 2022; 111:1287-1288. [PMID: 35178740 DOI: 10.1111/apa.16299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Beth Godden
- Department of Neonatal Medicine Women's and Children's Hospital North Adelaide South Australia Australia
| | - Amy Keir
- SAHMRI Women and Kids South Australian Health and Medical Institute North Adelaide South Australia Australia
- Robinson Research Institute and the Adelaide Medical School The University of Adelaide Adelaide South Australia Australia
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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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Horn-Oudshoorn EJJ, Knol R, Vermeulen MJ, Te Pas AB, Hooper SB, Cochius-den Otter SCM, Wijnen RMH, Crossley KJ, Rafat N, Schaible T, de Boode WP, Debeer A, Urlesberger B, Roberts CT, Kipfmueller F, Reiss IKM, DeKoninck PLJ. Physiological-based cord clamping versus immediate cord clamping for infants born with a congenital diaphragmatic hernia (PinC): study protocol for a multicentre, randomised controlled trial. BMJ Open 2022; 12:e054808. [PMID: 35304395 PMCID: PMC8935184 DOI: 10.1136/bmjopen-2021-054808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pulmonary hypertension is a major determinant of postnatal survival in infants with a congenital diaphragmatic hernia (CDH). The current care during the perinatal stabilisation period in these infants might contribute to the development of pulmonary hypertension after birth-in particular umbilical cord clamping before lung aeration. An ovine model of diaphragmatic hernia demonstrated that cord clamping after lung aeration, called physiological-based cord clamping (PBCC), avoided the initial high pressures in the lung vasculature while maintaining adequate blood flow, thereby avoiding vascular remodelling and aggravation of pulmonary hypertension. We aim to investigate if the implementation of PBCC in the perinatal stabilisation period of infants born with a CDH could reduce the incidence of pulmonary hypertension in the first 24 hours after birth. METHODS AND ANALYSIS We will perform a multicentre, randomised controlled trial in infants with an isolated left-sided CDH, born at ≥35.0 weeks. Before birth, infants will be randomised to either PBCC or immediate cord clamping, stratified by treatment centre and severity of pulmonary hypoplasia on antenatal ultrasound. PBCC will be performed using a purpose-built resuscitation trolley. Cord clamping will be performed when the infant is considered respiratory stable, defined as a heart rate >100 bpm, preductal oxygen saturation >85%, while using a fraction of inspired oxygen of <0.5. The primary outcome is pulmonary hypertension diagnosed in the first 24 hours after birth, based on clinical and echocardiographic parameters. Secondary outcomes include neonatal as well as maternal outcomes. ETHICS AND DISSEMINATION Central ethical approval was obtained from the Medical Ethical Committee of the Erasmus MC, Rotterdam, The Netherlands (METC 2019-0414). Local ethical approval will be obtained by submitting the protocol to the regulatory bodies and local institutional review boards. TRIAL REGISTRATION NUMBER NCT04373902.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Suzan C M Cochius-den Otter
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboudumc University Medical Center, Nijmegen, The Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Intensive Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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16
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Horn-Oudshoorn EJJ, Knol R, Cochius-den Otter SCM, Te Pas AB, Hooper SB, Roberts CT, Rafat N, Schaible T, de Boode WP, van der Lee R, Debeer A, Kipfmueller F, Roehr CC, Reiss IKM, DeKoninck PLJ. Spontaneous breathing approach in mild congenital diaphragmatic hernia: A resuscitation algorithm. Front Pediatr 2022; 10:945090. [PMID: 35923783 PMCID: PMC9339647 DOI: 10.3389/fped.2022.945090] [Citation(s) in RCA: 4] [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] [Received: 05/16/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infants with a congenital diaphragmatic hernia (CDH) and expected mild pulmonary hypoplasia have an estimated survival rate of 90%. Current guidelines for delivery room management do not consider the individual patient's disease severity, but an individualized approach with spontaneous breathing instead of routine mechanical ventilation could be beneficial for the mildest cases. We developed a resuscitation algorithm for this individualized approach serving two purposes: improving the success rate by structuring the approach and providing a guideline for other centers. METHODS An initial algorithm was discussed with all local stakeholders. Afterwards, the resulting algorithm was refined using input from international experts. RESULTS Eligible CDH infants: left-sided defect, observed to expected lung-to-head ratio ≥50%, gestational age at birth ≥37.0 weeks, and no major associated structural or genetic abnormalities. To facilitate fetal-to-neonatal transition, we propose to start stabilization with non-invasive respiratory support and to adjust this individually. CONCLUSIONS Infants with mild CDH might benefit from an individualized approach for neonatal resuscitation. Herein, we present an algorithm that could serve as guidance for centers implementing this.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Robin van der Lee
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Critical Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Charles C Roehr
- National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,Newborn Services Southmead Hospital, North Bristol Trust, Bristol, United Kingdom.,Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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17
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Mukthapuram S, Beebe J, Tkach JA, Arya S, Haberman B, Peiro J, Lim FY, Woods JC, Kingma PS. Magnetic Resonance Imaging Assessment of Pulmonary Vascularity in Infants with Congenital Diaphragmatic Hernia: A Novel Tool for Direct Assessment of Severity of Pulmonary Hypertension and Hypoplasia. J Pediatr 2021; 239:89-94. [PMID: 34339729 DOI: 10.1016/j.jpeds.2021.07.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the feasibility of magnetic resonance imaging (MRI) for postnatal assessment of pulmonary vascularity in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN Infants with prenatally diagnosed CDH (n = 24) received postnatal pulmonary MRI. Infants with nonpulmonary birth defects served as controls (n = 5). Semiautomatic segmentation was performed to obtain total vascular volume using time of flight images to assess vascularity. RESULTS Average vascular density (vascular volume/lung volume) in control infants was 0.23 ± 0.06 mm3/mm3 compared with 0.18 ± 0.06 mm3/mm3 in infants with CDH is (P = .09). When stratified further based on CDH severity, the difference between control infants and moderate CDH group was statistically significant. (0.23 mm3/mm3 vs 0.15 mm3/mm3, P = .01). Ipsilateral vascular density on MRI in infants with CDH significantly correlated with the prenatal pulmonary hypertensive index (P = .0004, Spearman R = +0.87) and with number of days on mechanical ventilation (P = .04, Spearman R = -0.44), total days on inhaled nitric oxide (P = .02, Spearman R = -0.47), use of epoprostenol for acute pulmonary hypertension (PH) (0.14 mm3/mm3 vs 0.20 mm3/mm3, P = .005), and use of sildenafil for chronic PH (0.15 mm3/mm3 vs 0.19 mm3/mm3, P = .03). CONCLUSIONS Our results suggest that postnatal pulmonary vascularity assessed by MRI strongly correlates with prenatal and postnatal markers of PH severity and that pulmonary vascularity may serve as a direct measure of pulmonary vascular hypoplasia in infants with CDH.
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Affiliation(s)
- Shanmukha Mukthapuram
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jessica Beebe
- Department of Physiology and Biophysics, Case Western Reserve School of Medicine, Cleveland, OH
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shreyas Arya
- Department of Newborn Medicine, Dayton Children's Hospital, Dayton, OH
| | - Beth Haberman
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jose Peiro
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Foong-Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jason C Woods
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Paul S Kingma
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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18
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Bendixen C, Brosens E, Chung WK. Genetic Diagnostic Strategies and Counseling for Families Affected by Congenital Diaphragmatic Hernia. Eur J Pediatr Surg 2021; 31:472-481. [PMID: 34911129 DOI: 10.1055/s-0041-1740337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a relatively common and severe birth defect with variable clinical outcome and associated malformations in up to 60% of patients. Mortality and morbidity remain high despite advances in pre-, intra-, and postnatal management. We review the current literature and give an overview about the genetics of CDH to provide guidelines for clinicians with respect to genetic diagnostics and counseling for families. Until recently, the common practice was (molecular) karyotyping or chromosome microarray if the CDH diagnosis is made prenatally with a 10% diagnostic yield. Undiagnosed patients can be reflexed to trio exome/genome sequencing with an additional diagnostic yield of 10 to 20%. Even with a genetic diagnosis, there can be a range of clinical outcomes. All families with a child with CDH with or without additional malformations should be offered genetic counseling and testing in a family-based trio approach.
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Affiliation(s)
- Charlotte Bendixen
- Department of General, Visceral, Vascular and Thoracic Surgery, Unit of Pediatric Surgery, Universitätsklinikum Bonn, Bonn, Germany
| | - Erwin Brosens
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Wendy Kay Chung
- Department of Medicine, Columbia University Irving Medical Center, New York, United States.,Department of Pediatrics, Columbia University Irving Medical Center, New York, United States
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19
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Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Griggio A, Conte L, Macchini F, Condò V, Persico N, Fabietti I, Ghirardello S, Pierro M, Tafuri B, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. A maChine and deep Learning Approach to predict pulmoNary hyperteNsIon in newbornS with congenital diaphragmatic Hernia (CLANNISH): Protocol for a retrospective study. PLoS One 2021; 16:e0259724. [PMID: 34752491 PMCID: PMC8577746 DOI: 10.1371/journal.pone.0259724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/25/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Outcome predictions of patients with congenital diaphragmatic hernia (CDH) still have some limitations in the prenatal estimate of postnatal pulmonary hypertension (PH). We propose applying Machine Learning (ML), and Deep Learning (DL) approaches to fetuses and newborns with CDH to develop forecasting models in prenatal epoch, based on the integrated analysis of clinical data, to provide neonatal PH as the first outcome and, possibly: favorable response to fetal endoscopic tracheal occlusion (FETO), need for Extracorporeal Membrane Oxygenation (ECMO), survival to ECMO, and death. Moreover, we plan to produce a (semi)automatic fetus lung segmentation system in Magnetic Resonance Imaging (MRI), which will be useful during project implementation but will also be an important tool itself to standardize lung volume measures for CDH fetuses. METHODS AND ANALYTICS Patients with isolated CDH from singleton pregnancies will be enrolled, whose prenatal checks were performed at the Fetal Surgery Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (Milan, Italy) from the 30th week of gestation. A retrospective data collection of clinical and radiological variables from newborns' and mothers' clinical records will be performed for eligible patients born between 01/01/2012 and 31/12/2020. The native sequences from fetal magnetic resonance imaging (MRI) will be collected. Data from different sources will be integrated and analyzed using ML and DL, and forecasting algorithms will be developed for each outcome. Methods of data augmentation and dimensionality reduction (feature selection and extraction) will be employed to increase sample size and avoid overfitting. A software system for automatic fetal lung volume segmentation in MRI based on the DL 3D U-NET approach will also be developed. ETHICS AND DISSEMINATION This retrospective study received approval from the local ethics committee (Milan Area 2, Italy). The development of predictive models in CDH outcomes will provide a key contribution in disease prediction, early targeted interventions, and personalized management, with an overall improvement in care quality, resource allocation, healthcare, and family savings. Our findings will be validated in a future prospective multicenter cohort study. REGISTRATION The study was registered at ClinicalTrials.gov with the identifier NCT04609163.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- Monza and Brianza Mother and Child Foundation, San Gerardo Hospital, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Luana Conte
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Condò
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Pierro
- NICU, Bufalini Hospital, Azienda Unità Sanitaria Locale della Romagna, Cesena, Italy
| | - Benedetta Tafuri
- Department of Mathematics and Physics “E. De Giorgi”, Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Università del Salento, Lecce, Italy
- Azienda Sanitaria Locale (ASL), Lecce, Italy
| | - Giuseppe Como
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università degli Studi di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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20
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Jeong J, Lee BS, Cha T, Jung E, Kim EAR, Kim KS, Kim DY, Namgoong JM, Kim SC, Lee MY, Won HS. Prenatal prognostic factors for isolated right congenital diaphragmatic hernia: a single center's experience. BMC Pediatr 2021; 21:460. [PMID: 34666738 PMCID: PMC8526355 DOI: 10.1186/s12887-021-02931-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is relatively rare compared with left-sided congenital diaphragmatic hernia (LCDH). Clinical data of RCDH, especially with respect to antenatal prediction of neonatal outcome, are lacking. The aim of this study was to report the treatment outcomes of patients with antenatally diagnosed RCDH and to evaluate the predictability of observed-to-expected lung area-to-head circumference ratio (O/E LHR) for perinatal outcomes, focused on mortality or extracorporeal membrane oxygenation (ECMO) requirement. METHODS We retrospectively reviewed the medical records of newborn infants with isolated RCDH. We analyzed and compared the clinical and prenatal characteristics including the fetal lung volume, which was measured as the O/E LHR, between the survivors and the non-survivors. RESULTS A total of 26 (66.7%) of 39 patients with isolated RCDH survived to discharge. The O/E LHR was significantly greater in survivors (64.7 ± 21.2) than in non-survivors (40.5 ± 23.4) (P =.027). It was greater in survivors without ECMO requirement (68.3 ± 15.1) than non-survivors or those with ECMO requirement (46.3 ± 19.4; P = .010). The best O/E LHR cut-off value for predicting mortality in isolated RCDH was 50. CONCLUSIONS The findings in this study suggest that O/E LHR, a well-characterized prognostic indicator in LCDH, could be applied to a fetus with antenatally diagnosed RCDH. A large cohort study is required to verify the association between O/E LHR values and the graded severity of RCDH.
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Affiliation(s)
- Jiyoon Jeong
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Byong Sop Lee
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Teahyen Cha
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Euiseok Jung
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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21
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Furman Y, Gavri-Beker A, Miller TE, Bilik R, Rosenblat O, Avnet H, Lipitz S, Yinon Y, Strauss T, Weisz B. Do Serial Sonographic Assessments of Fetuses with Isolated Congenital Diaphragmatic Hernia Help Us Predict Survival? Fetal Diagn Ther 2021; 48:421-429. [PMID: 34247165 DOI: 10.1159/000515693] [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: 11/27/2020] [Accepted: 03/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to assess the ability of serial prenatal sonographic measurements, and specifically changes in the observed-to-expected lung-to-head ratio (O/E LHR) throughout gestation and to predict survival in congenital diaphragmatic hernia (CDH). METHODS Retrospective study of CDH fetuses evaluated prenatally and treated postnatally in a single tertiary center, 2008-2020. Sonographic evaluations included side of herniation, liver involvement, and O/E LHR. All data were calculated to assess ability to predict survival. RESULTS Overall, 94 fetuses were evaluated prenatally and delivered in our medical center. Among them, 75 had isolated CDH and 19 nonisolated. CDH was categorized as left (n = 76; 80.8%), right (n = 16; 17.0%), or bilateral (n = 2; 2.2%). Overall perinatal survival rate was 57% for all live-born infants, 68% in isolated CDH, and 40% in nonisolated (excluding 2 cases that underwent fetoscopic endoluminal tracheal occlusion and did not survive). The O/E LHR was lower in cases with perinatal death compared to survivors. In cases with multiple evaluations, the minimal O/E LHR was the most accurate predictor of survival and need for perinatal extracorporeal membrane oxygenation (ECMO) support. This remained significant when excluding twin pregnancies or when evaluating only isolated left CDH. In addition to disease severity, the side of herniation and liver position was associated with preoperative mortality. CONCLUSION O/E LHR is associated with perinatal survival. In cases with multiple evaluations, the minimal O/E LHR is the most accurate and significant predictor of perinatal mortality and need for ECMO support.
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Affiliation(s)
- Yael Furman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Gavri-Beker
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neonatology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tal Elkan Miller
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Ron Bilik
- Department of Pediatric Surgery, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Orgad Rosenblat
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Hagay Avnet
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Shlomo Lipitz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Yoav Yinon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tzipora Strauss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neonatology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Boaz Weisz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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22
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Cannata G, Caporilli C, Grassi F, Perrone S, Esposito S. Management of Congenital Diaphragmatic Hernia (CDH): Role of Molecular Genetics. Int J Mol Sci 2021; 22:ijms22126353. [PMID: 34198563 PMCID: PMC8231903 DOI: 10.3390/ijms22126353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/04/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a relatively common major life-threatening birth defect that results in significant mortality and morbidity depending primarily on lung hypoplasia, persistent pulmonary hypertension, and cardiac dysfunction. Despite its clinical relevance, CDH multifactorial etiology is still not completely understood. We reviewed current knowledge on normal diaphragm development and summarized genetic mutations and related pathways as well as cellular mechanisms involved in CDH. Our literature analysis showed that the discovery of harmful de novo variants in the fetus could constitute an important tool for the medical team during pregnancy, counselling, and childbirth. A better insight into the mechanisms regulating diaphragm development and genetic causes leading to CDH appeared essential to the development of new therapeutic strategies and evidence-based genetic counselling to parents. Integrated sequencing, development, and bioinformatics strategies could direct future functional studies on CDH; could be applied to cohorts and consortia for CDH and other birth defects; and could pave the way for potential therapies by providing molecular targets for drug discovery.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (G.C.); (C.C.); (F.G.)
| | - Chiara Caporilli
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (G.C.); (C.C.); (F.G.)
| | - Federica Grassi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (G.C.); (C.C.); (F.G.)
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (G.C.); (C.C.); (F.G.)
- Correspondence: ; Tel.: +39-0521-7047
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23
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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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24
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Liberio BM, Brinton JT, Gist KM, Soranno DE, Kirkley MJ, Gien J. Risk factors for acute kidney injury in neonates with congenital diaphragmatic hernia. J Perinatol 2021; 41:1901-1909. [PMID: 34120147 PMCID: PMC8196921 DOI: 10.1038/s41372-021-01119-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine incidence of acute kidney injury (AKI), antenatal and postnatal predictors, and impact of AKI on outcomes in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN Single center retrospective study of 90 CDH infants from 2009-2017. Baseline characteristics, CDH severity, possible AKI predictors, and clinical outcomes were compared between infants with and without AKI. RESULT In total, 38% of infants developed AKI, 44% stage 1, 29% stage 2, 27% stage 3. Lower antenatal lung volumes and liver herniation were associated with AKI. Extracorporeal life support (ECLS), diuretics, abdominal closure surgery, hypotension, and elevated plasma free hemoglobin were associated with AKI. Overall survival was 79%, 47% with AKI, and 35% with AKI on ECLS. AKI is associated with increased mechanical ventilation duration and length of stay. CONCLUSION AKI is common among CDH infants and associated with adverse outcomes. Standardized care bundles addressing AKI risk factors may reduce AKI incidence and severity.
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Affiliation(s)
- Brianna M. Liberio
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - John T. Brinton
- grid.414594.90000 0004 0401 9614Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
| | - Katja M. Gist
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Cardiology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Danielle E. Soranno
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Nephrology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Megan J. Kirkley
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.239638.50000 0001 0369 638XDepartment of Pediatrics, Denver Health Medical Center, Denver, CO USA
| | - Jason Gien
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
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25
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de Haro Jorge I, Prat Ortells J, Martín-Solé O, Muñoz Fernandez E, Pertierra A, Martin-Lluis A, Tarrado X. Porcine dermal patches as a risk factor for recurrence after congenital diaphragmatic hernia repair. Pediatr Surg Int 2021; 37:59-65. [PMID: 33245446 DOI: 10.1007/s00383-020-04787-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Recurrence of congenital diaphragmatic hernia (CDH) is a treatment-related morbidity which can be preventable. There is no consensus about the ideal material for diaphragmatic substitution. The aim of our study is to identify if the use of porcine dermis patches increases the risk of CDH recurrence. METHODS Retrospective review of medical records of CDH patients treated between 2013 and 2017 in our center was carried out. Demographic, clinical and surgical variables were collected. Regression analysis was performed to identify which factors increase the risk of recurrence. RESULTS 50 patients entered the study. 94% of the patients had a left CDH, mean observed/expected lung-to-head ratio was 46%. 17 patients underwent a primary closure, the rest a patch closure: 25 Gore-Tex® and 8 porcine dermis patches were used. Seven patients presented recurrence (14%). Median follow-up time was 3.5 years (1.2-6.2). Univariate analysis revealed that the use of a porcine dermis patch (75%) increased the risk of recurrence compared with Gore-Tex® patch (4%) and primary closure (0%) p < 0.001 (HR 58.7; IC 95%: 6.9-501.2; p < 0.001). CONCLUSION The main risk factor for CDH recurrence is the use of a porcine dermis patch. We do not recommend the use of these patches for CDH repair.
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Affiliation(s)
- Irene de Haro Jorge
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Jordi Prat Ortells
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Oriol Martín-Solé
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Elena Muñoz Fernandez
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Africa Pertierra
- Department of Neonatology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Alba Martin-Lluis
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
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26
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Brosens E, Peters NCJ, van Weelden KS, Bendixen C, Brouwer RWW, Sleutels F, Bruggenwirth HT, van Ijcken WFJ, Veenma DCM, Otter SCMCD, Wijnen RMH, Eggink AJ, van Dooren MF, Reutter HM, Rottier RJ, Schnater JM, Tibboel D, de Klein A. Unraveling the Genetics of Congenital Diaphragmatic Hernia: An Ongoing Challenge. Front Pediatr 2021; 9:800915. [PMID: 35186825 PMCID: PMC8852845 DOI: 10.3389/fped.2021.800915] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/28/2021] [Indexed: 12/16/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital structural anomaly in which the diaphragm has not developed properly. It may occur either as an isolated anomaly or with additional anomalies. It is thought to be a multifactorial disease in which genetic factors could either substantially contribute to or directly result in the developmental defect. Patients with aneuploidies, pathogenic variants or de novo Copy Number Variations (CNVs) impacting specific genes and loci develop CDH typically in the form of a monogenetic syndrome. These patients often have other associated anatomical malformations. In patients without a known monogenetic syndrome, an increased genetic burden of de novo coding variants contributes to disease development. In early years, genetic evaluation was based on karyotyping and SNP-array. Today, genomes are commonly analyzed with next generation sequencing (NGS) based approaches. While more potential pathogenic variants are being detected, analysis of the data presents a bottleneck-largely due to the lack of full appreciation of the functional consequence and/or relevance of the detected variant. The exact heritability of CDH is still unknown. Damaging de novo alterations are associated with the more severe and complex phenotypes and worse clinical outcome. Phenotypic, genetic-and likely mechanistic-variability hampers individual patient diagnosis, short and long-term morbidity prediction and subsequent care strategies. Detailed phenotyping, clinical follow-up at regular intervals and detailed registries are needed to find associations between long-term morbidity, genetic alterations, and clinical parameters. Since CDH is a relatively rare disorder with only a few recurrent changes large cohorts of patients are needed to identify genetic associations. Retrospective whole genome sequencing of historical patient cohorts using will yield valuable data from which today's patients and parents will profit Trio whole genome sequencing has an excellent potential for future re-analysis and data-sharing increasing the chance to provide a genetic diagnosis and predict clinical prognosis. In this review, we explore the pitfalls and challenges in the analysis and interpretation of genetic information, present what is currently known and what still needs further study, and propose strategies to reap the benefits of genetic screening.
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Affiliation(s)
- Erwin Brosens
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Nina C J Peters
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Kim S van Weelden
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Charlotte Bendixen
- Unit of Pediatric Surgery, Department of General, Visceral, Vascular and Thoracic Surgery, University Hospital Bonn, Bonn, Germany
| | - Rutger W W Brouwer
- Center for Biomics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Frank Sleutels
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hennie T Bruggenwirth
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Wilfred F J van Ijcken
- Center for Biomics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Danielle C M Veenma
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suzan C M Cochius-Den Otter
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Alex J Eggink
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Marieke F van Dooren
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Heiko Martin Reutter
- Institute of Human Genetics, University Hospital of Bonn, Bonn, Germany.,Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Robbert J Rottier
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
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Kim AG, Mon R, Karmakar M, Lally PA, Hirschl RB, Mychaliska GB, Perrone EE. Predicting lethal pulmonary hypoplasia in congenital diaphragmatic hernia (CDH): Institutional experience combined with CDH registry outcomes. J Pediatr Surg 2020; 55:2618-2624. [PMID: 32951888 DOI: 10.1016/j.jpedsurg.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND The Severe Pulmonary Hypoplasia and Evaluation for Resuscitative Efforts (SPHERE) protocol was developed to attempt to identify CDH patients with likely lethal pulmonary hypoplasia. We present our experience with this protocol and utilize the CDH Registry to critically assess the protocol. METHODS SPHERE patients identified based on prenatal imaging (10/2009-1/2018) were offered ECMO if meeting postnatal physiologic criteria, while others received comfort measures. Within the CDH Registry, patients with suspected severe CDH were identified and separated into "passed" (lowest pCO2 ≤100) versus "failed" (lowest pCO2 >100) groups. RESULTS Of 23 SPHERE patients, 57% (13/23) passed criteria for ECMO and survival was 46% (6/13) in that cohort. Of 4912 patients in the CDH Registry, 265 met criteria. There was no difference in survival rates between those that "passed" (122/227; 54%) versus "failed" (18/38; 47%). However, the latter had longer ECMO runs and more required ventilator/ECMO support at 30 days. Amongst survivors, the "failed" group had longer hospital stays and more frequently required tube feeds at discharge. CONCLUSIONS The SPHERE protocol did not predict mortality in the CDH Registry. However, our data suggest resource utilization is significant when unable to reach pCO2 ≤100 despite resuscitation. Morbidity remains high in this group. LEVEL OF EVIDENCE Level III ANNOTATION OF CHANGES: Institutional Review Board Approval at University of Michigan (HUM00031524 and HUM00044010) TYPE OF STUDY: Retrospective Review.
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Affiliation(s)
- Aimee G Kim
- University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Rodrigo Mon
- Children's National Health System, Department of General and Thoracic Surgery, 111 Michigan Ave., NW, Washington, DC 20010, USA
| | - Monita Karmakar
- University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Pamela A Lally
- University of Texas Health Science Center at Houston, McGovern Medical School, Department of Pediatric Surgery, Suite 5.258, 6431 Fannin St., Houston, TX 77030, USA
| | - Ronald B Hirschl
- University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - George B Mychaliska
- University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Erin E Perrone
- University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA.
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28
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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29
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Perrone EE, Abbasi N, Cortes MS, Umar U, Ryan G, Johnson A, Ladino-Torres M, Ruano R. Prenatal assessment of congenital diaphragmatic hernia at north american fetal therapy network centers: A continued plea for standardization. Prenat Diagn 2020; 41:200-206. [PMID: 33125174 DOI: 10.1002/pd.5859] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Prenatal work-up for congenital diaphragmatic hernia (CDH) is important for risk stratification, standardization, counseling, and optimal therapeutic choice. To determine current practice patterns regarding prenatal CDH work-up, including prenatal ultrasound and magnetic resonance imaging (MRI) use, and to identify areas for standardization of such evaluation between fetal centers. METHODS A survey regarding prenatal CDH work-up was sent to each member center of the North American Fetal Therapy Network (NAFTNet) (n = 36). RESULTS All responded. Sonographic measurement of lung-to-head ratio (LHR) was determined by all, 89% (32/36) of which routinely calculate observed-to-expected LHR. The method for measuring LHR varied: 58% (21/36) used a "trace" method, 25% (9/36) used "longest axis," and 17% (6/36) used an "antero-posterior" method. Fetal MRI was routinely used in 78% (28/36) of centers, but there was significant variability in fetal lung volume measurement. Whereas all generated a total fetal lung volume, the planes, methodology and references values varied significantly. All evaluated liver position, 71% (20/28) evaluated stomach position and 54% (15/28) quantified the degree of liver herniation. More consistency in workup was seen between centers offering fetal intervention. CONCLUSION Prenatal CDH work-up and management differs considerably among North American fetal diagnostic centers, highlighting a need for its standardization.
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Affiliation(s)
- Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Uzma Umar
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hospital, University of Texas Health Science Center, Houston, Texas, USA
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo Ruano
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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30
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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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31
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Ruano R, Ibirogba ER, Wyatt MA, Balakrishnan K, Qureshi MY, Kolbe AB, Dearani JA, Boesch RP, Segura L, Arendt KW, Bendel-Stenzel E, Salik SS, Klinkner DB. Sequential Minimally Invasive Fetal Interventions for Two Life-Threatening Conditions: A Novel Approach. Fetal Diagn Ther 2020; 48:70-77. [PMID: 33080593 DOI: 10.1159/000510635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described. CASE PRESENTATION Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months. DISCUSSION/CONCLUSION Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, .,Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA,
| | - Eniola R Ibirogba
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Michelle A Wyatt
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Karthik Balakrishnan
- Department of Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - M Yasir Qureshi
- Department of Cardiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Amy B Kolbe
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - R Paul Boesch
- Division of Pediatric Pulmonology, Department of Pediatrics, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Leal Segura
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Shana S Salik
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Denise B Klinkner
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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32
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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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33
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Wada S, Ozawa K, Sugibayashi R, Suyama F, Amari S, Ito Y, Kanamori Y, Okuyama H, Usui N, Sasahara J, Kotani T, Hayakawa M, Kato K, Taguchi T, Endo M, Sago H. Feasibility and outcomes of fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: A Japanese experience. J Obstet Gynaecol Res 2020; 46:2598-2604. [PMID: 32989906 PMCID: PMC7756773 DOI: 10.1111/jog.14504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/03/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
AIM To present the feasibility, safety and outcomes of fetoscopic endoluminal tracheal occlusion (FETO) for the treatment of severe congenital diaphragmatic hernia (CDH). METHODS This was a single-arm clinical trial of FETO for isolated left-sided CDH with liver herniation and Kitano Grade 3 stomach position (>50% stomach herniation into the right chest). FETO was performed at 27-29 weeks of gestation for cases with observed/expected lung to head ratio (o/e LHR) <25% and at 30-31 weeks for cases with o/e LHR ≥25%. RESULTS Eleven cases were enrolled between March 2014 and March 2016, and balloon insertion was successful in all cases. The median o/e LHR at entry was 27% (range, 20-33%). The median gestational age at FETO was 30.9 (range, 27.1-31.7) weeks. There were no severe maternal adverse events. One fetus died unexpectedly at 33 weeks of gestation due to cord strangulation by the detached amniotic membrane. There were 3 cases (27%) of preterm premature rupture of membranes. In all 10 cases, balloon removal at 34-35 weeks of gestation was successful. The median gestational age at delivery was 36.5 (range, 34.2-38.3) weeks. The median duration of occlusion and the median interval between balloon insertion and delivery were 26 days (range: 17-49 days) and 43 days (range, 21-66 days), respectively. Both the survival rate at 90 days of age and the rate of survival to discharge were 45% (5/11). CONCLUSION The FETO is feasible without maternal morbidity in Japan and could be offered to women whose fetuses show severe isolated left-sided CDH to accelerate fetal lung growth.
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Affiliation(s)
- Seiji Wada
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Katsusuke Ozawa
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Rika Sugibayashi
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Fumio Suyama
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Shoichiro Amari
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yushi Ito
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yutaka Kanamori
- Division of Surgery, Department of Surgical SpecialtiesNational Center for Child Health and DevelopmentTokyoJapan
| | - Hiroomi Okuyama
- Department of Pediatric SurgeryOsaka University Graduate School of MedicineSuitaJapan
| | - Noriaki Usui
- Department of Pediatric SurgeryOsaka Women's and Children's HospitalIzumiJapan
| | - Jun Sasahara
- Department of Maternal Fetal MedicineOsaka Women's and Children's HospitalIzumiJapan
| | - Tomomi Kotani
- Department of Obstetrics and GynecologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal‐Neonatal CareNagoya University HospitalNagoyaJapan
| | - Kiyoko Kato
- Department of Obstetrics and GynecologyKyushu University School of MedicineFukuokaJapan
| | - Tomoaki Taguchi
- Department of Pediatric SurgeryKyushu University School of MedicineFukuokaJapan
| | - Masayuki Endo
- Department of Obstetrics and GynecologyOsaka University Graduate School of MedicineSuitaJapan
| | - Haruhiko Sago
- Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
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34
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Kim AG, Norwitz G, Karmakar M, Ladino-Torres M, Berman DR, Kreutzman J, Treadwell MC, Mychaliska GB, Perrone EE. Discordant prenatal ultrasound and fetal MRI in CDH: wherein lies the truth? J Pediatr Surg 2020; 55:1879-1884. [PMID: 31813580 DOI: 10.1016/j.jpedsurg.2019.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/23/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Prenatal risk assessment of congenital diaphragmatic hernia (CDH) relies on prenatal ultrasound (U/S) and fetal magnetic resonance imaging (MRI). When the modalities differ in prognosis, it is unclear which is more reliable. METHODS Retrospective chart review identified cases of prenatally diagnosed CDH from 4/2010-6/2018 meeting inclusion criteria. Demographic, radiologic, and postnatal outcomes data were collected. Ultrasound- versus MRI-based prognosis (mild, moderate, and severe) was compared with clinical outcomes. Kappa measures compared congruency in disease severity scaling between imaging modalities, while logistic regression and receiver operating characteristics curves compared the ability of each modality to predict outcomes. RESULTS Forty-two patients met criteria. Both U/S- and MRI-based prognosis categories differentiated for survival. MRI categories differentiated for ECMO use, surgical repair, and defect type. O/e TFLV better discriminated for survivors and defect type than o/e LHR. Seventeen (40.5%) had discordant prenatal prognostic categories. In 13/17 (76.5%), o/e TFLV predicted higher severity when compared to o/e LHR, but sample size was insufficient to compare accuracy in cases of discordance. CONCLUSIONS Clinical outcomes suggest fetal MRI may more accurately predict severe pulmonary hypoplasia compared to prenatal ultrasound. Our analysis suggests fetal MRI is a valuable adjunct in the prenatal evaluation of CDH. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Review.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Gabriella Norwitz
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine.
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35
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Vincent M, Karolak JA, Deutsch G, Gambin T, Popek E, Isidor B, Szafranski P, Le Caignec C, Stankiewicz P. Clinical, Histopathological, and Molecular Diagnostics in Lethal Lung Developmental Disorders. Am J Respir Crit Care Med 2020; 200:1093-1101. [PMID: 31189067 DOI: 10.1164/rccm.201903-0495tr] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lethal lung developmental disorders are a rare but important group of pediatric diffuse lung diseases presenting with neonatal respiratory failure. On the basis of histopathological appearance at lung biopsy or autopsy, they have been termed: alveolar capillary dysplasia with misalignment of the pulmonary veins, acinar dysplasia, congenital alveolar dysplasia, and other unspecified primary pulmonary hypoplasias. However, the histopathological continuum in these lethal developmental disorders has made accurate diagnosis challenging, which has implications for recurrence risk. Over the past decade, genetic studies in infants with alveolar capillary dysplasia with misalignment of the pulmonary veins have revealed the causative role of the dosage-sensitive FOXF1 gene and its noncoding regulatory variants in the distant lung-specific enhancer at chromosome 16q24.1. In contrast, the molecular bases of acinar dysplasia and congenital alveolar dysplasia have remained poorly understood. Most recently, disruption of the TBX4-FGF10-FGFR2 epithelial-mesenchymal signaling pathway has been reported in patients with these lethal pulmonary dysplasias. Application of next-generation sequencing techniques, including exome sequencing and whole-genome sequencing, has demonstrated their complex compound inheritance. These data indicate that noncoding regulatory elements play a critical role in lung development in humans. We propose that for more precise lethal lung developmental disorder diagnosis, a diagnostic pathway including whole-genome sequencing should be implemented.
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Affiliation(s)
- Marie Vincent
- Service de Genetique Medicale, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, L'institut du Thorax, Nantes, France
| | - Justyna A Karolak
- Department of Molecular and Human Genetics and.,Department of Genetics and Pharmaceutical Microbiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Gail Deutsch
- Department of Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Tomasz Gambin
- Department of Molecular and Human Genetics and.,Department of Medical Genetics, Institute of Mother and Child, Warsaw, Poland; and.,Institute of Computer Science, Warsaw University of Technology, Warsaw, Poland
| | - Edwina Popek
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Bertrand Isidor
- Service de Genetique Medicale, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, L'institut du Thorax, Nantes, France
| | | | - Cedric Le Caignec
- Service de Genetique Medicale, Centre Hospitalier Universitaire de Nantes, Nantes, France
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36
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Abstract
Because congenital diaphragmatic hernia (CDH) is characterized by a spectrum of severity, risk stratification is an essential component of care. In both the prenatal and postnatal periods, accurate prediction of outcomes may inform clinical decision-making, care planning, and resource allocation. This review examines the history and utility of the most well-established risk prediction tools currently available, and provides recommendations for their optimal use in the management of CDH patients.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap St., Second Floor, Memphis, TN, 38112, USA.
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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37
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Macchini F, Morandi A, Mazzoleni S, Ichino M, Cavallaro G, Raffaeli G, Ferrari C, Gangi S, Mosca F, Fabietti I, Persico N, Leva E. Is Fetal Endoscopic Tracheal Occlusion (FETO) a Predisposing Factor for Acid Gastro-Esophageal Reflux in Infants With Congenital Diaphragmatic Hernia? Front Pediatr 2020; 8:467. [PMID: 32984201 PMCID: PMC7477307 DOI: 10.3389/fped.2020.00467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/03/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction: Various anatomical defects predispose patients with congenital diaphragmatic hernia (CDH) to develop gastroesophageal reflux disease (GERD). The fetal endoscopic tracheal occlusion (FETO) has increased the survival of patients with severe CDHs. The aim of this study was to study GERD in patients who underwent FETO. Materials and Methods: We included patients with CDH treated with or without FETO ("FETO" and "no-FETO" group, respectively) from 2013 to 2016. Data on gestational age (GA), birth weight (BW), initial observed/expected lung to head ratio (O/E LHR), final O/E LHR, duration of ventilation and hospitalization, maximal tracheal diameter, and pulmonary volume were collected. All patients underwent pH-metry after 1 year of life, and the results were compared between groups and correlated to risk factors. Results: Thirty-two patients were included in the study: 10 FETO and 22 no-FETO. No significant differences were observed in the pH-metric results of the two groups. No correlation was found between GA, BW, initial O/E LHR, maximal tracheal diameter, pulmonary volume, and pH-metric results. pH-metric results were correlated with the total duration of ventilation (R = 0.5, p = 0.003) and of hospitalization (R = 0.54, p = 0.001). Gastric herniation is associated with the worse pH-metric result. Conclusions: The FETO procedure does not seem to represent an independent risk factor for GERD. However, patients with the most severe CDH have the worst GERD.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Mazzoleni
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Ichino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Carlo Ferrari
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Gangi
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Isabella Fabietti
- Unit of Obstetrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Unit of Obstetrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Kim AG, Mon RA, Karmakar M, Kreutzman J, Ladino-Torres M, Treadwell MC, Mychaliska GB, Perrone EE. Calculating Observed-to-Expected Total Fetal Lung Volume in CDH Fetuses in Twin Gestation: Is There a Better Way? Fetal Diagn Ther 2019; 47:545-553. [PMID: 31865353 DOI: 10.1159/000504510] [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] [Received: 05/02/2019] [Accepted: 10/31/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a potentially lethal birth defect, and identifying prenatal predictors of outcome is important. Observed-to-expected total fetal lung volume (o/e TFLV) has been shown to be a predictor of severity and useful in risk stratification but is variable due to different TFLV formulas. OBJECTIVES To calculate o/e TFLV for CDH patients part of a twin gestation using the unaffected sibling as an internal control and comparing these values to those calculated using published formulas for TFLV. METHODS Seven twin gestations with one fetus affected by CDH were identified between 2006 and 2017. The lung volume for each twin was calculated using magnetic resonance imaging (MRI), and o/e TFLV was calculated using the unaffected twin's TFLV. This percentage was then compared to the o/e TFLV calculated using published formulas. RESULTS Lung volumes in the unaffected twins were within normal ranges at the lower end of the spectrum. No single TFLV formula was found to correlate perfectly. Intraclass correlation coefficient estimate was most consistent for o/e TFLV calculated with the Meyers formula and supported by Bland-Altman plots. CONCLUSIONS O/e TFLV measured in CDH/non-CDH twin gestations using the unaffected sibling demonstrated agreement with o/e TFLV calculated using the Meyers formula. We urge the fetal community to standardize the method, use, and interpretation of fetal MRI in the prenatal evaluation of CDH.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo A Mon
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria Ladino-Torres
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Radiology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA, .,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA,
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Petroze RT, Caminsky NG, Trebichavsky J, Bouchard S, Le-Nguyen A, Laberge JM, Emil S, Puligandla PS. Prenatal prediction of survival in congenital diaphragmatic hernia: An audit of postnatal outcomes. J Pediatr Surg 2019; 54:925-931. [PMID: 30786991 DOI: 10.1016/j.jpedsurg.2019.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/27/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Effective antenatal counseling in congenital diaphragmatic hernia (CDH) relies on proper measurement of prognostic indices. This quality initiative audited the accuracy of prenatal imaging with postnatal outcomes at two tertiary pediatric referral centers. METHODS Prenatal lung-head ratio (LHR) and total fetal lung volume (TFLV) for CDH patients treated between 2006 and 2017 were retrieved. Study inclusion required at least one LHR or TFLV measurement between 24 and 32 weeks gestational age. Postnatal outcomes [mortality, extracorporeal life support (ECLS) need, patch repair, persistent pulmonary hypertension, oxygen requirement at 28 days] were abstracted from the Canadian Pediatric Surgery Network (CAPSNet) database and local chart review. Univariate and descriptive analyses were conducted. RESULTS Eighty-two of 121 eligible CDH patients (68%) were included. Overall mortality, ECLS rates, and patch repair were 33%, 12.5%, and 45%, respectively. Lower LHR values correlated with increased rates of each outcome and persisted despite multiple measurements. Values obtained were higher than those in published schemata. LHR values >45% were most associated with survival, avoidance of ECLS, and primary repair. TFLV values only correlated with mortality and patch repair. CONCLUSIONS This audit confirms that LHR and TFLV values predict CDH outcomes. However, absolute values obtained require careful interpretation and internal review. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Robin T Petroze
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Natasha G Caminsky
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | | | - Sarah Bouchard
- Division of Pediatric Surgery, CHU Sainte-Justine, Montreal, QC, Canada
| | - Annie Le-Nguyen
- Department of General Surgery, University of Montreal, Montreal, QC, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Pramod S Puligandla
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Morandi A, Macchini F, Ophorst M, Borzani I, Ciralli F, Farolfi A, Porro GA, Franzini S, Fabietti I, Persico N, Mosca F, Leva E. Tracheal Diameter and Respiratory Outcome in Infants with Congenital Diaphragmatic Hernia Treated by Fetal Endoscopic Tracheal Occlusion. Fetal Diagn Ther 2018; 46:296-305. [PMID: 30481746 DOI: 10.1159/000491785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/02/2018] [Indexed: 11/19/2022]
Abstract
AIM To evaluate tracheal diameters and their clinical impact in patients with congenital diaphragmatic hernia (CDH) after fetal endoscopic tracheal occlusion (FETO). METHODS Patients born with CDH between January 2012 and August 2016 were divided into two groups: noFETO and FETO. Tracheal diameters at three levels (T1, carina, and maximum tracheal dilation) on chest X-ray at 1, 3, 6, 12, 24, and 36 months of follow-up, requirements of invasive and noninvasive respiratory support, the incidence of respiratory infections, and results of pulmonary function tests (PFT) were compared. RESULTS A total of 71 patients with CDH were born in the study period, and there were 34/41 survivors in the no-FETO group (82.9%) and 13/30 in the FETO group (43.3%). The maximum tracheal diameter was significantly greater in the FETO group at all ages. No differences were observed in the diameters at T1 and the carina, in the requirements of invasive and noninvasive respiratory support, and in the incidence respiratory infections. At the PFT (6-12 months), the FETO group presented higher respiratory rates (46.1 ± 6.2 vs. 36.5 ± 10.6, p = 0.02). No differences in PFT results were found between the groups after the 1st year of life. CONCLUSIONS The FETO procedure leads to persistent tracheomegaly. However, the tracheomegaly does not seem to have a significant clinical impact.
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Affiliation(s)
- Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy,
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Marijke Ophorst
- NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Borzani
- Radiology Unit, Pediatric Division, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabrizio Ciralli
- NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Farolfi
- NICU, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuliana Anna Porro
- Anesthesia and Pediatric Intensive Care Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Franzini
- Anesthesia and Pediatric Intensive Care Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- NICU, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
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Prenatal findings of serpentine-like syndrome with congenital intrathoracic stomach: differential diagnosis from congenital diaphragmatic hernia. J Med Ultrason (2001) 2018; 46:263-266. [PMID: 30094766 DOI: 10.1007/s10396-018-0896-8] [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: 06/01/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
Congenital rachischisis and brachioesophagus with secondary intrathoracic stomach, which is described as "serpentine-like syndrome", is a very rare condition. We report the prenatal findings of serpentine-like syndrome in a fetus at 18 weeks of gestation. The stomach was entirely elevated into the thoracic area, but the liver retained its normal position. Our initial diagnosis was isolated left congenital diaphragmatic hernia (CDH). At 20 weeks of gestation, the pregnancy was terminated, and a male newborn weighing 338 g was vaginally delivered. The autopsy findings revealed an extremely short esophagus, and the stomach was located in the posterior mediastinum as a result of congenital esophagus hiatal hernia. A severe case of rachischisis was identified from the cervical to thoracic vertebrae. The prognosis of congenital intrathoracic stomach associated with serpentine-like syndrome is extremely poor compared to the prognosis of isolated CDH. It is difficult to make a definite diagnosis by ultrasound alone; however, atypical findings, such as the presence of the entire intrathoracic stomach despite the normally located liver, may warrant further exploration. Obstetricians and neonatal clinicians presented with similar cases should be alerted to the significance of these prenatal findings and the differences in outcomes to ensure appropriate counseling of parents.
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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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Snoek KG, Peters NCJ, van Rosmalen J, van Heijst AFJ, Eggink AJ, Sikkel E, Wijnen RM, IJsselstijn H, Cohen-Overbeek TE, Tibboel D. The validity of the observed-to-expected lung-to-head ratio in congenital diaphragmatic hernia in an era of standardized neonatal treatment; a multicenter study. Prenat Diagn 2017; 37:658-665. [PMID: 28453882 PMCID: PMC5518227 DOI: 10.1002/pd.5062] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/03/2017] [Accepted: 04/21/2017] [Indexed: 01/06/2023]
Abstract
Objective To assess the predictive value of observed‐to‐expected lung‐to‐head ratio (O/E LHR) for survival and chronic lung disease (CLD) in survivors of left‐sided congenital diaphragmatic hernia (CDH) in an era of standardized neonatal treatment, and to evaluate the predictive value of the O/E LHR trajectory for survival. Methods This retrospective cohort study was performed in two high‐volume CDH centers in the Netherlands in prenatally detected, isolated left‐sided CDH patients born between 2008 and 2014. O/E LHR and liver position were determined using 2D‐ultrasonography at three time points during gestation from 19 weeks onwards. Ultrasound measurements were performed on stored ultrasound data by one single experienced operator blinded to postnatal outcome. Results Of the 122 included cases, 77.9% survived of whom 38.9% developed CLD. A significant association was found between the first measured O/E LHR and survival and development of CLD in survivors. Prenatal liver position did not have additional predictive value. No significant association was found between the trajectory of the O/E LHR and survival. Conclusion In an era of standardized neonatal treatment for neonates with CDH, the first measured O/E LHR per patient significantly predicts survival and development of CLD in survivors in isolated left‐sided CDH infants. © 2017 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Kitty G Snoek
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Arno F J van Heijst
- Department of Neonatology, Radboud University Medical Centre Nijmegen, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Esther Sikkel
- Department of Obstetrics and Gynecology, Radboud University Medical Centre Nijmegen, The Netherlands
| | - René M Wijnen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
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Coughlin MA, Werner NL, Gajarski R, Gadepalli S, Hirschl R, Barks J, Treadwell MC, Ladino-Torres M, Kreutzman J, Mychaliska GB. Prenatally diagnosed severe CDH: mortality and morbidity remain high. J Pediatr Surg 2016; 51:1091-5. [PMID: 26655216 DOI: 10.1016/j.jpedsurg.2015.10.082] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE This study sought to evaluate prenatal markers' ability to predict severe congenital diaphragmatic hernia(CDH) and assess this subgroup's morbidity and mortality. METHODS A retrospective review was performed between 2006 and 2014. Prenatal criteria for severe CDH included: liver herniation, lung-to-head ratio (LHR) <1 on prenatal ultrasound and/or observed-to-expected LHR (o/eLHR) <25%, and/or observed-to-expected total lung volume (o/eTLV) <25% on fetal MRI. Postnatal characteristics included: mortality, ECMO utilization, patch closure, persistent suprasystemic pulmonary hypertension (PHtn), O2 requirement at discharge, and few ventilator-free days in the first 60. Statistics performed used unpaired t-test, p<0.05 significant. RESULTS Overall, 47.5%(29/61) of patients with prenatally diagnosed, isolated CDH met severe criteria. Mean LHR: 1.04±0.35, o/eLHR: 31±10% and o/eTLV: 20±7%. Distribution was 72% LCDH, 24% R-CDH. Overall survival: 38%. ECMO requirement: 92%. Patch rate: 91%. Mean ventilator-free days in 60: 7.1±14. Supplemental oxygen at discharge was required in 27%. In this prenatally diagnosed severe cohort, 58%(15/26) had persistent PHtn post-ECMO requiring inhaled nitric oxide±epoprostenol. Comparing patients with and without PHtn: mean ECMO duration 18±10 days versus 9±7 days (p=0.01) and survival 20% versus 72% (p=0.006). CONCLUSION A combination of prenatal markers accurately identified severe CDH patients. Outcomes of this group remain poor and persistent PHtn contributes significantly to mortality.
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Affiliation(s)
- Megan A Coughlin
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI.
| | - Nicole L Werner
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Robert Gajarski
- Division of Pediatric Cardiology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Samir Gadepalli
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Ronald Hirschl
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - John Barks
- Division of Neonatology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Marjorie C Treadwell
- Division of Maternal Fetal Medicine, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Maria Ladino-Torres
- Division of Pediatric Radiology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
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Benoist G, Mokhtari M, Deschildre A, Khen-Dunlop N, Storme L, Benachi A, Delacourt C. Risk of Readmission for Wheezing during Infancy in Children with Congenital Diaphragmatic Hernia. PLoS One 2016; 11:e0155556. [PMID: 27171167 PMCID: PMC4865179 DOI: 10.1371/journal.pone.0155556] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/29/2016] [Indexed: 11/19/2022] Open
Abstract
Rationale Congenital diaphragmatic hernia (CDH) is associated with a high incidence of respiratory problems, even after initial hospital discharge. These problems are likely to lead to re-hospitalization during infancy, although actual frequency of readmissions is unknown. Objective We aimed to determine the rate of hospitalization for wheezing in infants with CDH between the time of initial discharge and 24 months of age, and to identify factors associated with readmission. Methods Data about infants with CDH born in three French reference tertiary centers between January 2009 and March 2013 who were alive at hospital discharge, were extracted from a prospective national database. Results Ninety-two children were identified, and 86 were included in the analysis. In total, 116 wheezing episodes requiring a doctor’s visit occurred in 50 infants (58%) before 24 months of age. Twenty-two children (26%) were readmitted at least once for wheezing exacerbations. RSV was present in 6 of 15 (40%) of children with available nasal samples at first readmission, and 1 of 5 (20%) at second readmission. Thoracic herniation of the liver, low gestational age, longer initial hospitalization, need for oxygen therapy at home, and eczema were all significantly associated with readmission for wheezing exacerbations. Fifty-three infants (62%) received palivizumab prophylaxis, but there was no association with the overall rate of readmission for wheezing exacerbations or RSV-related hospitalization. Conclusions The rate of readmission for wheezing among infants with CDH is high, and significantly influenced by several prenatal and neonatal factors. Palivizumab prophylaxis was not associated with the rate of readmission.
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Affiliation(s)
- Gregoire Benoist
- Pneumologie Pédiatrique, Necker, AP-HP, Paris, France, Centre de Référence des Maladies Respiratoires Rares, Paris, France
| | | | | | - Naziha Khen-Dunlop
- Chirurgie Pédiatrique, Necker, AP-HP, Paris, France
- Université Paris-Descartes, Paris, France
| | | | - Alexandra Benachi
- Gynécologie Obstétrique, Antoine Béclère, AP-HP, Paris, France, Centre de Référence des Hernies Diaphragmatiques, Clamart, France
| | - Christophe Delacourt
- Pneumologie Pédiatrique, Necker, AP-HP, Paris, France, Centre de Référence des Maladies Respiratoires Rares, Paris, France
- Université Paris-Descartes, Paris, France
- * E-mail:
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47
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Nawapun K, Eastwood MP, Diaz-Cobos D, Jimenez J, Aertsen M, Gomez O, Claus F, Gratacós E, Deprest J. In vivo evidence by magnetic resonance volumetry of a gestational age dependent response to tracheal occlusion for congenital diaphragmatic hernia. Prenat Diagn 2015; 35:1048-56. [PMID: 26135752 DOI: 10.1002/pd.4642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/23/2015] [Accepted: 06/25/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to assess in vivo changes in lung and liver volumes in fetuses with isolated congenital diaphragmatic hernia, either expectantly managed or treated in utero. METHOD This is a secondary analysis of prospectively collected data at two fetal therapy centers. We used archived magnetic resonance images of fetuses taken ≥7 days apart, creating paired observations in 20 expectantly managed cases, 41 with a second magnetic resonance prior to balloon reversal and 64 after balloon removal. We measured observed to expected total fetal lung volume (O/E TFLV) and liver-to-thoracic volume ratio. We calculated changes in volume as compared with the initial measurement and its rate as a function of gestational age (GA) at occlusion. RESULTS The liver-to-thoracic volume ratio did not change in either group. In expectantly managed fetuses, O/E TFLV did not increase with gestation. In fetuses undergoing tracheal occlusion, the measured increase in volume was 2.6 times larger with balloon in place as compared with that after its removal. GA at tracheal occlusion was an independent predictor of the O/E TFLV. The net rate seems to initially increase and plateau at a maximum of 1.5% per week by 35 to 45 days after occlusion. CONCLUSIONS Tracheal occlusion induces a net increase in volume, its magnitude essentially dependent on the GA at occlusion.
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Affiliation(s)
- Katika Nawapun
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand
| | - Mary Patrice Eastwood
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Daysi Diaz-Cobos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Julio Jimenez
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Aertsen
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Olga Gomez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Filip Claus
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium.,Department of Radiology, Onze Lieve Vrouw Hospital Aalst, Aalst, Belgium
| | - Eduard Gratacós
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Jan Deprest
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
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Eastwood MP, Russo FM, Toelen J, Deprest J. Medical interventions to reverse pulmonary hypoplasia in the animal model of congenital diaphragmatic hernia: A systematic review. Pediatr Pulmonol 2015; 50:820-38. [PMID: 25994108 DOI: 10.1002/ppul.23206] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 02/24/2015] [Accepted: 03/23/2015] [Indexed: 12/25/2022]
Abstract
We aimed to systematically review all published pre-clinical research on prenatal medical treatment of pulmonary hypoplasia in congenital diaphragmatic hernia (CDH). Background The neonatal mortality due to isolated CDH remains high. Whether fetal endoscopic tracheal occlusion (FETO) reduces mortality is still to be demonstrated. Therefore more potent preferentially medical therapy would be welcomed. Methods We searched MEDLINE (Pubmed), Embase and the Web of Science including all studies from the earliest date (1951) to December 2013. Article quality was assessed using the modified CAMRADES checklist. Inclusion criteria were those animal studies addressing prenatal medical interventions and principal variables were confirmation of a diaphragmatic defect, lung to body weight ratio (LBWR), formal airway morphometry or DNA/protein content. Results In total 983 articles were identified. Following abstract review, 96 articles were assessed by two authors in agreement with a third for eligibility. Of these, 43 were included in the final analysis. The median number of study quality checklist items (maximum 10) scored was 4 (IQ range: 2-5). Thirty (69.8%) of studies were in the nitrofen rat. The majority were treated with vitamins or glucocorticoids. Single studies reported some improvement in lung morphology with alternative therapies. It was impossible to identify a pattern in animal model selection or creation, mode, time point or duration of treatment and readouts. Only one study reported a sample size calculation. Conclusion Comparison in pre-clinical studies in CDH is challenging due to methodological variation. Agreed standardized methods need to be applied in future investigation of new medical therapies.
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Affiliation(s)
- Mary Patrice Eastwood
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Francesca Maria Russo
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jaan Toelen
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Paediatrics, UZ Leuven, KU Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Fetal Medicine Unit, UZ Leuven, Leuven, Belgium
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Phithakwatchara N, Coleman A, Peiro JL, Lee AE, Keswani SG, Kline-Fath B, Lim FY, Shaaban AF. Differential patterns of prenatal ipsilateral and contralateral lung growth in cases of isolated left-sided congenital diaphragmatic hernia. Prenat Diagn 2015; 35:769-76. [DOI: 10.1002/pd.4605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 03/01/2015] [Accepted: 04/14/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Nisarat Phithakwatchara
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology; Faculty of Medicine Siriraj Hospital; Bangkok Thailand
| | - Alan Coleman
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Jose L. Peiro
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Amanda E. Lee
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Sundeep G. Keswani
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Beth Kline-Fath
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric Radiology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Foong-Yen Lim
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Aimen F. Shaaban
- Cincinnati Fetal Center; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
- Division of Pediatric General and Thoracic Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
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50
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Deprest J, Brady P, Nicolaides K, Benachi A, Berg C, Vermeesch J, Gardener G, Gratacos E. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med 2014; 19:338-48. [PMID: 25447987 DOI: 10.1016/j.siny.2014.09.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, and Academic Department of Development and Regeneration, Organ System Cluster, Leuven, Belgium; TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial).
| | - Paul Brady
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Kypros Nicolaides
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Harris Birthright Centre, King's College Hospital, London, UK
| | - Alexandra Benachi
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine Beclere, University Paris Sud, Clamart, France
| | - Christoph Berg
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, and Department of Obstetrics and Gynecology, University of Cologne, Germany
| | - Joris Vermeesch
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Glenn Gardener
- Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Eduard Gratacos
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); BCNatal - Barcelona Center for Maternal-Fetal 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
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