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Sevilmis YD, Olutoye OO, Peiffer S, Mehl SC, Belfort MA, Rhee CJ, Garcia-Prats JA, Vogel AM, Lee TC, Keswani SG, King A. Surfactant Therapy in Congenital Diaphragmatic Hernia and Fetoscopic Endoluminal Tracheal Occlusion. J Surg Res 2024; 296:239-248. [PMID: 38295711 DOI: 10.1016/j.jss.2023.12.003] [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] [Received: 03/01/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is a complex pathology with severe pulmonary morbidity. Administration of surfactant in CDH is controversial, and the advent of fetoscopic endoluminal tracheal occlusion (FETO) has added further complexity. While FETO has been shown to improve survival outcomes, there are risks of prematurity and potential surfactant deficiency. We aim to evaluate the characteristics and outcomes of surfactant administration for CDH infants and elucidate potential benefits or risks in this unique population. METHODS A single-center retrospective cohort review of patients with unilateral CDH from September 2015 to July 2022 was performed. Demographics, prognostic perinatal imaging features, and outcomes were collected. Patients were stratified by surfactant administration and history of FETO. Data were analyzed with descriptive statistics, two-sample t-tests, chi-squared analyses, and logistic regression. RESULTS Of 105 included patients, 19 (18%) underwent FETO and 25 (24%) received surfactant. Overall, surfactant recipients were born at earlier gestational ages and lower birthweights regardless of FETO history. Surfactant recipients possessed significantly worse prenatal prognostic features such as observed to expected total fetal lung volume, observed to expected lung to head ratio, and percent liver herniation. In CDH patients without FETO history, surfactant recipients demonstrated worse outcomes than nonrecipients. This association is notably absent in the FETO population, where surfactant recipients have more favorable survival and comparable outcomes. When controlling for defect severity or surfactant usage, as a proxy for respiratory status, surfactant recipients that underwent FETO trended toward improved survival and decreased ECMO use. CONCLUSIONS Surfactant administration is not associated with increased morbidity and mortality and may be beneficial in CDH patients that have undergone FETO.
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Affiliation(s)
- Y Deniz Sevilmis
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas
| | - Christopher J Rhee
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Joseph A Garcia-Prats
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas.
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De Bie FR, Regin Y, Dubois A, Scuglia M, Arai T, Muylle E, Basurto D, Regin M, Croubels S, Cherlet M, Partridge EA, Allegaert K, Russo FM, Deprest JA. Prenatal treprostinil improves pulmonary arteriolar hypermuscularization in the rabbit model of congenital diaphragmatic hernia. Biomed Pharmacother 2024; 170:115996. [PMID: 38086148 DOI: 10.1016/j.biopha.2023.115996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital malformation characterized by pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Pulmonary hypertension represents the major cause of neonatal mortality and morbidity. Prenatal diagnosis allows assessment of severity and selection of foetal surgery candidates. We have shown that treprostinil, a prostacyclin analogue with an anti-remodelling effect, attenuates the relative hypermuscularization of the pulmonary vasculature in rats with nitrofen-induced CDH. Here we confirm these observations in a large animal model of surgically-created CDH. In the rabbit model, subcutaneous maternal administration of treprostinil at 150 ng/kg/min consistently reached target foetal concentrations without demonstrable detrimental foetal or maternal adverse effects. In pups with CDH, prenatal treprostinil reduced pulmonary arteriolar proportional medial wall thickness and downregulated inflammation and myogenesis pathways. No effect on alveolar morphometry or lung mechanics was observed. These findings provide further support towards clinical translation of prenatal treprostinil for CDH.
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Affiliation(s)
- Felix R De Bie
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium
| | - Yannick Regin
- Unit of Woman and Child, Department of Development and Regeneration, KU Leuven, Belgium
| | - Antoine Dubois
- Unit of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
| | - Marianna Scuglia
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium
| | - Tomohiro Arai
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium
| | - Ewout Muylle
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium
| | - David Basurto
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium
| | - Marius Regin
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Belgium
| | - Siska Croubels
- Department of Pathobiology, Pharmacology and Zoological Medicine, Laboratory of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Marc Cherlet
- Department of Pathobiology, Pharmacology and Zoological Medicine, Laboratory of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Emily A Partridge
- Center for Fetal Research, The Children's Hospital of Philadelphia, United States
| | - Karel Allegaert
- Unit of Woman and Child, Department of Development and Regeneration, KU Leuven, Belgium; Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium; Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Francesca M Russo
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium; Division of Obstetrics and Gynecology, University Hospitals Leuven, Belgium
| | - Jan A Deprest
- Unit of Urogenital, Abdominal and Plastic Surgery, Department of Development and Regeneration, KU Leuven, Belgium; Division of Obstetrics and Gynecology, University Hospitals Leuven, Belgium; Institute for Women's Health, University College London, United Kingdom.
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3
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Beck V, Froyen G, Deckx S, Sandaite I, Deprest T, Plevoets K, Deprest JA. Lung proliferation is dependent on the duration not the timepoint of tracheal occlusion in nitrofen rats with diaphragmatic hernia. Prenat Diagn 2023; 43:1274-1283. [PMID: 37658742 DOI: 10.1002/pd.6428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/12/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Prenatal tracheal occlusion (TO) promotes lung growth and is applied clinically in fetuses with congenital diaphragmatic hernia (CDH). Limited data are available regarding the effect of duration versus timepoint of TO. Our objective was to document the impact of TO on lung development in the near-term period in rats with nitrofen-induced CDH. METHOD Nitrofen was administered on embryonic day (ED)9 and fetal TO was performed on ED18.5, 19, or 20 (term = ED22). Sham-operated and untouched littermates served as controls. Lungs were harvested in 0.5-day steps and only fetuses with a left-sided CDH were included in further analyses. Healthy fetuses provided a reference for normal near-term lung development. RESULTS Duration of TO in the nitrofen rat model for CDH predicts lung growth in terms of lung-body-weight ratio as well as an increased mRNA level of the proliferation marker Ki67. Longer TO also induced a more complex airway architecture. The timepoint of TO was not predictive of lung growth. CONCLUSION In the nitrofen rat model of CDH, a longer period of TO leads to enhanced lung growth and more refined airway architecture.
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Affiliation(s)
- Veronika Beck
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Guy Froyen
- Laboratory for Molecular Diagnostics, Department of Clinical Biology, Jessa Hospital, Hasselt, Belgium
| | - Sebastiaan Deckx
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Inga Sandaite
- Division of Medical Imaging, University Hospital Gasthuisberg, Leuven, Belgium
| | - Thomas Deprest
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Koen Plevoets
- Faculty of Sciences, Department of Applied Mathematics, Computer Science and Statistics, Universiteit Gent, Ghent, Belgium
| | - Jan A Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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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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Miyake Y, Tse WH, Wang JQ, Leon ND, Mourin M, Patel D, Aptekmann AO, Yamataka A, Keijzer R. The effect of tracheal occlusion in congenital diaphragmatic hernia in the nitrofen rat lung explant model. Pediatr Surg Int 2022; 39:61. [PMID: 36564649 DOI: 10.1007/s00383-022-05340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Here, we establish a tracheal occlusion (TO) model with rat lung explants in nitrofen-induced pulmonary hypoplasia in the congenital diaphragmatic hernia (CDH). METHODS We extracted lungs from rats on an embryonic day 18. We mimicked TO in the lung explants by tying the trachea. We assessed lung weight, morphometry, and abundance of Ki-67, Active caspase-3, and Prosurfactant Protein C (proSP-C) with immunofluorescence. RESULTS Lung weight was higher in TO + than TO - on day 1. Abundance of Ki-67 was higher in TO + than TO - (0.15 vs. 0.32, p = 0.009 for day 1, 0.07 vs. 0.17, p = 0.004 for day 2, 0.07 vs. 0.12, p = 0.044 for day 3), and Active caspase-3 was higher in TO + than TO - on day 2 and day 3 (0.04 vs. 0.03 p = 0.669 for day 1, 0.03 vs. 0.13 p < 0.001 for day 2, 0.04 vs. 0.17 p = 0.008 for day3). However, proSP-C protein abundance was lower in TO + than TO - (67.9 vs. 59.1 p = 0.033 for day 1, 73.5 vs. 51.6 p = 0.038 for day 2, 83.1 vs. 56.4 p = 0.009 for day 3). CONCLUSIONS The TO model in lung explants mimics the outcomes of current surgical models of TO and further studies can reveal the cellular and molecular effects of TO in CDH lungs.
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Affiliation(s)
- Yuichiro Miyake
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada.,Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Wai Hei Tse
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Jia Qi Wang
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Nolan De Leon
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Muntahi Mourin
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Daywin Patel
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Arzu Ozturk Aptekmann
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Richard Keijzer
- Department of Surgery, Division of Pediatric Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada.
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6
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Van Calster B, Benachi A, Nicolaides KH, Gratacos E, Berg C, Persico N, Gardener GJ, Belfort M, Ville Y, Ryan G, Johnson A, Sago H, Kosiński P, Bagolan P, Van Mieghem T, DeKoninck PLJ, Russo FM, Hooper SB, Deprest JA. The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data. Am J Obstet Gynecol 2022; 226:560.e1-560.e24. [PMID: 34808130 DOI: 10.1016/j.ajog.2021.11.1351] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Two randomized controlled trials compared the neonatal and infant outcomes after fetoscopic endoluminal tracheal occlusion with expectant prenatal management in fetuses with severe and moderate isolated congenital diaphragmatic hernia, respectively. Fetoscopic endoluminal tracheal occlusion was carried out at 27+0 to 29+6 weeks' gestation (referred to as "early") for severe and at 30+0 to 31+6 weeks ("late") for moderate hypoplasia. The reported absolute increase in the survival to discharge was 13% (95% confidence interval, -1 to 28; P=.059) and 25% (95% confidence interval, 6-46; P=.0091) for moderate and severe hypoplasia. OBJECTIVE Data from the 2 trials were pooled to study the heterogeneity of the treatment effect by observed over expected lung-to-head ratio and explore the effect of gestational age at balloon insertion. STUDY DESIGN Individual participant data from the 2 trials were reanalyzed. Women were assessed between 2008 and 2020 at 14 experienced fetoscopic endoluminal tracheal occlusion centers and were randomized in a 1:1 ratio to either expectant management or fetoscopic endoluminal tracheal occlusion. All received standardized postnatal management. The combined data involved 287 patients (196 with moderate hypoplasia and 91 with severe hypoplasia). The primary endpoint was survival to discharge from the neonatal intensive care unit. The secondary endpoints were survival to 6 months of age, survival to 6 months without oxygen supplementation, and gestational age at live birth. Penalized regression was used with the following covariates: intervention (fetoscopic endoluminal tracheal occlusion vs expectant), early balloon insertion (yes vs no), observed over expected lung-to-head ratio, liver herniation (yes vs no), and trial (severe vs moderate). The interaction between intervention and the observed over expected lung-to-head ratio was evaluated to study treatment effect heterogeneity. RESULTS For survival to discharge, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion was 1.78 (95% confidence interval, 1.05-3.01; P=.031). The additional effect of early balloon insertion was highly uncertain (adjusted odds ratio, 1.53; 95% confidence interval, 0.60-3.91; P=.370). When combining these 2 effects, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion with early balloon insertion was 2.73 (95% confidence interval, 1.15-6.49). The results for survival to 6 months and survival to 6 months without oxygen dependence were comparable. The gestational age at delivery was on average 1.7 weeks earlier (95% confidence interval, 1.1-2.3) following fetoscopic endoluminal tracheal occlusion with late insertion and 3.2 weeks earlier (95% confidence interval, 2.3-4.1) following fetoscopic endoluminal tracheal occlusion with early insertion compared with expectant management. There was no evidence that the effect of fetoscopic endoluminal tracheal occlusion depended on the observed over expected lung-to-head ratio for any of the endpoints. CONCLUSION This analysis suggests that fetoscopic endoluminal tracheal occlusion increases survival for both moderate and severe lung hypoplasia. The difference between the results for the Tracheal Occlusion To Accelerate Lung growth trials, when considered apart, may be because of the difference in the time point of balloon insertion. However, the effect of the time point of balloon insertion could not be robustly assessed because of a small sample size and the confounding effect of disease severity. Fetoscopic endoluminal tracheal occlusion with early balloon insertion in particular strongly increases the risk for preterm delivery.
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Affiliation(s)
- Ben Van Calster
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands; EPI-center, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology of the Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | | | | | - Nicola Persico
- Hospital Maggiore Policlinico IRCCS, University of Milan, Milan, Italy
| | | | - Michael Belfort
- Texas Children's Hospital, Baylor College of Medicine Houston, TX
| | | | - Greg Ryan
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Haruhiko Sago
- National Center for Child Health and Development, Tokyo, Japan
| | - Przemysław Kosiński
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Pietro Bagolan
- Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Tim Van Mieghem
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philip L J DeKoninck
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesca M Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Jan A Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Institute for Women's Health, University College London Hospital, London, United Kingdom.
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Olutoye Ii OO, Short WD, Gilley J, Hammond Ii JD, Belfort MA, Lee TC, King A, Espinoza J, Joyeux L, Lingappan K, Gleghorn JP, Keswani SG. The Cellular and Molecular Effects of Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:925106. [PMID: 35865706 PMCID: PMC9294219 DOI: 10.3389/fped.2022.925106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a complex disease associated with pulmonary hypoplasia and pulmonary hypertension. Great strides have been made in our ability to care for CDH patients, specifically in the prenatal improvement of lung volume and morphology with fetoscopic endoluminal tracheal occlusion (FETO). While the anatomic effects of FETO have been described in-depth, the changes it induces at the cellular and molecular level remain a budding area of CDH research. This review will delve into the cellular and molecular effects of FETO in the developing lung, emphasize areas in which further research may improve our understanding of CDH, and highlight opportunities to optimize the FETO procedure for improved postnatal outcomes.
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Affiliation(s)
- Oluyinka O Olutoye Ii
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Walker D Short
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jamie Gilley
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - J D Hammond Ii
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Luc Joyeux
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jason P Gleghorn
- Department of Biomedical Engineering, University of Delaware, Newark, DE, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
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8
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Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia. Ann Surg 2020; 275:e586-e595. [PMID: 33055583 DOI: 10.1097/sla.0000000000003943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the effect of combining antenatal sildenafil with fetal tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). BACKGROUND Although antenatal sildenafil administration rescues vascular abnormalities in lungs of fetal rabbits with CDH, it only partially improves airway morphometry. We hypothesized that we could additionally stimulate lung growth by combining this medical treatment with fetal TO. METHODS CDH was created on gestational day (GD)23 (n=54). Does were randomized to receive either sildenafil 10 mg/kg/d or placebo by subcutaneous injection from GD24 to GD30. On GD28, fetuses were randomly assigned to TO or sham neck dissection. At term (GD30) fetuses were delivered, ventilated, and finally harvested for histological and molecular analyses. Unoperated littermates served as controls. RESULTS The lung-to-body-weight ratio was significantly reduced in sham-CDH fetuses either (1.2 ± 0.3% vs 2.3 ± 0.3% in controls, P=0.0003). Sildenafil had no effect on this parameter, while CDH fetuses undergoing TO had a lung-to-body-weight ratio comparable to that of controls (2.5 ± 0.8%, P<0.0001). Sildenafil alone induced an improvement in the mean terminal bronchiolar density (2.5 ± 0.8 br/mm vs 3.5 ± 0.9 br/mm, P=0.043) and lung mechanics (static elastance 61 ± 36 cmH2O /mL vs 113 ± 40 cmH2O/mL, P=0.008), but both effects were more pronounced in fetuses undergoing additional TO (2.1 ± 0.8 br/mm, P=0.001 and 31 ± 9 cmH2O/mL, P<0.0001 respectively). Both CDH-sham and CDH-TO fetuses treated with placebo had an increased medial wall thickness of peripheral pulmonary vessels (41.9 ± 2.9% and 41.8 ± 3.2%, vs 24.0 ± 2.9% in controls, P<0.0001). CDH fetuses treated with sildenafil, either with or without TO, had a medial thickness in the normal range (29.4% ± 2.6%). Finally, TO reduced gene expression of vascular endothelial growth factor and surfactant protein A and B, but this effect was counteracted by sildenafil. CONCLUSION In the rabbit model for CDH, the combination of maternal sildenafil and TO has a complementary effect on vascular and parenchymal lung development.
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Heterogeneous Response in Rabbit Fetal Diaphragmatic Hernia Lungs After Tracheal Occlusion. J Surg Res 2020; 250:23-38. [PMID: 32014698 DOI: 10.1016/j.jss.2019.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/10/2019] [Accepted: 12/11/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fetal tracheal occlusion (TO) is an experimental therapeutic approach to stimulate lung growth in the most severe congenital diaphragmatic hernia (CDH) cases. We have previously demonstrated a heterogeneous response of normal fetal rabbit lungs after TO with the appearance of at least two distinct zones. The aim of this study was to examine the fetal lung response after TO in a left CDH fetal rabbit model. METHODS Fetal rabbits at 25 d gestation underwent surgical creation of CDH followed by TO at 27 d and harvest on day 30. Morphometric analysis, global metabolomics, and fluorescence lifetime imaging microscopy (FLIM) were performed to evaluate structural and metabolic changes in control, CDH, and CDH + TO lungs. RESULTS Right and left lungs were different at the baseline and had a heterogeneous pulmonary growth response in CDH and after TO. The relative percent growth of the right lungs in CDH + TO was higher than the left lungs. Morphometric analyses revealed heterogeneous tissue-to-airspace ratios, in addition to size and number of airspaces within and between the lungs in the different groups. Global metabolomics demonstrated a slower rate of metabolism in the CDH group with the left lungs being less metabolically active. TO stimulated metabolic activity in both lungs to different degrees. FLIM analysis demonstrated local heterogeneity in glycolysis, oxidative phosphorylation (OXPHOS), and FLIM "lipid-surfactant" signal within and between the right and left lungs in all groups. CONCLUSIONS We demonstrate that TO leads to a heterogeneous morphologic and metabolic response within and between the right and left lungs in a left CDH rabbit model.
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Marwan AI, Shabeka U, Reisz JA, Zheng C, Serkova NJ, Dobrinskikh E. Unique Heterogeneous Topological Pattern of the Metabolic Landscape in Rabbit Fetal Lungs following Tracheal Occlusion. Fetal Diagn Ther 2018; 45:145-154. [PMID: 29669344 PMCID: PMC6314905 DOI: 10.1159/000487752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/13/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Fetal tracheal occlusion (TO) is currently an experimental approach to drive accelerated lung growth. It is stimulated by mechanotransduction that results in increased cellular proliferation and growth. However, it is currently unknown how TO affects the metabolic landscape of fetal lungs. MATERIALS AND METHODS TO or sham was performed on fetal rabbits at 26 days followed by lung harvest on day 30. Mass spectrometry was performed to evaluate global metabolic changes. Fluorescence lifetime intensity microscopy (FLIM) was performed to estimate local free/bound NADH relative ratio as an indicator of aerobic glycolysis versus oxidative phosphorylation (glycolysis/OXPHOS). RESULTS TO results in a metabolic shift from tricarboxylic acid cycle towards glycolysis. FLIM reveals uniform structures in control lungs characterized by similar ratios of free/bound NADH indicating a homogenous topological pattern. Similar uniform structures are observed in shams with some variability in the glycolysis/OXPHOS ratio. In contrast, lungs following TO demonstrate different types of unique distinct topological zones: one with enlarged alveoli and a shift towards glycolysis; the other maintains balance between glycolysis/OXPHOS similar to control lungs. CONCLUSION We demonstrate for the first time a unique variable topological pattern of metabolism in fetal lungs following TO with a wide variation of metabolism between zones.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado,
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Connie Zheng
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Natalie J Serkova
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Evgenia Dobrinskikh
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Delabaere A, Marceau G, Coste K, Blanchon L, Déchelotte PJ, Blanc P, Sapin V, Gallot D. Effects of tracheal occlusion with retinoic acid administration on normal lung development. Prenat Diagn 2017; 37:427-434. [DOI: 10.1002/pd.5012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/09/2017] [Accepted: 01/29/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Amélie Delabaere
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Fetal Maternal Medicine Unit, Obstetrics and Gynecology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Geoffroy Marceau
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Biochemistry and Molecular Biology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Karen Coste
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Department of Paediatrics; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Loïc Blanchon
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
| | | | - Pierre Blanc
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
| | - Vincent Sapin
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Biochemistry and Molecular Biology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Denis Gallot
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Fetal Maternal Medicine Unit, Obstetrics and Gynecology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
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12
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Marwan AI, Shabeka U, Dobrinskikh E. Suggested Mechanisms of Tracheal Occlusion Mediated Accelerated Fetal Lung Growth: A Case for Heterogeneous Topological Zones. Front Pediatr 2017; 5:295. [PMID: 29376042 PMCID: PMC5770375 DOI: 10.3389/fped.2017.00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022] Open
Abstract
In this article, we report an up-to-date summary on tracheal occlusion (TO) as an approach to drive accelerated lung growth and strive to review the different maternal- and fetal-derived local and systemic signals and mechanisms that may play a significant biological role in lung growth and formation of heterogeneous topological zones following TO. Pulmonary hypoplasia is a condition whereby branching morphogenesis and embryonic pulmonary vascular development are globally affected and is classically seen in congenital diaphragmatic hernia. TO is an innovative approach aimed at driving accelerated lung growth in the most severe forms of diaphragmatic hernia and has been shown to result in improved neonatal outcomes. Currently, most research on mechanisms of TO-induced lung growth is focused on mechanical forces and is viewed from the perspective of homogeneous changes within the lung. We suggest that the key principle in understanding changes in fetal lungs after TO is taking into account formation of unique variable topological zones. Following TO, fetal lungs might temporarily look like a dynamically changing topologic mosaic with varying proliferation rates, dissimilar scale of vasculogenesis, diverse patterns of lung tissue damage, variable metabolic landscape, and different structures. The reasons for this dynamic topological mosaic pattern may include distinct degree of increased hydrostatic pressure in different parts of the lung, dissimilar degree of tissue stress/damage and responses to this damage, and incomparable patterns of altered lung zones with variable response to systemic maternal and fetal factors, among others. The local interaction between these factors and their accompanying processes in addition to the potential role of other systemic factors might lead to formation of a common vector of biological response unique to each zone. The study of the interaction between various networks formed after TO (action of mechanical forces, activation of mucosal mast cells, production and secretion of damage-associated molecular pattern substances, low-grade local pulmonary inflammation, and cardiac contraction-induced periodic agitation of lung tissue, among others) will bring us closer to an appreciation of the biological phenomenon of topological heterogeneity within the fetal lungs.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Evgenia Dobrinskikh
- Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, United States
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Vuckovic A, Herber-Jonat S, Flemmer AW, Strizek B, Engels AC, Jani JC. Antenatal BAY 41-2272 reduces pulmonary hypertension in the rabbit model of congenital diaphragmatic hernia. Am J Physiol Lung Cell Mol Physiol 2016; 310:L658-69. [PMID: 26873974 DOI: 10.1152/ajplung.00178.2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 02/03/2016] [Indexed: 01/05/2023] Open
Abstract
Infants with congenital diaphragmatic hernia (CDH) fail to adapt at birth because of persistent pulmonary hypertension (PH), a condition characterized by excessive muscularization and abnormal vasoreactivity of pulmonary vessels. Activation of soluble guanylate cyclase by BAY 41-2272 prevents pulmonary vascular remodeling in neonatal rats with hypoxia-induced PH. By analogy, we hypothesized that prenatal administration of BAY 41-2272 would improve features of PH in the rabbit CDH model. Rabbit fetuses with surgically induced CDH at day 23 of gestation were randomized at day 28 for an intratracheal injection of BAY 41-2272 or vehicle. After term delivery (day 31), lung mechanics, right ventricular pressure, and serum NH2-terminal-pro-brain natriuretic peptide (NT-proBNP) levels were measured. After euthanasia, lungs were processed for biological or histological analyses. Compared with untouched fetuses, the surgical creation of CDH reduced the lung-to-body weight ratio, increased mean terminal bronchial density, and impaired lung mechanics. Typical characteristics of PH were found in the hypoplastic lungs, including increased right ventricular pressure, higher serum NT-proBNP levels, thickened adventitial and medial layers of pulmonary arteries, reduced capillary density, and lower levels of endothelial nitric oxide synthase. A single antenatal instillation of BAY 41-2272 reduced mean right ventricular pressure and medial thickness of small resistive arteries in CDH fetuses. Capillary density, endothelial cell proliferation, and transcripts of endothelial nitric oxide synthase increased, whereas airway morphometry, lung growth, and mechanics remained unchanged. These results suggest that pharmacological activation of soluble guanylate cyclase may provide a new approach to the prenatal treatment of PH associated with CDH.
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Affiliation(s)
- Aline Vuckovic
- Laboratory of Physiology and Pathophysiology, Université Libre de Bruxelles, Brussels, Belgium;
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. von Hauner Children's Hospital, Perinatal Center Grosshadern, Ludwig-Maximilian-University, Munich, Germany; and
| | - Andreas W Flemmer
- Division of Neonatology, Dr. von Hauner Children's Hospital, Perinatal Center Grosshadern, Ludwig-Maximilian-University, Munich, Germany; and
| | - Brigitte Strizek
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander C Engels
- Division of Neonatology, Dr. von Hauner Children's Hospital, Perinatal Center Grosshadern, Ludwig-Maximilian-University, Munich, Germany; and
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Vuckovic A, Herber-Jonat S, Flemmer AW, Ruehl IM, Votino C, Segers V, Benachi A, Martinovic J, Nowakowska D, Dzieniecka M, Jani JC. Increased TGF-β: a drawback of tracheal occlusion in human and experimental congenital diaphragmatic hernia? Am J Physiol Lung Cell Mol Physiol 2015; 310:L311-27. [PMID: 26637634 DOI: 10.1152/ajplung.00122.2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 12/03/2015] [Indexed: 12/15/2022] Open
Abstract
Survivors of severe congenital diaphragmatic hernia (CDH) present significant respiratory morbidity despite lung growth induced by fetal tracheal occlusion (TO). We hypothesized that the underlying mechanisms would involve changes in lung extracellular matrix and dysregulated transforming growth factor (TGF)-β pathway, a key player in lung development and repair. Pulmonary expression of TGF-β signaling components, downstream effectors, and extracellular matrix targets were evaluated in CDH neonates who died between birth and the first few weeks of life after prenatal conservative management or TO, and in rabbit pups that were prenatally randomized for surgical CDH and TO vs. sham operation. Before tissue harvesting, lung tissue mechanics in rabbits was measured using the constant-phase model during the first 30 min of life. Human CDH and control fetal lungs were also collected from midterm onwards. Human and experimental CDH did not affect TGF-β/Smad2/3 expression and activity. In human and rabbit CDH lungs, TO upregulated TGF-β transcripts. Analysis of downstream pathways indicated increased Rho-associated kinases to the detriment of Smad2/3 activation. After TO, subtle accumulation of collagen and α-smooth muscle actin within alveolar walls was detected in rabbit pups and human CDH lungs with short-term mechanical ventilation. Despite TO-induced lung growth, mediocre lung tissue mechanics in the rabbit model was associated with increased transcription of extracellular matrix components. These results suggest that prenatal TO increases TGF-β/Rho kinase pathway, myofibroblast differentiation, and matrix deposition in neonatal rabbit and human CDH lungs. Whether this might influence postnatal development of sustainably ventilated lungs remains to be determined.
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Affiliation(s)
- Aline Vuckovic
- Laboratory of Physiology and Pathophysiology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium;
| | - Susanne Herber-Jonat
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Ina M Ruehl
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Carmela Votino
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Valérie Segers
- Unit of Pediatric Pathology, Pathology Department, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology and Centre de Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris (APHP), Université Paris Sud, Paris, France
| | - Jelena Martinovic
- Unit of Fetal Pathology, Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris (APHP), Université Paris Sud, Paris, France
| | - Dorota Nowakowska
- Department of Fetal-Maternal Medicine and Gynecology, Medical University and the Research Institute Polish Mother's Memorial Hospital, Lodz, Poland; and
| | - Monika Dzieniecka
- Department of Clinical Pathology, Medical University and the Research Institute Polish Mother's Memorial Hospital, Lodz, Poland
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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DeKoninck P, Toelen J, Zia S, Albersen M, Lories R, Coppi PD, Deprest J. Routine isolation and expansion late mid trimester amniotic fluid derived mesenchymal stem cells in a cohort of fetuses with congenital diaphragmatic hernia. Eur J Obstet Gynecol Reprod Biol 2014; 178:157-62. [DOI: 10.1016/j.ejogrb.2014.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/11/2014] [Accepted: 04/08/2014] [Indexed: 02/03/2023]
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Prat Ortells J, Albert A, Tarrado X, Krauel L, Cruz R, Moreno-Álvarez Ó, Fuste V, Castañón M. Airway and vascular maturation stimulated by tracheal occlusion do not correlate in the rabbit model of diaphragmatic hernia. Pediatr Res 2014; 75:487-92. [PMID: 24366514 DOI: 10.1038/pr.2013.244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 07/29/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND In animal models of congenital diaphragmatic hernia (CDH), tracheal occlusion (TO) has induced maturation of both airway spaces and vascular structures. Airway and vascular response to TO are assumed to occur in parallel. This study aims to describe and measure the relationship between airway and vascular maturation induced by TO. METHODS A rabbit model of CDH on gestational day (GD) 23 and TO on GD 28 (term = GD 31) has been used. Two study groups have been defined: DH (diaphragmatic hernia) and TO (DH treated with TO). Animals were collected on GD 30 and blood flow data of the pulmonary artery (pulsatility index (PI) and fractional moving blood volume) were ultrasonographically measured. Lung morphometry consisted of measurements of radial alveolar count (RAC) and arterial muscular thickness. RESULTS Animals in the DH group (n = 9) had the worst hemodynamic parameters; their lungs were hypoplastic and had the thickest arterial muscular layer. Animals in the TO group (n = 10) had all these effects reversed. There were no correlations among hemodynamic, airway, and vascular parameters, except for RAC and PI (r = -0.528, P = 0.043). CONCLUSION Airway and vascular maturation after TO appear to be uncorrelated effects. TO could trigger several pathways that separately regulate airway and vascular responses.
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Affiliation(s)
- Jordi Prat Ortells
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Asteria Albert
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Lucas Krauel
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Rogelio Cruz
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Óscar Moreno-Álvarez
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, Universitat de Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Victoria Fuste
- Department of Pathology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Montserrat Castañón
- Department of Pediatric Surgery, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Vuckovic A, Herber-Jonat S, Flemmer AW, Roubliova XI, Jani JC. Alveolarization genes modulated by fetal tracheal occlusion in the rabbit model for congenital diaphragmatic hernia: a randomized study. PLoS One 2013; 8:e69210. [PMID: 23840910 PMCID: PMC3698086 DOI: 10.1371/journal.pone.0069210] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 06/08/2013] [Indexed: 12/12/2022] Open
Abstract
Background The mechanisms by which tracheal occlusion (TO) improves alveolarization in congenital diaphragmatic hernia (CDH) are incompletely understood. Therefore transcriptional and histological effects of TO on alveolarization were studied in the rabbit model for CDH. The question of the best normalization strategy for gene expression analysis was also addressed. Methods Fetal rabbits were randomized for CDH or sham operation on gestational day 23/31 and for TO or sham operation on day 28/31 resulting in four study groups. Untouched littermates were added. At term and before lung harvest, fetuses were subjected to mechanical ventilation or not. Quantitative real-time PCR was performed on lungs from 4–5 fetuses of each group with and without previous ventilation. Stability of ten housekeeping genes (HKGs) and optimal number of HKGs for normalization were determined, followed by assessment of HKG expression levels. Expression levels of eleven target genes were studied in ventilated lungs, including genes regulating elastogenesis, cell-environment interactions, and thinning of alveolar walls. Elastic staining, immunohistochemistry and Western blotting completed gene analysis. Results Regarding HKG expression, TO increased β-actin and β-subunit of ATP synthase. Mechanical ventilation increased β-actin and β2-microglobulin. Flavoprotein subunit of succinate dehydrogenase and DNA topoisomerase were the most stable HKGs. CDH lungs showed disorganized elastin deposition with lower levels for tropoelastin, fibulin-5, tenascin-C, and α6-integrin. After TO, CDH lungs displayed a normal pattern of elastin distribution with increased levels for tropoelastin, fibulin-5, tenascin-C, α6-integrin, ß1-integrin, lysyl oxidase, and drebrin. TO increased transcription and immunoreactivity of tissue inhibitor of metalloproteinase-1. Conclusions Experimental TO might improve alveolarization through the mechanoregulation of crucial genes for late lung development. However part of the transcriptional changes involved genes that were not affected in CDH, raising the question of TO-induced disturbances of alveolar remodeling. Attention should also be paid to selection of HKGs for studies on mechanotransduction-mediated gene expressions.
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Affiliation(s)
- Aline Vuckovic
- Laboratory of Physiology and Physiopathology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium.
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Muensterer OJ, Nicola T, Farmer S, Harmon CM, Ambalavanan N. Temporary fetal tracheal occlusion using a gel plug in a rabbit model of congenital diaphragmatic hernia. J Pediatr Surg 2012; 47:1063-6. [PMID: 22703770 DOI: 10.1016/j.jpedsurg.2012.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 03/05/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE Temporary tracheal occlusion induces lung growth in congenital diaphragmatic hernia (CDH) but has significant drawbacks because the device must be removed in utero. We devised a gel plug (GP) that can be placed in the fetal trachea in a rabbit model of CDH to provide temporary tracheal occlusion and evaluated its effect on lung growth and postnatal ventilation mechanics. METHODS In each of 16 pregnant rabbits, experimental CDH was created in 4 fetuses. These were randomized to intratracheal instillation of a fibrin GP, tracheal suture ligation, intratracheal instillation of normal saline, or sham amniotomy. Unmanipulated fetuses of the litter without CDH served as controls. Fetuses were harvested at gestational day 29 and mechanically ventilated to determine lung compliance and airway resistance. Fetal lung-to-body weight was compared among the groups. RESULTS Mean fetal lung-to-body weight was higher in GP-treated fetuses than in the normal saline group, although not as high as that in fetuses subjected to tracheal ligation. Gel plug-treated fetuses had the highest airway resistance, whereas non-CDH control fetuses had the most compliant lungs. CONCLUSIONS Prenatal instillation of an intratracheal GP leads to increased postnatal lung mass in rabbit fetuses with CDH but also increases airway resistance.
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Affiliation(s)
- Oliver J Muensterer
- Division of Pediatric Surgery, Weill Cornell Medical College, Box 209, New York, NY 10065, USA.
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Beck V, Davey MG, Mayer S, Froyen G, Deckx S, Klaritsch P, Roubliova XI, Petersen SG, Deprest JA. A longer tracheal occlusion period results in increased lung growth in the nitrofen rat model. Prenat Diagn 2011; 32:39-44. [DOI: 10.1002/pd.2881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 08/21/2011] [Accepted: 08/22/2011] [Indexed: 11/10/2022]
Affiliation(s)
| | - Marcus G. Davey
- Center for Fetal Therapy; The Children's Hospital of Philadelphia; Philadelphia; PA; 19104; USA
| | - Steffi Mayer
- Center for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; Minderbroederstraat 17; 3000; Leuven; Belgium
| | | | - Sebastiaan Deckx
- Center for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; Minderbroederstraat 17; 3000; Leuven; Belgium
| | - Philipp Klaritsch
- Center for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; Minderbroederstraat 17; 3000; Leuven; Belgium
| | - Xenia I. Roubliova
- Center for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; Minderbroederstraat 17; 3000; Leuven; Belgium
| | - Scott G. Petersen
- Center for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; Minderbroederstraat 17; 3000; Leuven; Belgium
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Grushka JR, Al-Abbad S, Baird R, Puligandla P, Kaplan F, Laberge JM. The effect of in vitro tracheal occlusion on branching morphogenesis in fetal lung explants from the rat nitrofen model of congenital diaphragmatic hernia. J Pediatr Surg 2010; 45:943-7. [PMID: 20438932 DOI: 10.1016/j.jpedsurg.2010.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/02/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Fetal tracheal occlusion (TO) has been investigated as a treatment option for lung hypoplasia secondary to congenital diaphragmatic hernia. Tracheal occlusion has been shown to accelerate lung growth, but its effect on bronchial branching is unknown. In this study, we characterize the effects of in vitro TO on bronchial branch development in fetal lung explants derived from the nitrofen rat model of congenital diaphragmatic hernia. METHODS Rat dams were gavaged nitrofen on gestational day 9.5, and fetal lungs were harvested for explant culture on gestational day 14 (term, 22 days). Four experimental groups were investigated, with TO performed ex vivo using cautery: control, control + TO, nitrofen, and nitrofen + TO. Explants were incubated for 72 hours. Representative photographs were taken at 0, 24, 48, and 72 hours from the time of culture, and the number of distal branches was counted for each explant. The Student t test was used to compare distal branch measurements. RESULTS A minimum of 12 fetal lung explants were cultured for each group. By 24 hours, all explants undergoing TO had more branch iterations than explants that did not. Moreover, TO in nitrofen-exposed explants increased bronchial branching to control levels by 24 hours in culture. CONCLUSION Our results suggest that TO at day 14 increases branching in normal and nitrofen-exposed lung explants. In addition, TO increases airway branching in nitrofen-exposed explants to control levels suggesting that early TO reverses the lung hypoplasia seen in this model.
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Affiliation(s)
- Jeremy R Grushka
- Division of Pediatric Surgery, The Montreal Children's Hospital, Montreal, Quebec, Canada
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21
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Antenatal fetal VEGF therapy to promote pulmonary maturation in a preterm rabbit model. Early Hum Dev 2010; 86:99-105. [PMID: 20181445 DOI: 10.1016/j.earlhumdev.2010.01.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 01/18/2010] [Accepted: 01/31/2010] [Indexed: 10/19/2022]
Abstract
AIM To assess the effects of fetal tracheal administration of VEGF on pulmonary maturation in a preterm rabbit model. METHODS On day 26 (term=31days), fetal rabbits received recombinant rat VEGF (30microg in 70microL normal saline) or placebo (normal saline 70microL) intratracheally, with or without subsequent tracheal occlusion. Non-operated littermates served as internal controls. Fetuses were harvested on day 28 for morphometric study of the lungs or for mechanical ventilation and measurement of lung mechanics. In total, 96 fetuses from 42 does were used, 47 for ventilation and 49 for morphometry. RESULTS In fetuses receiving intratracheal VEGF, an increase in immunoreactivity for Flk-1 was observed throughout the lung parenchyma. Tracheal occlusion (TO) adversely affected pulmonary mechanics as compared to un-occluded controls. That effect is partly reversed by intratracheal VEGF. Intratracheal injection of VEGF without tracheal occlusion improves lung mechanics but no more than what was observed in placebo injected controls. CONCLUSION Antenatal intratracheal VEGF administration was associated with an increase in Flk-1 immunoreactivity. It also improves lung mechanics, however more so when the trachea is occluded. Without TO, the effects were comparable to placebo controls.
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Roubliova XI, Lewi PJ, Verbeken EK, Vaast P, Jani JC, Lu H, Tibboel D, Deprest JA. The effect of maternal betamethasone and fetal tracheal occlusion on pulmonary vascular morphometry in fetal rabbits with surgically induced diaphragmatic hernia: a placebo controlled morphologic study. Prenat Diagn 2009; 29:674-81. [DOI: 10.1002/pd.2243] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Mesas-Burgos C, Nord M, Didon L, Eklöf AC, Frenckner B. Gene expression analysis after prenatal tracheal ligation in fetal rat as a model of stimulated lung growth. J Pediatr Surg 2009; 44:720-8. [PMID: 19361631 DOI: 10.1016/j.jpedsurg.2008.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 06/23/2008] [Indexed: 12/28/2022]
Abstract
PURPOSE Prenatal tracheal occlusion or ligation (TL) has been proven to accelerate lung growth, but the mechanism of this is poorly understood. To increase understanding of the biological mechanisms involved in growth stimulation after TL in the fetal lung, we performed Global gene expression analysis using microarray technology. MATERIAL AND METHODS Sprague-Dawley rats underwent surgery on gestational day 19. After a small hysterotomy, the trachea was mobilized and tied. As controls, we used littermates to manipulated fetuses. On day 21, fetuses were removed and lungs harvested. Global gene expression analysis was performed using Affymetrix Platform and the RAE 230 set arrays (Affymetrix Inc, Santa Clara, Calif). For validation of microarray data, we performed real time polymerase chain reaction (PCR) of the most significant upregulated or downregulated genes, combined with immunohistochemical (IHC) analysis of lung sections. RESULTS In the group that underwent TL, several growth factors had an increased expression including connective tissue growth factor (CTGF), insulin-like growth factor 1 (IGF-1), and fibroblast growth factor 18 (FGF-18). Some of the genes that were downregulated in the group that underwent TL compared with controls were surfactant protein A (SP-A), apolipoprotein E (Apo-E), and phospholipase group II A2 (plg2a2). These results could be confirmed with real time PCR and IHC studies. DISCUSSION Tracheal occlusion or ligation is a well-documented stimulator of fetal lung growth, and the present study provides novel insights into the underlying molecular mechanisms, with increased expression of genes and proteins with growth factor activity. One of these growth factors, CTGF, has never been previously described in this model. Also, decreased levels of genes involved in surfactant metabolism were observed, providing molecular insights into the decreased surfactant production that is known to occur in TL. Increased understanding of the molecular mechanisms that control lung growth may be the key to develop novel therapeutic techniques to stimulate prenatal and/or postnatal lung growth.
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Affiliation(s)
- Carmen Mesas-Burgos
- Astrid Lindgren s Children Hospital, Division for Pediatric Surgery, Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden
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Jani JC, Flemmer AW, Bergmann F, Gallot D, Roubliova X, Muensterer OJ, Hajek K, Deprest JA. The effect of fetal tracheal occlusion on lung tissue mechanics and tissue composition. Pediatr Pulmonol 2009; 44:112-21. [PMID: 19137593 DOI: 10.1002/ppul.20915] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fetal tracheal occlusion (TO) is currently used to treat severe cases of congenital diaphragmatic hernia (DH). Clinical and experimental studies suggest an improved postnatal outcome, but lung tissue mechanics after TO have not been studied. We determined the effect of TO on mechanical impedance and lung tissue components in a rabbit model for DH. At 23 days of gestation (term = 31 days) either a sham thoracotomy or a diaphragmatic defect was induced. DH fetuses were randomly assigned to undergo 5 days later TO. Fetuses were delivered by term cesarean section to determine lung to body weight ratio (LBWR), dynamic lung mechanics and lung impedance. Airway resistance (R(aw)), elastance (H(L)), tissue damping (G(L)) and hysteresivity (G(L)/H(L)) were calculated from impedance data. Collagen I and III and elastin were quantified histologically. LBWR was significantly increased by TO compared to DH (P < 0.001) and resistance and compliance of the respiratory system (R(rs), C(rs)) were improved as well. TO resulted in a significant decrease of R(aw) comparable to observations in sham-fetuses, without effect on lung tissue mechanics H(L), G(L) and hysteresivity. This coincides with a significant decrease of collagen I, III and elastin in comparison to DH fetuses. In this first report on lung tissue mechanics in a rabbit model of DH, TO had a substantial effect on tissue morphology yet this was not mirrored in lung mechanics. We conclude that the effect of TO on lung mechanics without in utero reversal of occlusion, is dominated by airway remodeling.
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Affiliation(s)
- Jacques C Jani
- Faculty of Medicine, Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium
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Deprest JA, Flemmer AW, Gratacos E, Nicolaides K. Antenatal prediction of lung volume and in-utero treatment by fetal endoscopic tracheal occlusion in severe isolated congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2009; 14:8-13. [PMID: 18845492 DOI: 10.1016/j.siny.2008.08.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe malformation with an overall survival between 30% and 90%. Survival in the presence of associated malformations is very low. The condition should be detected in ultrasound screening programmes, but whether and how prenatal imaging can accurately predict outcome remains a matter of debate. Predictions based on the lung area:head circumference ratio and liver position are best studied. This information is highly relevant in counselling patients, leaving to severe cases the option of termination of pregnancy as experimental prenatal intervention aiming to reverse pulmonary hypoplasia. The purpose of this review is to update current knowledge regarding predictive value of prenatal assessment in terms of neonatal survival. We will also discuss experimental evidence and clinical data regarding fetal tracheal occlusion.
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Affiliation(s)
- Jan A Deprest
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Minderbroedersstraat 17, B-3000 Leuven, Belgium
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Prédiction anténatale de l’hypoplasie pulmonaire et traitement in-utero par occlusion trachéale fœtale endoscopique (FETO) dans la hernie diaphragmatique congénitale isolée sévère. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2008. [DOI: 10.1016/s0001-4079(19)32665-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Flemmer AW, Jani JC, Bergmann F, Muensterer OJ, Gallot D, Hajek K, Sugawara J, Till H, Deprest JA. Lung tissue mechanics predict lung hypoplasia in a rabbit model for congenital diaphragmatic hernia. Pediatr Pulmonol 2007; 42:505-12. [PMID: 17469148 DOI: 10.1002/ppul.20618] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Several animal models have been proposed to study the pathophysiology of congenital diaphragmatic hernia (CDH). Surgical induction of CDH in fetal rabbits during the pseudoglandular phase has been shown to induce severe pulmonary hypoplasia, but functional studies in this model are scarce. We aimed to measure neonatal pulmonary impedance and related it to the severity of lung hypoplasia. CDH was surgically created in rabbits at 23 days of gestation. Following cesarean delivery at term (31 days) pups were subjected to measurement of total lung capacity (TLC), lung to body weight ratio (LBWR) and lung impedance by forced oscillation technique (FOT). Airway resistance (R(aw)), tissue elastance (H(L)), tissue damping (G(L)), and hysteresivity (eta) (G(L)/H(L)) were calculated from impedance data. Twelve CDH fetuses and 15 controls were available for final analysis. LBWR and TLC were significantly lower in the CDH group compared to gestational and age matched controls (P<0.001). R(aw), H(L), and G(L) were significantly increased in CCDH fetuses. eta and H(L) best reflected lung hypoplasia (LBWR) (r(2) = 0.42 and 0.43; P=0.001), indicating a dominant contribution of lung tissue mechanics to CDH-induced lung hypoplasia. We successfully introduced lung impedance measurement by FOT in neonatal rabbits. Following surgical induction of CDH in the pseudoglandular phase, they have, next to morphological evidence of pulmonary hypoplasia, changes in lung mechanics. Our results for lung tissue mechanics support the concept of delayed pulmonary tissue modeling. We propose to employ functional studies in future experiments when evaluating prenatal interventions aimed at reversing pulmonary hypoplasia.
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Affiliation(s)
- Andreas W Flemmer
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Grosshadern, Germany
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Abstract
Advances in prenatal ultrasound have revealed the poor natural history of fetal congenital diaphragmatic hernia (CDH) and its hidden mortality during gestation and immediately after birth. Attempts to improve this poor outcome led to the development of prenatal surgical intervention for severe CDH by Harrison and his colleagues at the University of California San Francisco. Prenatal surgical intervention for CDH has seen four phases: open fetal surgical repair, open surgical tracheal occlusion, endoscopic external tracheal occlusion, and endoscopic endoluminal tracheal occlusion. After extensive work in the laboratory, prenatal intervention has been applied in humans since 1984. With the most recent techniques, maternal risk is significantly reduced as is the incidence of preterm labor. In the meantime, the survival rate of fetuses with CDH without fetal intervention has improved mainly due to the minimization of iatrogenic lung injury by gentle ventilation, first described in 1985. However, the morbidity of the survivors with severe CDH remains high. Prenatal intervention for CDH will be justified if improvement in survival or morbidity can be demonstrated when compared to planned delivery and postnatal management with gentle ventilation strategy.
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Affiliation(s)
- Yoshihiro Kitano
- Division of General Surgery, Saitama Children's Medical Center, Saitama, Japan.
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Khan PA, Cloutier M, Piedboeuf B. Tracheal occlusion: A review of obstructing fetal lungs to make them grow and mature. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2007; 145C:125-38. [PMID: 17436297 DOI: 10.1002/ajmg.c.30127] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Fetal lung growth and functional differentiation are affected strongly by the extent that pulmonary tissue is distended (expanded) by liquid that naturally fills developing future airspaces. Methods that prevent normal egress of this lung fluid through the trachea magnify mechanical stretching of lung parenchymal cells, thereby promoting lung development. Indeed, experimental observations demonstrate that in utero tracheal occlusion (TO) performed on fetuses during the late canalicular-early saccular stage potently stimulates pulmonary growth and maturation. In this review, we present the four principle non-human animal models of TO/obstruction and discuss them in relation to their utility in elucidating lung development, in remedying congenital diaphragmatic hernia (CDH) as well as in investigating the stretching effects on growth and remodeling of the fine vasculature.
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Affiliation(s)
- Paul A Khan
- CRCHUL Medical Research Centre, Laval University, Québec, Canada
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Jani JC, Nicolaides KH, Gratacós E, Vandecruys H, Deprest JA. Fetal lung-to-head ratio in the prediction of survival in severe left-sided diaphragmatic hernia treated by fetal endoscopic tracheal occlusion (FETO). Am J Obstet Gynecol 2006; 195:1646-50. [PMID: 16769018 DOI: 10.1016/j.ajog.2006.04.004] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 03/10/2006] [Accepted: 04/04/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to investigate the value of fetal lung area to head circumference ratio in the prediction of the postnatal outcome in left-sided congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion. STUDY DESIGN The lung area to head circumference ratio was measured before fetoscopic endoluminal tracheal occlusion in 28 fetuses with congenital diaphragmatic hernia at 25 to 29 weeks. Regression analysis was used to investigate the effect on survival of lung area to head circumference ratio, gestation at fetoscopic endoluminal tracheal occlusion, gestation at delivery, preterm amniorrhexis following fetoscopic endoluminal tracheal occlusion, and prenatal removal of the balloon. RESULTS The median lung area to head circumference ratio prior to fetoscopic endoluminal tracheal occlusion was 0.7 (range 0.5 to 0.9). The median gestation at delivery was 34 (range 27 to 39) weeks, and there were 16 survivors (57%). Only lung area to head circumference ratio provided significant prediction of survival, which increased from 17% for lung area to head circumference ratio of 0.4 to 0.5 to 62% for lung area to head circumference ratio of 0.6 to 0.7 and 78% for lung area to head circumference ratio of 0.8 to 0.9. CONCLUSION In congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion, postnatal survival can be predicted by the lung area to head circumference ratio measured prior to the procedure.
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Affiliation(s)
- Jacques C Jani
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium
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Deprest J, Jani J, Cannie M, Debeer A, Vandevelde M, Done E, Gratacos E, Nicolaïdes K. Prenatal intervention for isolated congenital diaphragmatic hernia. Curr Opin Obstet Gynecol 2006; 18:355-67. [PMID: 16735838 DOI: 10.1097/01.gco.0000193000.12416.80] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We aim to review the recent literature regarding early prenatal prediction of outcome in babies diagnosed with isolated congenital diaphragmatic hernia, as well as results of fetal therapy for this condition. RECENT FINDINGS Current survival rates in population-based studies are around 55-70%. Highly specialized centers report 80% and more, but discount the hidden mortality, mainly in the antenatal period. Fetuses presenting with liver herniation and a lung-to-head ratio of less than 1.0 measured in midgestation have a poor prognosis. Other volumetric techniques are being evaluated for use in midtrimester. Recently, a randomized trial failed to show benefit from prenatal therapy, but lacked power to document the potential advantage of prenatal therapy in severe cases. We proposed percutaneous fetal endoluminal tracheal occlusion with a balloon at 26-28 weeks through a 3.3 mm incision. In severe cases, fetal endoluminal tracheal occlusion increased lung size as well as survival, with an early (7 day) survival, late neonatal (28 day) survival and survival at discharge of 75, 58 and 50%, respectively, comparing favorably with 9% in contemporary controls. Airways can be restored prior to birth improving neonatal survival (83.3% compared with 33.3%). The procedure carries a risk for preterm prelabour rupture of the fetal membranes, although that may decrease with experience. SUMMARY Fetuses with severe congenital diaphragmatic hernia can be identified in the second trimester. Fetal endoluminal tracheal occlusion can be considered as a minimally invasive fetal therapy, improving outcome in such highly selected cases.
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Affiliation(s)
- Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium.
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Danzer E, Robinson LE, Davey MG, Schwarz U, Volpe M, Adzick NS, Flake AW, Hedrick HL. Tracheal occlusion in fetal rats alters expression of mesenchymal nuclear transcription factors without affecting surfactant protein expression. J Pediatr Surg 2006; 41:774-80. [PMID: 16567192 DOI: 10.1016/j.jpedsurg.2006.02.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Mesenchymal nuclear transcription factors (MNTF) are involved in lung development and maturation and regulate surfactant protein (SP) expression. Prolonged (>2 weeks) fetal tracheal occlusion (TO) has been shown to accelerate lung growth and inhibit pulmonary surfactant synthesis. The effects of TO on SP expression and MNTF, however, have not been formally assessed. The objectives of this study were to evaluate the effects of short-term (3 days) TO on normal lung growth and protein expression of pulmonary MNTF involved in SP synthesis. METHODS At E19 (term, 22 days), 2 fetuses per time-dated Sprague-Dawley rats underwent either TO (n = 23) or a sham (n = 22) operation. Lungs were harvested 72 hours post surgery. Pulmonary SP-A; SP-B; SP-C messenger RNA (mRNA) expression; and SP-A and SP-B, Hoxb5, thyroid transcription factor 1, and retinoic X receptor-alpha protein expression were analyzed. RESULTS Lung weight was significantly increased by TO (TO 0.32 +/- 0.02g vs SHAM 0.14 +/- 0.01 g; P < .001), resulting in 123% increase of the lung-to-body-weight ratio. No difference of SP-A-mRNA (177 +/- 4.3 TO vs 169 +/- 4.4 SHAM; P = .25), SP-B-mRNA (87.7 +/- 0.2 TO vs 87.4 +/- 0.02 SHAM; P = .33), and SP-C-mRNA (186.5 +/- 3.2 TO vs 183.2 +/- 2.7 SHAM; P = .45) expression was found. Surfactant protein A (175.6 +/- 25.3 TO vs 192.5 +/- 19.8 SHAM; P = .59) and SP-B (163.4 +/- 5.2 TO vs 166.8 +/- 9.3 SHAM; P = .75) protein expression were similar in both groups; however, Hoxb5 (70.3 +/- 18.9 TO vs 130.6 +/- 5.1 SHAM; P = .02) and thyroid transcription factor 1 (102.6 +/- 19 TO vs 181.1 +/- 6.3 SHAM; P = .007) expression were significantly decreased. Retinoic X receptor-alpha expression tended to be increased by TO (171.9 +/- 6.0 TO vs 155.4 +/- 6.7 SHAM; P = .06). CONCLUSIONS Short-term TO late in gestation induces rapid lung growth. Surfactant protein-mRNA and protein expression are not significantly altered. Thyroid transcription factor 1 and Hoxb5 are down-regulated by TO, suggesting that duration and timing of occlusion are important in balancing the effects of TO on lung growth vs lung maturation.
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Affiliation(s)
- Enrico Danzer
- The Children's Institute for Surgical Science, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4318, USA
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Jani J, Gratacós E, Greenough A, Pieró JL, Benachi A, Harrison M, Nicolaïdes K, Deprest J. Percutaneous fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia. Clin Obstet Gynecol 2006; 48:910-22. [PMID: 16286838 DOI: 10.1097/01.grf.0000184774.02793.0c] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Jani
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium
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Affiliation(s)
- A Mortell
- Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland
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Deprest J, Jani J, Van Schoubroeck D, Cannie M, Gallot D, Dymarkowski S, Fryns JP, Naulaers G, Gratacos E, Nicolaides K. Current consequences of prenatal diagnosis of congenital diaphragmatic hernia. J Pediatr Surg 2006; 41:423-30. [PMID: 16481263 DOI: 10.1016/j.jpedsurg.2005.11.036] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Today, the diagnosis of congenital diaphragmatic hernia (CDH) can readily be made in the prenatal period during screening ultrasound examination. Patients ought to be referred to rule out associated anomalies, and in isolated cases, prognosis is poor when the liver is intrathoracic and the lung-to-head ratio (LHR) is less than 1. In these patients, prenatal intervention aiming to reverse pulmonary hypoplasia can be considered. METHODS We present our current algorithm for counselling patients presenting with CDH. Patients with a poor prognosis are offered percutaneous fetal endoluminal tracheal occlusion (FETO) with a balloon, inserted at 26 to 28 weeks. We report on the evolution of technique and results in a consecutive homogeneous case series and compare outcome in cases with similar severity managed in the postnatal period. RESULTS Within a period of 28 months, FETO was performed between 26 and 28 weeks in 24 fetuses with severe left-sided CDH. Under general (n = 5), epidural (n = 17) or local (n = 2) anesthesia, the balloon was successfully positioned at first surgery (23/24) with a mean operation time of 20 minutes (range, 3-60 minutes). There were no serious maternal complications or direct fetal adverse effects. In the first 2 weeks after FETO, LHR increased from 0.7 to 1.7. Premature prelabour rupture of the membrane (PPROM) occurred in 16.7% and 33.3% at 28 and 32 weeks or earlier, respectively. Gestational age at delivery was 33.5 weeks. Patency of airways was restored either in the prenatal (n = 12) or perinatal period (n = 12). Early (7 days) and late (28 days) survival, and survival at discharge were 75% (18/24), 58.3% (14/24) and 50% (12/24), respectively. Half of nonsurvivors (n = 6) died of pulmonary hypoplasia and hypertension, in combination with PPROM and preterm delivery (n = 4) and balloon dislodgement (n = 2), which coincided with a short tracheal occlusion (TO) period (12 days). In the other 6, TO period was comparable to that in the 12 survivors (47 vs 42 days, respectively). In that group of 6 babies, only 2 died of pulmonary problems. Late neonatal survival (28 days) was higher with prenatal vs perinatal balloon retrieval 83.3% vs 33.3% (P = .013). In a multicentre study validating the criteria, survival till discharge in 37 comparable cases was 9% (3/32) and 13% (5/37) of parents opted for termination. CONCLUSION Fetuses with isolated left-sided CDH, liver herniation, and LHR of less than 1 have a poor prognosis. Percutaneous FETO is minimally invasive and may improve the outcome in these highly selected cases. Airways can be restored before birth, allowing vaginal delivery and return to the referring tertiary unit and may improve survival rate. The procedure carries a risk for PPROM, although that may decrease with experience.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven B-3000, Belgium.
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Bütter A, Bratu I, Flageole H, Laberge JM, Kovacs L, Faucher D, Piedoboeuf B. Fetal tracheal occlusion in lambs with congenital diaphragmatic hernia: role of exogenous surfactant at birth. Pediatr Res 2005; 58:689-94. [PMID: 16189194 DOI: 10.1203/01.pdr.0000180534.42731.95] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fetal tracheal occlusion (TO) has been used to reverse the lung hypoplasia associated with congenital diaphragmatic hernia (CDH). However, TO has a detrimental effect on type II pneumocyte function and surfactant production. Previously, we have shown that in surgically created CDH lambs, TO improved markedly the response to resuscitation even though the lungs remain surfactant deficient. The goal of this investigation was to assess the effects of exogenous surfactant administered at birth to CDH lambs with or without fetal TO during 8 h of resuscitation. Lambs were divided into five groups: CDH, CDH+surfactant (SURF), CDH+TO, CDH+TO+SURF, and nonoperated controls. A left-sided CDH was created in fetal lambs at 80 d gestation. TO was performed at 108 d, and the lambs were delivered by hysterotomy at 136 d. Bovine lipid extract surfactant was administered before the first breath and again at 4 h of life. All CDH+SURF lambs, but only three of five CDH lambs, survived up to 8 h. When compared with the corresponding nonsurfactant-treated group, surfactant-treated CDH and CDH+TO lambs did not demonstrate improved alveolar-arterial oxygen gradients, pH, or Pco(2). In fact, in the CDH+TO group, surfactant treatment significantly worsened ventilation efficiency as measured by the ventilation efficiency index. The observed improvement in pulmonary compliance secondary to surfactant treatment was not significant. This investigation demonstrates that prophylactic surfactant treatment at birth does not improve gas exchange or ventilation efficiency in CDH lambs with or without TO.
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Affiliation(s)
- Andreana Bütter
- Division of Pediatric Surgery, Montréal Children's Hospital, McGill University Health Centre, Canada
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Chapin CJ, Ertsey R, Yoshizawa J, Hara A, Sbragia L, Greer JJ, Kitterman JA. Congenital diaphragmatic hernia, tracheal occlusion, thyroid transcription factor-1, and fetal pulmonary epithelial maturation. Am J Physiol Lung Cell Mol Physiol 2005; 289:L44-52. [PMID: 15764645 DOI: 10.1152/ajplung.00342.2004] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) occurs in ∼1:2,500 human births and has high morbidity and mortality rates, primarily due to pulmonary hypoplasia and pulmonary hypertension. Tracheal occlusion (TO), in experimental animals, distends lungs and increases lung growth and alveolar type I cell maturation but decreases surfactant components and reduces alveolar type II cell density. We examined effects of CDH and CDH+TO on lung growth and maturation in fetal rats. To induce CDH, we administered nitrofen (100 mg) to dams at 9.5 days of gestation. We compared lungs from fetuses with CDH, CDH+TO, and those exposed to nitrofen without CDH. CDH decreased lung wet weight bilaterally ( P < 0.0001) and DNA content in lung ipsilateral to CDH ( P < 0.05). CDH+TO significantly increased lung wet weights bilaterally; DNA content was intermediate between CDH and NC. To evaluate effects on the distal pulmonary epithelium, we examined surfactant mRNA and protein levels, type I and II cell-specific markers (RTI40 and RTII70, respectively), and transcriptional regulator thyroid transcription factor-1 (TTF-1). Decreased lung distension (due to CDH) increased SP-C mRNA and TTF-1 protein expression and reduced RTI40 ( P < 0.05 for all). Increased lung distension (due to CDH+TO) reduced expression of SP mRNAs and pro-SP-C and TTF-1 proteins and enhanced expression of RTI40 (mRNA and protein; P < 0.05 for all). We conclude that CDH+TO partially reverses effects of CDH; it corrects the pulmonary hypoplasia and restores type I cell differentiation but adversely affects SP expression in type II cells. These effects may be mediated through changes in TTF-1 expression.
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Affiliation(s)
- Cheryl J Chapin
- Cardiovascular Research Institute, University of California, San Francisco, 94143, USA.
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Muensterer OJ, Klis VJ, Till H, Bergmann F, Metzger R, Simbruner G. Intrapulmonary perfluorooctyl bromide instillation in fetal rabbits. J Pediatr Surg 2005; 40:1094-9. [PMID: 16034751 DOI: 10.1016/j.jpedsurg.2005.03.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Instilling perfluorooctyl bromide (PFOB) into the fetal lung may lead to alveolar distension. OBJECTIVE The aim of the study was to evaluate the safety of PFOB instillation into fetal lungs and to determine the radiographic distribution and tissue concentration of PFOB in New Zealand white rabbits. METHODS Sibling fetuses of pregnant (day 27) New Zealand white rabbits were randomized to intratracheal instillation of 1 mL PFOB with tracheal ligation, instillation without ligation, and unmanipulated controls. The maternal animals were killed directly after instillation, at 3 or 6 hours (n = 10 each). For each study cohort, we determined fetal lung/body weight (FLBW) ratios, the radiographic distribution of PFOB, as well as pulmonary PFOB and water content by tissue distillation. PFOB concentrations in maternal and fetal tissues were assessed by gas chromatography. RESULTS The relative amount of fetal lung PFOB recovered by fractional distillation was highest in ligated (25%) and lower in unligated lungs (9%). Extrapulmonary PFOB was found in the fetal brain (2.0 +/- 0.7 ppm), but not in any other fetal or maternal tissues. Mean FLBW ratios were highest in ligated fetuses, followed by unligated fetuses and controls. PFOB partially displaced fetal lung water. PFOB was visible in the lungs of all treated fetuses. Fetal survival between manipulated and unmanipulated fetuses did not differ. CONCLUSIONS After prenatal intrapulmonary instillation, some PFOB remains in the lung, even if the trachea is not ligated, and may exert distending pressure on the alveoli.
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Affiliation(s)
- Oliver J Muensterer
- Department of Pediatric Surgery, Dr von Hauner Children's Hospital, University of Munich, 80337 Munich, Germany.
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Abstract
Our understanding of lung development in the past two decades has moved from an anatomical to a histological basis and, most recently, to a molecular basis. Tissue interactions specify tracheal and lung primordia formation, program branching morphogenesis of the airway epithelium and regulate epithelial differentiation. In addition, lung development is influenced by mechanical and humoral factors. The regulatory molecules involved in morphogenetic signaling include growth and transcription factors and extracellular matrix molecules. These morphogenetic signals are responsible for lung patterning and differentiation. We will provide a brief overview of molecular signaling during early respiratory formation, airway branching, pulmonary vascularization and epithelial differentiation. We will then review aberrant morphogenetic signaling in human lung abnormalities, such as tracheoesophageal fistula, congenital diaphragmatic hernia, pulmonary hyperplasia, alveolar capillary dysplasia, congenital cystic adenomatoid malformation and bronchopulmonary dysplasia.
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Affiliation(s)
- Frederick Groenman
- Program in Lung Biology Research, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Toronto, Canada
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40
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Deprest J, Jani J, Gratacos E, Vandecruys H, Naulaers G, Delgado J, Greenough A, Nicolaides K. Fetal intervention for congenital diaphragmatic hernia: the European experience. Semin Perinatol 2005; 29:94-103. [PMID: 16050527 DOI: 10.1053/j.semperi.2005.04.006] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fetuses with CDH presenting with liver herniation and a lung area-to-head circumference ratio of less than 1.0 have a high chance for neonatal death due to pulmonary hypoplasia. Fetal tracheal occlusion (TO) prevents egress of lung liquid, which triggers lung growth. In animal experiments, we were able to develop a minimally invasive technique for Fetoscopic Endoluminal Tracheal Occlusion (FETO) with a detachable balloon. In 2001, we demonstrated feasibility of FETO by percutaneous access in fetuses with severe CDH. In a retrospective multicenter review, we obtained LHR measurements and position of the liver in 134 cases of isolated left-sided CDH between 24 and 28 weeks. Eleven patients (8%) with LHR < 1.4 opted for termination. Overall survival of liveborn babies was 47% (58/123). LHR and position of the liver correlated both to survival. Combination of both variables predicted neonatal outcome better: liver up and LHR < 1.0 predicted a survival of 9%. When LHR < 0.6, there were no survivors irrespective of liver position. We could successfully perform endotracheal placement of the balloon in 20 cases at a median gestational age of 26 weeks. The mean duration of the operation was 22 (range 5-54) minutes. In 11 (55%) of these patients, there was postoperative prelabor (ie, <37 weeks) amniorrhexis. Membranes ruptured before 32 weeks in 35%, with a decreasing trend as experience increased. Ultrasound scans after FETO demonstrated an increase in the echogenicity of the lungs within 48 hours and improvement in the LHR from a median 0.7 (range 0.4-0.9) before FETO to 1.8 (range 1.1-2.9) within 2 weeks after surgery. The median gestation at delivery was 33.2 (range 27-38) weeks, and in 14 (70%) this occurred after 32 weeks. Surgical repair of the diaphragmatic hernia could be done in 13 babies, and in all but 1 the defect was extensive and required the insertion of a patch. Survival to discharge was 50%. These 10 long-term surviving babies are now aged 7 to 26 (median 19) months without known neurologic morbidity. Eight babies died in the neonatal period due to complications of the underlying disease. Two nonsurvivors died from other causes but with appropriately developed lungs. Improved survival coincided with increasing experience, in turn related to reduced incidence of postoperative amniorrhexis, later delivery, and a change in the policy on the timing of removal of the balloon from intrapartum to the prenatal period. Survival in eligible contemporary controls was 1/12 (8%). The presence of liver herniation and a low lung-to-head ratio (LHR <1.0) is a good predictor of poor prognosis at different tertiary centers around the world. Severe CDH may be successfully treated with FETO, which is minimally invasive and may improve postnatal survival.
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Affiliation(s)
- Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics, University Hospital Gasthuisberg, Leuven, Belgium.
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41
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Abstract
Congenital Diaphragmatic Hernia (CDH) is a congenital disorder with an incidence of 1 in 2500 live births. Respiratory distress of newborns with CDH is the result of pulmonary hypoplasia and pulmonary hypertension. Hypoplastic lungs are characterized by a decreased number of airways with smaller airspaces, whereas the combination of a decreased number of vascular branches and an increased adventitia and medial thickness of the pulmonary arterial walls result in pulmonary hypertension. The appearance of the CDH lungs suggests that its complete formation is stalled during development. Understanding the basic mechanisms of lung development is mandatory to unravel the origin of CDH. Although the histological abnormalities in CDH lungs have been well described, less is known about the underlying molecular mechanisms. In this review we will discuss the current molecular and genetic background of lung formation, as well as a reflection of this knowledge towards CDH.
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Affiliation(s)
- Robbert Rottier
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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42
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Muensterer OJ, Flemmer AW, Bergmann F, Hajek KS, Lu HQ, Simbruner G, Deprest JA, Till H. Postnatal lung mechanics, lung composition, and surfactant synthesis after tracheal occlusion vs prenatal intrapulmonary instillation of perfluorocarbon in fetal rabbits. J Pediatr Surg 2005; 40:26-31. [PMID: 15868554 DOI: 10.1016/j.jpedsurg.2004.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Fetal tracheal occlusion (TO) accelerates lung growth but decreases surfactant production. We have previously shown that instillation of perfluorooctylbromide (PFOB) into fetal rabbit lungs leads to lung growth similar to TO. This study compares neonatal lung mechanics and surfactant production after prenatal intrapulmonary PFOB instillation vs TO. METHODS In each of 18 pregnant rabbits on gestational day 27, sets of 4 fetuses underwent either (1) intrapulmonary instillation of 1 mL PFOB, (2) TO, (3) instillation of 1 mL 0.9% NaCl (saline), and (4) hysteroamniotomy without fetal manipulation (control). Fetuses were born by cesarean delivery after 48 hours. Fetuses of 12 rabbits were mechanically ventilated for 15 minutes to evaluate lung compliance and airway resistance. Pulmonary surfactant protein B (SP-B) was quantified by immunohistochemistry in fetuses of the remaining 6 rabbits. RESULTS Compliance was decreased in the TO group after cesarean delivery (0.33 +/- 0.13 mL/cm H2O) compared with PFOB (0.59 +/- 0.12 mL/cm H2O), saline (0.50 +/- 0.12 mL/cm H2O), and control (0.52 +/- 0.10 mL/cm H2O) fetuses. Mean fetal lung to body weight ratio was higher in TO and PFOB fetuses compared with saline and control. Higher water content and lower numbers of surfactant protein B-positive cells were found in the TO-treated fetuses. CONCLUSIONS Both prenatal intrapulmonary instillation of PFOB and TO accelerate lung growth, but TO is associated with decreased postnatal lung compliance, possibly influenced by decreased surfactant production and increased fluid retention. Conversely, instillation of PFOB preserved lung compliance and surfactant synthesis.
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Affiliation(s)
- Oliver J Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University of Munich, 80337 Munich, Germany.
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Keller RL, Hawgood S, Neuhaus JM, Farmer DL, Lee H, Albanese CT, Harrison MR, Kitterman JA. Infant pulmonary function in a randomized trial of fetal tracheal occlusion for severe congenital diaphragmatic hernia. Pediatr Res 2004; 56:818-25. [PMID: 15319458 DOI: 10.1203/01.pdr.0000141518.19721.d7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Congenital diaphragmatic hernia (CDH) carries a high mortality risk secondary to pulmonary hypoplasia and respiratory failure. In experimental animals, fetal tracheal occlusion (TO) induces lung growth and morphologic maturation. We measured indicators of pulmonary function in 20 infants who were enrolled in a randomized trial of fetal TO as treatment for severe CDH [nine with conventional treatment (controls); 11 with TO]. We hypothesized that TO would improve lung function. At birth, the TO group had a lower mean gestational age (30.8 +/- 2.0 versus 37.4 +/- 1.0 wk; p=0.0002). All infants required assisted ventilation. Mortality did not differ between groups (64 versus 78%, TO and control, respectively; p=0.64). We measured respiratory mechanics at four study points: 1) first 24 h, 2) before CDH operative repair (5.9 +/- 2.2 d), 3) immediately after repair (7.0 +/- 2.2 d), and 4) before elective extubation (32.5 +/- 16.1 d). We calculated perioperative oxygenation index and alveolar-arterial oxygen difference to assess efficiency of pulmonary gas exchange. Data were analyzed by univariate and repeated measures techniques. Respiratory system compliance (Crs) was low. The rate of increase in Crs over the four study points was greater in the TO group than in control subjects. Crs in the TO group was significantly greater at study 2 (0.28 +/- 0.12 versus 0.17 +/- 0.04 mL.cm H2O(-1).kg(-1); p=0.02) and study 4 (0.93 +/- 0.45 versus 0.51 +/- 0.16 mL.cmH2O(-1).kg(-1); p=0.02). oxygenation index did not differ between groups, but alveolar-arterial oxygen difference was lower in the TO infants. We conclude that fetal TO for severe CDH results in modest improvements in neonatal pulmonary function that are of questionable clinical significance.
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Affiliation(s)
- Roberta L Keller
- The Cardiovascular Research Institute and Department of Pediatrics , UCSF Box 0748, San Francisco, CA 94143, USA.
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Roubliova XI, Verbeken EK, Wu J, Vaast P, Jani J, Deprest JA. Effect of tracheal occlusion on peripheric pulmonary vessel muscularization in a fetal rabbit model for congenital diaphragmatic hernia. Am J Obstet Gynecol 2004; 191:830-6. [PMID: 15467550 DOI: 10.1016/j.ajog.2004.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the effects on peripheric pulmonary vessel muscularization by tracheal occlusion (TO) performed at different gestational ages in fetal rabbits with surgically induced diaphragmatic hernia. STUDY DESIGN In 23 New Zealand white does, both ovarian end fetuses underwent surgical creation of diaphragmatic hernia at 23 days of gestation (pseudoglandular phase). At 26, 27, or 28 days 1 fetus underwent TO, the contralateral one underwent a sham operation for a total of 46 fetuses. At 30 days (alveolar phase), fetuses were harvested together with 1 nonoperated internal control. Lungs were processed for vascular morphometry. Proportionate medial thickness and muscularization of intra-acinar vessels were evaluated. RESULTS Late TO (day 28; saccular phase) normalizes the lung-to-body weight ratio and causes significant medial thinning in vessels up to 35 microm diameter. CONCLUSION Tracheal occlusion decreases muscularization of intra-acinar pulmonary vessels in a gestational age-dependent fashion, with maximal effect when TO is performed at 28 days.
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MESH Headings
- Actins/analysis
- Animals
- Disease Models, Animal
- Female
- Gestational Age
- Hernia, Diaphragmatic/complications
- Hernias, Diaphragmatic, Congenital
- Ligation
- Lung/blood supply
- Lung/embryology
- Muscle, Smooth, Vascular/anatomy & histology
- Muscle, Smooth, Vascular/chemistry
- Muscle, Smooth, Vascular/embryology
- Pregnancy
- Rabbits
- Trachea/physiology
- Trachea/surgery
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Affiliation(s)
- Xenia I Roubliova
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Biard JM, Lu HQ, Vanamo K, Maenhout B, De Langhe E, Verbeken E, Deprest J. Pulmonary effects of gastroschisis in a fetal rabbit model. Pediatr Pulmonol 2004; 37:99-103. [PMID: 14730653 DOI: 10.1002/ppul.10393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Respiratory insufficiency is a significant cause of mortality and morbidity among infants with anterior abdominal wall defects (AWD). The aim of this study was to evaluate the pulmonary effects in a fetal rabbit model where gastroschisis was induced at midgestation. Gastroschisis (GAS) was created in 20 rabbit fetuses on day 22 or 23 of gestation (pseudoglandular phase; term = 31-32 days). The amniotic sacs of 13 fetuses were subjected to hysterotomy and amniotomy only (HYST), while 13 underwent a sham laparotomy which was immediately closed by sutures (SHAM). Eleven nonoperated littermates served as internal controls (CTR). Fetuses were harvested by cesarean section on day 31 of gestation prior to respiration. Pulmonary response was evaluated by left lung to body weight ratio (LWBWR), airway morphometry, and density of type II pneumocytes, as evaluated by the number of surfactant protein B-positive cells. Fetuses from the GAS group had significantly lower body weights than did CTR (P = 0.0129). Of these fetuses, 27% were growth-restricted, i.e., with a body weight under the 10th percentile of the CTR population. There were no differences in left lung weight and LWBWR among the GAS and CTR groups. Moreover, the GAS group had similar alveolar size, alveolar wall thickness, and type II cell density as CTR fetuses. Only mean terminal bronchiolar density (MTBD), which is inversely related to the alveolar space, was slightly increased in the GAS group, but without reaching significance (P = 0.0821). No effect on lung growth and maturation could be demonstrated in this study.
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Affiliation(s)
- Jean-Marc Biard
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Heerema AE, Rabban JT, Sydorak RM, Harrison MR, Jones KD. Lung pathology in patients with congenital diaphragmatic hernia treated with fetal surgical intervention, including tracheal occlusion. Pediatr Dev Pathol 2003; 6:536-46. [PMID: 15018453 DOI: 10.1007/s10024-003-5054-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fetal intervention for congenital diaphragmatic hernia was developed to lessen the high morbidity and mortality of pulmonary hypoplasia. Lung pathology and morphometry in patients treated with fetal intervention have not been described. We report clinical and autopsy findings, as well as basic lung morphometry in 16 cases of congenital diaphragmatic hernia with fetal intervention (12 cases tracheal occlusion; 4 cases hernia repair), and 19 cases of congenital diaphragmatic hernia without fetal intervention. All patients who underwent fetal intervention were born premature. Lung enlargement with increased lung-to-body weight ratio was observed with fetal tracheal occlusion, accompanied by lower than normal radial alveolar counts and increased alveolar size. Patients treated with tracheal occlusion also had early alveolar development (at 29.8, 30.6, and 30.9 wk postconceptual age) as well as mucous fluid pooling in airways and alveoli. All cases showed severe alveolar septal widening, more extensive in patients without fetal intervention. When grouped by postconceptual age, no statistically significant difference was found between patients with and without fetal intervention with respect to lung-to-body weight ratio, radial alveolar count, mean alveolar length, and relative arteriolar media thickness. Lung enlargement has been observed with fetal tracheal occlusion sonographically; our studies suggest that this is due in part to emphysema and mucous fluid pooling. The lung remains abnormal with low radial alveolar counts and increased alveolar size. Tracheal occlusion did not prevent development of lung pathology associated with pulmonary hypoplasia.
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Affiliation(s)
- Amy E Heerema
- Department of Pathology, University of California, San Francisco, 300 Parnassus Avenue, Box 0506, San Francisco, CA 94143-0506, USA.
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Unger S, Copland I, Tibboel D, Post M. Down-regulation of sonic hedgehog expression in pulmonary hypoplasia is associated with congenital diaphragmatic hernia. THE AMERICAN JOURNAL OF PATHOLOGY 2003; 162:547-55. [PMID: 12547712 PMCID: PMC1851145 DOI: 10.1016/s0002-9440(10)63848-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The pathogenesis of pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) is unknown. The sonic hedgehog (Shh) cascade is crucial for the patterning of the early respiratory system in mice. To establish whether Shh plays a role in the pathogenesis of lung hypoplasia in CDH, we investigated the gestation-specific expression of Shh in normal rat and human lungs using in situ hybridization and immunohistochemistry. The expression pattern was compared with that of age-matched samples of hypoplastic lungs associated with CDH in humans and in the 2,4-dichlorophenyl-p-nitrophenylether (nitrofen) rat model. Our results showed that in normal controls the expression of Shh increased with advancing gestation, peaked in the late pseudoglandular stage, and declined thereafter. The expression of Shh is initially down-regulated in pulmonary hypoplasia associated with CDH and peaks instead during the late canalicular stage. These data indicate that maximal expression of Shh occurs when respiratory bronchioles develop and thinning of the interstitium takes place, suggesting that Shh may play a role in these processes. Furthermore, we observed that Shh inhibited fetal lung fibroblast proliferation in vitro. Therefore, it is tempting to speculate that alterations in Shh expression may affect these developmental processes, thereby contributing to the pulmonary abnormality in CDH.
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Affiliation(s)
- Sharon Unger
- Lung Biology Research Program, Department of Pediatrics, Hospital for Sick Children Research Institute, University of Toronto, Toronto, Canada
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