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Walcutt JE, Kline-Fath BM, Zhang B, Lim FY, Habli MA, Divanovic AA, Nagaraj UD. Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence. Pediatr Radiol 2024; 54:702-714. [PMID: 38488924 DOI: 10.1007/s00247-024-05879-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multiple gestation pregnancies, in which the pump twin provides hemodynamic support to a nonviable co-twin (acardius). Fetal magnetic resonance imaging (MRI) is used to detect pump twin abnormalities, particularly brain ischemia, prior to fetal intervention to interrupt umbilical blood flow to the acardius. OBJECTIVE To summarize the imaging findings of TRAP sequence pregnancies in a large series. MATERIALS AND METHODS A single-center retrospective review was performed of all TRAP sequence pregnancies referred for fetal MRI (2004-2021). Fetal MRI, ultrasound, and echocardiography data were collected. RESULTS Eighty-eight TRAP sequence pregnancies with MRI were included (mean gestational age, 19.8±2.8 weeks). Demise of the pump twin was noted in two pregnancies at the time of MRI. By MRI, 12% (10/86) of live pump twins had abnormalities, including 3% (3/86) with brain abnormalities and 9% (8/86) with extra-cranial abnormalities. By echocardiography, 7% (6/86) of pump twins had structural cardiac abnormalities. Three acardius morphological subtypes were identified by MRI: acephalus (55%, 48/88), anceps (39%, 34/88), and amorphous (7%, 6/88). The mean ultrasound acardius to pump twin ratio A/P ratio, calculated for each twin pair as the ratio of the acardius trunk (and head, if present) plus limb volume to the pump twin estimated fetal weight) differed among the three acardius subtypes (P=.03). The mean A/P ratio moderately correlated with pump twin cardiothoracic ratio and combined cardiac output (Pearson's r=0.45 and 0.48, respectively, both P<.001). CONCLUSION Fetal MRI of TRAP sequence pregnancies found anomalies in a substantial number of pump twins. The three acardius subtypes differed in A/P ratio, which moderately correlated with the pump twin cardiothoracic ratio and combined cardiac output.
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Affiliation(s)
- Julie E Walcutt
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Division of Radiology, Children's Nebraska, 8200 Dodge Street, Omaha, NE, 68114, USA.
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mounira A Habli
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Obstetrics and Gynecology, TriHealth Good Samaritan Hospital, Cincinnati, OH, USA
| | - Allison A Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Usha D Nagaraj
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Aydın E, Khanmammadova N, Burns P, Lim FY, Habli MA, Peiró JL. Bias in the prenatal lung measurements in fetal congenital diaphragmatic hernia with intrauterine growth restriction. J Perinat Med 2024; 0:jpm-2023-0425. [PMID: 38634775 DOI: 10.1515/jpm-2023-0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/23/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES The failure of a fetus to develop to its full potential due to maternal or placental factors is known as intrauterine growth restriction (IUGR). Fetal head growth is usually preserved in that situation producing a potential discordance between head and body size. Our goal is to discover if IUGR has an impact on the prenatal ultrasound measurements taken to assess pulmonary development in congenital diaphragmatic hernia (CDH). METHODS A retrospective chart review (IRB#2017-6361) was performed on all prenatally diagnosed CDH patients from 2007 to 2016. Patient demographics, fetal and neonatal anthropometric measurements, and fetal lung parameters were the main subjects of the data that were gathered. Fetal growth was assessed by the curves based on US data by Olsen et al. and by Peleg et al. Of 147 CDH patients, 19 (12.9 %) patients were diagnosed with IUGR before the 30th gestational week while there were 20 (13.6 %) patients after the 30th gestational week. RESULTS Patients with IUGR and the observed-to-expected lung-to-head ratio (O/E LHR) less than 25 % had better survival rates both to discharge and date compared to non IUGR group (p=0.226, OR 2.25 95 % CI 0.60-1.08 and p=0.175, OR 2.40 95 % CI 0.66-1.17, respectively). Moreover, the ECMO need of the patients who had IUGR and O/E LHR less than 25 % was significantly less than the patients without IUGR (38.5 vs. 80.0 %, p=0.005). CONCLUSIONS This study confirms that the intrauterine measurements to predict pulmonary hypoplasia in CDH patients are misleading in the presence of IUGR and cause an overestimation.
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Affiliation(s)
- Emrah Aydın
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, 2518 Cincinnati Children's Hospital Medical Center (CCHMC) , Cincinnati, OH, USA
- Department of Pediatric Surgery, 472605 Tekirdag Namik Kemal University School of Medicine , Tekirdag, Türkiye
| | - Narmina Khanmammadova
- Department of Pediatric Surgery, 472605 Tekirdag Namik Kemal University School of Medicine , Tekirdag, Türkiye
| | - Patricia Burns
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, 2518 Cincinnati Children's Hospital Medical Center (CCHMC) , Cincinnati, OH, USA
| | - Foong-Yen Lim
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, 2518 Cincinnati Children's Hospital Medical Center (CCHMC) , Cincinnati, OH, USA
| | - Mounira A Habli
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, 2518 Cincinnati Children's Hospital Medical Center (CCHMC) , Cincinnati, OH, USA
| | - Jose Luis Peiró
- Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, 2518 Cincinnati Children's Hospital Medical Center (CCHMC) , Cincinnati, OH, USA
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Forde B, Martin S, Watanabe-Chailland M, Lim FY. Acute Fetal Metabolomic Changes in Twins Undergoing Fetoscopic Surgery for Twin-Twin Transfusion Syndrome. Twin Res Hum Genet 2024:1-8. [PMID: 38515292 DOI: 10.1017/thg.2024.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Fetuses undergo major surgical stress as well as fluid shifts secondary to both twin-twin transfusion (TTTS) as well as the fetoscopic surgery for treatment of TTTS. While the pathophysiology of TTTS is understood, the acute metabolic changes that fetuses experience from fetoscopic surgery are not. We sought to evaluate the changes in recipient metabolomic profile secondary to TTTS surgery. Amniotic fluid was collected at the beginning and end of four TTTS surgical cases performed from 12/2022-2/2023. Samples were immediately processed and evaluated via NMR-based Metabolomics Facility protocol. In univariate analysis, 12 metabolites (glucose, lactate, and 10 key amino acids) showed statistically significant changes between the beginning and end of the surgery. Among these, 11 metabolites decreased at the end, while only lactate increased. Supervised oPLS-DA modeling revealed pyruvate and lactate as the two metabolites most impact on the variance between cases, and that 40% of metabolomic changes could be attributed directly to the timing that the sample was taken (i.e., if pre- or postoperatively). These results indicate significant metabolic changes in the recipient twin during fetoscopic surgery for TTTS. These findings of decreased glucose, increased lactate, and decreased amnio acids would indicate increased catabolism during surgery. This study raises questions regarding optimal maternal and fetal nutrition during surgery and if nutritional status could be optimized to further improve twin survival during fetoscopic surgery.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samuel Martin
- Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Miki Watanabe-Chailland
- NMR-Based Metabolomics Facility, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Foong-Yen Lim
- Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
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Bergh E, Baschat AA, Cortes MS, Hedrick HL, Ryan G, Lim FY, Zaretsky MV, Schenone MH, Crombleholme TM, Ruano R, Gosnell KA, Johnson A. Fetoscopic Endoluminal Tracheal Occlusion for Severe, Left-Sided Congenital Diaphragmatic Hernia: The North American Fetal Therapy Network Fetoscopic Endoluminal Tracheal Occlusion Consortium Experience. Obstet Gynecol 2024; 143:440-448. [PMID: 38128107 PMCID: PMC10863657 DOI: 10.1097/aog.0000000000005491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed. METHODS We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients. RESULTS Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014). CONCLUSION In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%).
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Affiliation(s)
- Eric Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth Houston, the University of Texas McGovern Medical School, and the Fetal Center at Children's Memorial Hermann Hospital, and the Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Texas Children's Hospital Fetal Center, Baylor College of Medicine, Houston, Texas; the Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; the Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; the Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; the Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado; the Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, Minnesota; the Fetal Care Center Dallas, Dallas, Texas; and the Fetal Treatment Center, University of California, San Francisco, San Francisco, California
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Forde B, Lim FY, McKinney DN, Habli M, Markham KB, Hoffman M, Tabbah S, Oria M, Peiro JL. Association of amnioinfusion volume at the time of surgery for twin-twin transfusion syndrome and latency to delivery. Prenat Diagn 2023; 43:1239-1246. [PMID: 37553727 DOI: 10.1002/pd.6415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/24/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE To evaluate the impact of amnioinfusion and other peri-operative factors on pregnancy outcomes in the setting of Twin-twin transfusion syndrome (TTTS) treated via fetoscopic laser photocoagulation (FLP). METHODS Retrospective study of TTTS treated via FLP from 2010 to 2019. Pregnancies were grouped by amnioinfusion volume during FLP (<1 L vs. ≥1 L). The primary outcome was latency from surgery to delivery. An amnioinfusion statistic (AIstat) was created for each surgery based on the volume of fluid infused and removed and the preoperative deepest vertical pocket. Regression analysis was planned to assess the association of AIstat with latency. RESULTS Patients with amnioinfusion of ≥1 L at the time of FLP had decreased latency from surgery to delivery (61 ± 29.4 vs. 73 ± 28.8 days with amnioinfusion <1 L, p < 0.001) and increased preterm prelabor rupture of membranes (PPROM) <34 weeks (44.7% vs. 33.5%, p = 0.042). Amnioinfusion ≥1 L was associated with an increased risk of delivery <32 weeks (aRR 2.6, 95% CI 1.5-4.5), 30 weeks (aRR 2.4, 95% CI 1.5-3.8), and 28 weeks (aRR 1.9, 95% CI 1.1-2.3). Cox-proportional regression revealed that AIstat was inversely associated with latency (HR 1.1, 95% CI 1.1-1.2). CONCLUSION Amnioinfusion ≥1 L during FLP was associated with decreased latency after surgery and increased PPROM <34 weeks.
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Affiliation(s)
- Braxton Forde
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Foong-Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Thoracic Surgery, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David N McKinney
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mounira Habli
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, TriHealth Health System, Cincinnati, Ohio, USA
| | - Kara B Markham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mallory Hoffman
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, TriHealth Health System, Cincinnati, Ohio, USA
| | - Sammy Tabbah
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, TriHealth Health System, Cincinnati, Ohio, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Riverside Methodist Hospital, Cincinnati, Ohio, USA
| | - Marc Oria
- Division of General and Thoracic Surgery, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jose L Peiro
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Thoracic Surgery, Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Perry T, Henry B, Cooper DS, Keswani SG, Burton KS, Lim FY, Chernoguz A, Frischer JS. Antithrombin III infusion improves anticoagulation in congenital diaphragmatic hernia patients on extracorporeal membrane oxygenation. Perfusion 2023; 38:507-514. [PMID: 34939461 DOI: 10.1177/02676591211063805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Achieving effective anticoagulation during neonatal extracorporeal membrane oxygenation (ECMO) without increasing the risk of hemorrhage remains challenging. The use of antithrombin III (AT-III) for this purpose has been examined, but studies have been limited to intermittent bolus dosing. We aimed to evaluate the efficacy and safety of an institutionally developed AT-III continuous infusion protocol in neonates receiving ECMO for the treatment of congenital diaphragmatic hernia (CDH). METHODS In this single center, retrospective study, all neonates with a CDH who received ECMO support during the study period were included. Data on anticoagulation labs and therapy, life-threatening bleeding, and circuit changes were analyzed. RESULTS Eleven patients were divided into two groups: patients with AT-III continuous infusion (n = 5) and without (n = 6). There were no differences in the gestational age (p = 0.29), sex (p = 1.00), ECMO duration (p = 0.59), or initial AT-III levels (p = 0.76) between groups. Patients in the AT-III infusion group had on average 18.5% higher AT-III levels (p < 0.0001). Patients receiving continuous AT-III infusions spent a significantly higher percentage of ECMO time within the therapeutic range, measured using anti-Factor Xa levels (64.9±4.2% vs. 29.1±8.57%, p = 0.008), and required fewer changes to the heparin infusion rate (6.48±0.88 vs 2.38±0.36 changes/day changes/day, p = 0.005). Multivariate analysis revealed continuous infusion of AT-III did not increase the rate of intracranial or surgical bleeding (p = 0.27). CONCLUSION AT-III as a continuous infusion in CDH neonates on ECMO provides a decreased need to modify heparin infusion and more consistent therapeutic anticoagulation without increasing the risk of life-threatening bleeding.
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Affiliation(s)
- Tanya Perry
- The Heart Institute, Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Brandon Henry
- The Heart Institute, Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- The Heart Institute, Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sundeep G Keswani
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kimberly S Burton
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Artur Chernoguz
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason S Frischer
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Riddle S, Peiro JL, Lim FY, Habli M, McKinney D, Kingma P. Fetal Tracheal Occlusion for Congenital Diaphragmatic Hernia. Neoreviews 2023; 24:e263-e269. [PMID: 37002399 DOI: 10.1542/neo.24-4-e263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Stefanie Riddle
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Jose L Peiro
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
- Department of Surgery, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Foong-Yen Lim
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
- Department of Surgery, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Mounira Habli
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Good Samaritan Hospital, Cincinnati, OH
| | - David McKinney
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Department of Obstetrics and Gynecology, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Paul Kingma
- Cincinnati Children's Fetal Care Center, Cincinnati, OH
- Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
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Zenilman A, Fan W, Hernan R, Wynn J, Abramov A, Farkouh-Karoleski C, Aspelund G, Krishnan US, Khlevner J, Azarow K, Crombleholme T, Cusick R, Chung D, Danko ME, Potoka D, Lim FY, McCulley DJ, Mychaliska GB, Schindel D, Soffer S, Wagner AJ, Warner BW, Chung WK, Duron VP. Being small for gestational age is not an independent risk factor for mortality in neonates with congenital diaphragmatic hernia: a multicenter study. J Perinatol 2022; 42:1183-1188. [PMID: 35449444 DOI: 10.1038/s41372-022-01326-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 11/21/2021] [Accepted: 01/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) accounts for 8% of all major congenital anomalies. Neonates who are small for gestational age (SGA) generally have a poorer prognosis. We sought to identify risk factors and variables associated with outcomes in neonates with CDH who are SGA in comparison to neonates who are appropriate for gestational age (AGA). METHODS We used the multicenter Diaphragmatic Hernia Research & Exploration Advancing Molecular Science (DHREAMS) study to include neonates enrolled from 2005 to 2019. Chi-squared or Fisher's exact tests were used to compare categorical variables and t tests or Wilcoxon rank sum for continuous variables. Cox model analyzed time to event outcomes and logistic regression analyzed binary outcomes. RESULTS 589 neonates were examined. Ninety were SGA (15.3%). SGA patients were more likely to be female (p = 0.003), have a left sided CDH (p = 0.05), have additional congenital anomalies and be diagnosed with a genetic syndrome (p < 0.001). On initial single-variable analysis, SGA correlated with higher frequency of death prior to discharge (p < 0.001) and supplemental oxygen requirement at 28 days (p = 0.005). Twice as many SGA patients died before repair (12.2% vs 6.4%, p = 0.04). Using unadjusted Cox model, the risk of death prior to discharge among SGA patients was 1.57 times the risk for AGA patients (p = 0.029). There was no correlation between SGA and need for ECMO, pulmonary hypertensive medication at discharge or oxygen at discharge. After adjusting for confounding variables, SGA no longer correlated with mortality prior to discharge or incidence of unrepaired defects but remained significant for oxygen requirement at 28 days (p = 0.03). CONCLUSION Infants with CDH who are SGA have worse survival and poorer lung function than AGA infants. However, the outcome of SGA neonates is impacted by other factors including gestational age, genetic syndromes, and particularly congenital anomalies that contribute heavily to their poorer prognosis.
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Affiliation(s)
- A Zenilman
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
| | - W Fan
- Department of Biostatistics, Columbia University Irving Medical Center, New York, NY, USA
| | - R Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - J Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - A Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - C Farkouh-Karoleski
- Department of Neonatology, Columbia University Irving Medical Center, New York, NY, USA
| | - G Aspelund
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - U S Krishnan
- Department of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - J Khlevner
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, NY, USA
| | - K Azarow
- Pediatric Surgery Division, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - T Crombleholme
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Cusick
- Division of Pediatric Surgery, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA
| | - D Chung
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - M E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - D Potoka
- Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - F Y Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - D J McCulley
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - G B Mychaliska
- Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - D Schindel
- Division of Pediatric Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - S Soffer
- Department of Pediatric Surgery, Northwell Health, New York, NY, USA
| | - A J Wagner
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B W Warner
- Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - W K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA.,Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - V P Duron
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Moise KJ, Vlastos EJ, Papanna R, Chmait RH, Baschat AA, Lim FY. Current Status of the Workforce and Training at Fetal Therapy Centers in the North America. Fetal Diagn Ther 2022; 49:333-339. [PMID: 36041413 DOI: 10.1159/000525529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022]
Abstract
An anonymous electronic survey was developed to query the 34 centers in the North American Fetal Treatment Network (NAFTNet) regarding the demographics and training of their faculty. Telephone surveys were conducted with directors of known fetal intervention fellowships. More than 50% of Maternal-Fetal Medicine (MFM) faculty at fetal centers were female; more than two thirds of pediatric surgical faculty were male. Most of the training of faculty was undertaken by visiting more experienced centers or having new faculty work with more experienced ones at the same center. Current fetal intervention fellowships appear to achieve levels of competency for intrauterine transfusions and laser therapy for twin-twin transfusion syndrome. Two thirds of centers stated that they would be able to offer a position to an MFM who completed a formal fellowship in fetal intervention.
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Affiliation(s)
- Kenneth Joseph Moise
- Department of Women's Health, Dell Medical School, UT Health Austin, Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas, USA
| | - Emanuel Joseph Vlastos
- Obstetrics and Gynecology, University of Missouri-Kansas School of Medicine, Kansas City, Missouri, USA
- Fetal Therapy Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Medicine, McGovern School of Medicine - UT Health Houston, Houston, Texas, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine at the Medical University of Southern California, Los Angeles, California, USA
- Los Angeles Fetal Surgery, CHLA-USC Fetal-Maternal Center, Los Angeles, California, USA
| | - Ahmet A Baschat
- Department of Obstetrics and Gynecology, John Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Fetal Therapy, Baltimore, Maryland, USA
| | - Foong-Yen Lim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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10
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Eyerly-Webb SA, Ylvisaker H, Beh M, Lim FY, Liechty K, Velasco P, Dion E, Snowise S, Lillegard JB, Feltis B. Understanding the Care Journey and Needs of Advanced Fetal Care Center Patients. Perm J 2022; 26:11-20. [DOI: 10.7812/tpp/21.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Megan Beh
- Midwest Fetal Care Center, Minneapolis, MN, USA
| | | | | | | | - Eric Dion
- Midwest Fetal Care Center, Minneapolis, MN, USA
| | | | - Joseph B Lillegard
- Midwest Fetal Care Center, Minneapolis, MN, USA
- Pediatric Surgical Associates, Minneapolis, MN, USA
- Mayo Clinic, Division of General Surgery Research, Rochester, MN, USA
| | - Brad Feltis
- Midwest Fetal Care Center, Minneapolis, MN, USA
- Pediatric Surgical Associates, Minneapolis, MN, USA
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11
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Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States.
| | - Meredith Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Gabriella Grisotti
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Stefanie Riddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States
| | - Pramod Reddy
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Donna Claes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Brian VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
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12
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Aydin E, Torlak N, Haberman B, Lim FY, Peiro JL. The Survivorship Bias in Congenital Diaphragmatic Hernia. Children 2022; 9:children9020218. [PMID: 35204938 PMCID: PMC8869836 DOI: 10.3390/children9020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 11/16/2022]
Abstract
Current literature for congenital diaphragmatic hernia (CDH) focuses on the comparison of the overall mortality in CDH patients. Only a few studies concentrate on analyzing the unstable patients who could not achieve surgical repair, as well as those who could but did not survive after. Hence, this study aimed to analyze the effects of various parameters on the timing of death. A retrospective analysis was performed by using the data of all CDH patients from 2003 to 2016 at a single tertiary center. Patients who were diagnosed with left-sided CDH and expired were included in the study regardless of the cause. Of the 66 expired patients, 5 were excluded due to right-sided CDH. The study population constituted a total of 61 patients, of which 31 patients expired prior to CDH repair, and 30 patients expired at different times after CDH repair. Multinomial regression analysis identified that the ECMO need (B = 20.257, p = 0.000, OR: 62.756, 95% CI 10.600–371.384) and O/E LHR (B = 20.376, p = 0.000, OR: 70.663, 95% CI 48.716–102.415) values were the independent predictors that influenced mortality in this cohort. Prenatal pulmonary measurements are the major predictors determining the severity of the disease in patients with CDH.
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Affiliation(s)
- Emrah Aydin
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- Department of Pediatric Surgery, Tekirdağ Namık Kemal University School of Medicine, 59030 Tekirdağ, Turkey
- Correspondence:
| | - Nilhan Torlak
- Cellular and Molecular Medicine, Koç University Graduate School of Health Sciences, 34450 Istanbul, Turkey;
| | - Beth Haberman
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Jose L. Peiro
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (F.-Y.L.); (J.L.P.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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13
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Fabelo C, He H, Lim FY, Atzinger C, Wong B. Factors impacting surgical decision making between prenatal and postnatal repair for myelomeningocele. Prenat Diagn 2021; 42:27-36. [PMID: 34931327 DOI: 10.1002/pd.6080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/12/2021] [Accepted: 12/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine factors influencing patients to choose prenatal or postnatal repair of their child's myelomeningocele (MMC) when both treatment options are offered. METHODS We distributed a retrospective survey via email and social media to parents of children with MMC who were offered both prenatal and postnatal surgery as intervention options. RESULTS A total of 127 surveys met all inclusion criteria. The majority of responders considered partner's opinion (85%), maternal risks of prenatal surgery (71%), and risk for preterm labor (76%) as influencers. Financially, the costs of childcare (39.4% postnatal, 13.8% prenatal, p = 0.002), relocation (57.6% postnatal, 36.2% prenatal, p = 0.019), and travel (51.5% postnatal, 33% prenatal, p = 0.033) were more influential for the postnatal group while insurance coverage (36.4% postnatal, 68.1% prenatal, p = 0.003) was more influential to the prenatal group. Of the medical factors, the consideration of maternal risk for transfusion was different between surgical groups (39.4% postnatal, 18.1% prenatal, p = 0.015). The open responses suggest that both surgical groups found the quality of life for the baby to be significant to their decision-making. CONCLUSIONS These findings should guide providers to tailor counseling to patient's needs. Comprehensive counseling should include information on financial resources, referral to financial counselors, and psychosocial support services.
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Affiliation(s)
- Corrie Fabelo
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hua He
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Foong-Yen Lim
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA.,Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carrie Atzinger
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Beatrix Wong
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Cincinnati Children's Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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15
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Mukthapuram S, Beebe J, Tkach JA, Arya S, Haberman B, Peiro J, Lim FY, Woods JC, Kingma PS. Magnetic Resonance Imaging Assessment of Pulmonary Vascularity in Infants with Congenital Diaphragmatic Hernia: A Novel Tool for Direct Assessment of Severity of Pulmonary Hypertension and Hypoplasia. J Pediatr 2021; 239:89-94. [PMID: 34339729 DOI: 10.1016/j.jpeds.2021.07.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the feasibility of magnetic resonance imaging (MRI) for postnatal assessment of pulmonary vascularity in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN Infants with prenatally diagnosed CDH (n = 24) received postnatal pulmonary MRI. Infants with nonpulmonary birth defects served as controls (n = 5). Semiautomatic segmentation was performed to obtain total vascular volume using time of flight images to assess vascularity. RESULTS Average vascular density (vascular volume/lung volume) in control infants was 0.23 ± 0.06 mm3/mm3 compared with 0.18 ± 0.06 mm3/mm3 in infants with CDH is (P = .09). When stratified further based on CDH severity, the difference between control infants and moderate CDH group was statistically significant. (0.23 mm3/mm3 vs 0.15 mm3/mm3, P = .01). Ipsilateral vascular density on MRI in infants with CDH significantly correlated with the prenatal pulmonary hypertensive index (P = .0004, Spearman R = +0.87) and with number of days on mechanical ventilation (P = .04, Spearman R = -0.44), total days on inhaled nitric oxide (P = .02, Spearman R = -0.47), use of epoprostenol for acute pulmonary hypertension (PH) (0.14 mm3/mm3 vs 0.20 mm3/mm3, P = .005), and use of sildenafil for chronic PH (0.15 mm3/mm3 vs 0.19 mm3/mm3, P = .03). CONCLUSIONS Our results suggest that postnatal pulmonary vascularity assessed by MRI strongly correlates with prenatal and postnatal markers of PH severity and that pulmonary vascularity may serve as a direct measure of pulmonary vascular hypoplasia in infants with CDH.
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Affiliation(s)
- Shanmukha Mukthapuram
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jessica Beebe
- Department of Physiology and Biophysics, Case Western Reserve School of Medicine, Cleveland, OH
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shreyas Arya
- Department of Newborn Medicine, Dayton Children's Hospital, Dayton, OH
| | - Beth Haberman
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jose Peiro
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Foong-Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jason C Woods
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Paul S Kingma
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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16
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Qiao L, Xu L, Yu L, Wynn J, Hernan R, Zhou X, Farkouh-Karoleski C, Krishnan US, Khlevner J, De A, Zygmunt A, Crombleholme T, Lim FY, Needelman H, Cusick RA, Mychaliska GB, Warner BW, Wagner AJ, Danko ME, Chung D, Potoka D, Kosiński P, McCulley DJ, Elfiky M, Azarow K, Fialkowski E, Schindel D, Soffer SZ, Lyon JB, Zalieckas JM, Vardarajan BN, Aspelund G, Duron VP, High FA, Sun X, Donahoe PK, Shen Y, Chung WK. Rare and de novo variants in 827 congenital diaphragmatic hernia probands implicate LONP1 as candidate risk gene. Am J Hum Genet 2021; 108:1964-1980. [PMID: 34547244 PMCID: PMC8546037 DOI: 10.1016/j.ajhg.2021.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/25/2021] [Indexed: 12/21/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly that is often accompanied by other anomalies. Although the role of genetics in the pathogenesis of CDH has been established, only a small number of disease-associated genes have been identified. To further investigate the genetics of CDH, we analyzed de novo coding variants in 827 proband-parent trios and confirmed an overall significant enrichment of damaging de novo variants, especially in constrained genes. We identified LONP1 (lon peptidase 1, mitochondrial) and ALYREF (Aly/REF export factor) as candidate CDH-associated genes on the basis of de novo variants at a false discovery rate below 0.05. We also performed ultra-rare variant association analyses in 748 affected individuals and 11,220 ancestry-matched population control individuals and identified LONP1 as a risk gene contributing to CDH through both de novo and ultra-rare inherited largely heterozygous variants clustered in the core of the domains and segregating with CDH in affected familial individuals. Approximately 3% of our CDH cohort who are heterozygous with ultra-rare predicted damaging variants in LONP1 have a range of clinical phenotypes, including other anomalies in some individuals and higher mortality and requirement for extracorporeal membrane oxygenation. Mice with lung epithelium-specific deletion of Lonp1 die immediately after birth, most likely because of the observed severe reduction of lung growth, a known contributor to the high mortality in humans. Our findings of both de novo and inherited rare variants in the same gene may have implications in the design and analysis for other genetic studies of congenital anomalies.
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Affiliation(s)
- Lu Qiao
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Le Xu
- Department of Pediatrics, University of California, San Diego Medical School, San Diego, CA 92093, USA
| | - Lan Yu
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Xueya Zhou
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | | | - Usha S Krishnan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Julie Khlevner
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Aliva De
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Annette Zygmunt
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | | | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Howard Needelman
- University of Nebraska Medical Center College of Medicine, Omaha, NE 68114, USA
| | - Robert A Cusick
- University of Nebraska Medical Center College of Medicine, Omaha, NE 68114, USA
| | | | - Brad W Warner
- Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Melissa E Danko
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
| | - Dai Chung
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
| | | | | | - David J McCulley
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 52726, USA
| | | | - Kenneth Azarow
- Oregon Health & Science University, Portland, OR 97239, USA
| | | | | | | | - Jane B Lyon
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Badri N Vardarajan
- Department of Neurology, Taub Institute for Research on Alzheimer Disease and the Aging Brain and the Gertrude H. Sergievsky Center, Columbia University, New York, NY 10032, USA
| | - Gudrun Aspelund
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Vincent P Duron
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Frances A High
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA; Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Xin Sun
- Department of Pediatrics, University of California, San Diego Medical School, San Diego, CA 92093, USA
| | - Patricia K Donahoe
- Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Yufeng Shen
- Department of Systems Biology, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY 10032, USA; JP Sulzberger Columbia Genome Center, Columbia University Irving Medical Center, New York, NY 10032, USA.
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA; Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA.
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17
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Usmani MA, Ahmed ZM, Magini P, Pienkowski VM, Rasmussen KJ, Hernan R, Rasheed F, Hussain M, Shahzad M, Lanpher BC, Niu Z, Lim FY, Pippucci T, Ploski R, Kraus V, Matuszewska K, Palombo F, Kianmahd J, Martinez-Agosto JA, Lee H, Colao E, Motazacker MM, Brigatti KW, Puffenberger EG, Riazuddin SA, Gonzaga-Jauregui C, Chung WK, Wagner M, Schultz MJ, Seri M, Kievit AJ, Perrotti N, Klein Wassink-Ruiter J, van Bokhoven H, Riazuddin S, Riazuddin S, Riazuddin S. De novo and bi-allelic variants in AP1G1 cause neurodevelopmental disorder with developmental delay, intellectual disability, and epilepsy. Am J Hum Genet 2021; 108:1330-1341. [PMID: 34102099 DOI: 10.1016/j.ajhg.2021.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/14/2021] [Indexed: 12/15/2022] Open
Abstract
Adaptor protein (AP) complexes mediate selective intracellular vesicular trafficking and polarized localization of somatodendritic proteins in neurons. Disease-causing alleles of various subunits of AP complexes have been implicated in several heritable human disorders, including intellectual disabilities (IDs). Here, we report two bi-allelic (c.737C>A [p.Pro246His] and c.1105A>G [p.Met369Val]) and eight de novo heterozygous variants (c.44G>A [p.Arg15Gln], c.103C>T [p.Arg35Trp], c.104G>A [p.Arg35Gln], c.229delC [p.Gln77Lys∗11], c.399_400del [p.Glu133Aspfs∗37], c.747G>T [p.Gln249His], c.928-2A>C [p.?], and c.2459C>G [p.Pro820Arg]) in AP1G1, encoding gamma-1 subunit of adaptor-related protein complex 1 (AP1γ1), associated with a neurodevelopmental disorder (NDD) characterized by mild to severe ID, epilepsy, and developmental delay in eleven families from different ethnicities. The AP1γ1-mediated adaptor complex is essential for the formation of clathrin-coated intracellular vesicles. In silico analysis and 3D protein modeling simulation predicted alteration of AP1γ1 protein folding for missense variants, which was consistent with the observed altered AP1γ1 levels in heterologous cells. Functional studies of the recessively inherited missense variants revealed no apparent impact on the interaction of AP1γ1 with other subunits of the AP-1 complex but rather showed to affect the endosome recycling pathway. Knocking out ap1g1 in zebrafish leads to severe morphological defect and lethality, which was significantly rescued by injection of wild-type AP1G1 mRNA and not by transcripts encoding the missense variants. Furthermore, microinjection of mRNAs with de novo missense variants in wild-type zebrafish resulted in severe developmental abnormalities and increased lethality. We conclude that de novo and bi-allelic variants in AP1G1 are associated with neurodevelopmental disorder in diverse populations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Saima Riazuddin
- Department of Otorhinolaryngology Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; Department of Molecular Biology and Biochemistry, School of Medicine, University of Maryland, Baltimore, MD 21201, USA.
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18
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Patel SK, Habli MA, McKinney DN, Tabbah SM, Lim FY, Peiro JL, Stevenson CB. Fetoscopic Multilayer, Dural Patch Closure Technique for Intrauterine Myelomeningocele Repair: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E131-E132. [PMID: 33047136 DOI: 10.1093/ons/opaa309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/27/2020] [Indexed: 11/14/2022] Open
Abstract
Myelomeningocele (MMC) is the most common open neural tube defect associated with long-term survival. In 2011, The Management of Myelomeningocele Study (MOMS) trial demonstrated that fetal repair for MMC reduced the rate of shunted hydrocephalus and improved developmental, motor, and ambulation outcomes at 30 mo compared to postnatal intervention.1 Recent studies have demonstrated the safety and feasibility of fetoscopic MMC repair as well as reduction in preterm birth, lower risk of uterine dehiscence, and the option of vaginal delivery with this approach compared to open fetal repair.2-4 The patient is a 25-yr-old female, G4 P2, who presented at 20 wk's gestation with ultrasound findings concerning for MMC and Chiari II malformation. These findings were further corroborated with fetal magnetic resonance imaging. After extensive prenatal counseling in a multidisciplinary fashion and discussion regarding risks and benefits of prenatal closure of the MMC, the patient chose to undergo prenatal repair and surgical consent was obtained. At 25 wk's gestation, the patient underwent a fetoscopic multilayer closure with dural patch repair using a standardized, 3-port, carbon dioxide insufflation technique for the intrauterine treatment of MMC without any postoperative complications. The duration of the entire procedure was 275 min. At 36 wk's and 1 d's gestational age, the patient had a spontaneous vaginal delivery, resulting in a healthy male newborn. The surgical site was well healed without complications, and follow-up radiographic imaging was reassuring. This edited, 2-dimensional operative video highlights the key steps of the fetoscopic closure with follow-up postnatal clinical and radiographic outcomes.
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Affiliation(s)
- Smruti K Patel
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mounira A Habli
- Maternal and Fetal Medicine, Tri-State Maternal-Fetal Medicine Associates, Cincinnati, Ohio.,Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David N McKinney
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sammy M Tabbah
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Foong-Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jose L Peiro
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Charles B Stevenson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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19
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Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
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Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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20
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Patel SK, Kashyrina O, Duru S, Miyabe M, Lim FY, Peiro JL, Stevenson CB. Comparison of two- and three-dimensional endoscopic visualization for fetal myelomeningocele repair: a pilot study using a fetoscopic surgical simulator. Childs Nerv Syst 2021; 37:1613-1621. [PMID: 33392653 DOI: 10.1007/s00381-020-04999-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/03/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the utility of three-dimensional (3D) versus conventional two-dimensional (2D) endoscopy for fetal myelomeningocele repair using a low-fidelity fetoscopic surgical simulator. METHODS A low-fidelity fetoscopic box trainer was developed for surgical simulation of myelomeningocele repair. Participants with varying surgical experience were recruited and completed three essential tasks (cutting skin, dural patch placement, and suturing skin) using both 2D and 3D endoscopic visualization. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion was measured for each task, and each participant subsequently completed the NASA Load Index test and a questionnaire evaluating their experience. RESULTS Sixteen participants completed the study tasks using both 2D and 3D endoscopes in the simulator. While the mean performance time across all tasks was shorter with 3D versus 2D endoscopy (cutting skin, 47 vs. 54 seconds; dural patch placement, 38 vs. 52 seconds; and suturing skin, 424 vs. 499 seconds), the results did not reach statistical significance. When comparing times to completion of each of the three tasks between levels of expertise, participants in the expert category were faster when suturing skin on the 2D modality (P = 0.047). Under 3D visualization, experts were faster at cutting the skin (P = 0.008). When comparing experiences using the NASA-TLX test, participants felt that their performance was better using 3D over the 2D system (P = 0.045). Overall, 13 of 16 (81.3%) participants preferred 3D over 2D visualization. CONCLUSIONS Three-dimensional endoscopes could potentially be used in the near future for relative improvement in visualization and possibly performance during complex fetoscopic procedures such as prenatal repair of myelomeningocele defects. Further studies utilizing 3D scopes for other related procedures may potentially support clinical implementation of this technology in fetal surgery and also prove to be a useful tool in surgical training.
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Affiliation(s)
- Smruti K Patel
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2016, Cincinnati, OH, 45229-3039, USA
| | | | - Soner Duru
- Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marcos Miyabe
- Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jose L Peiro
- Center for Fetal and Placental Research, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charles B Stevenson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2016, Cincinnati, OH, 45229-3039, USA. .,Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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21
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Brewington JJ, Benscoter DT, Torres-Silva CA, McHendry CM, Lim FY, Cortezzo DE, Hysinger EB. Flexible Bronchoscopic Thrombus Cryoextraction in a Neonate on Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2021; 203:633-635. [PMID: 33095995 DOI: 10.1164/rccm.202007-2817le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- John J Brewington
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Dan T Benscoter
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Cherie A Torres-Silva
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Carolyn M McHendry
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - DonnaMaria E Cortezzo
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Erik B Hysinger
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio and.,University of Cincinnati College of Medicine Cincinnati, Ohio
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22
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Abstract
Fetal tracheal occlusion (TO), an established treatment modality, promotes fetal lung growth and survival in severe congenital diaphragmatic hernia (CDH). Following TO, retention of the secreted epithelial fluid increases luminal pressure and induces lung growth. Various animal models have been defined to understand the pathophysiology of CDH and TO. All have their own advantages and disadvantages such as the difficulty of the technique, the size of the animal, cost, high mortality rates, and the availability of genetic tools. Herein, a novel transuterine model of murine fetal TO is described. Pregnant mice were anesthetized, and the uterus exposed via a midline laparotomy. The trachea of selected fetuses were ligated with a single transuterine suture placed behind the trachea, one carotid artery, and one jugular vein. The dam was closed and allowed to recover. Fetuses were collected just before parturition. Lung to body weight ratio in TO fetuses was higher than that in control fetuses. This model provides researchers with a new tool to study the impact of both TO and increased luminal pressure on lung development.
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Affiliation(s)
- Emrah Aydın
- The Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center; Department of Pediatric Surgery, Tekirdag Namik Kemal University School of Medicine;
| | - Rashika Joshi
- The Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | - Marc Oria
- The Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center
| | - Foong-Yen Lim
- The Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center
| | - Brian Michael Varisco
- The Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | - Jose Luis Peiro
- The Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center
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23
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Del Mar Romero Lopez M, Carratola M, Redmann A, Evers PD, Lim FY, Kline-Fath BM, Lehenbauer DG, Rymeski B, Torres-Silva CA, Rutter MJ. Right mainstem bronchial atresia successfully corrected with slide tracheobronchoplasty. Pediatr Pulmonol 2021; 56:329-332. [PMID: 33210842 DOI: 10.1002/ppul.25159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/11/2020] [Accepted: 11/01/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Maria Del Mar Romero Lopez
- Division of Neonatology, Perinatal Institute, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Maria Carratola
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew Redmann
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick D Evers
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Beth M Kline-Fath
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David G Lehenbauer
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Congenital Heart Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Beth Rymeski
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cherie A Torres-Silva
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Rutter
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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24
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Forde B, Fresch R, Masters HR, DeFranco E, Tabbah S, McKinney D, Lim FY, Peiro J, Habli M. 543 Does the time of laser usage during surgery for twin-twin transfusion syndrome impact pregnancy outcomes? Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Masters HR, Czarny H, Fresch R, Forde B, Tabbah S, DeFranco E, Lim FY, Peiro J, McKinney D. 985 Influence of gestational age of treatment of twin-twin transfusion syndrome on latency-to-delivery and outcomes. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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26
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Affiliation(s)
- Stefanie Riddle
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Jose L Peiro
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Foong-Yen Lim
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Paul S Kingma
- Cincinnati Fetal Center, Cincinnati, OH.,Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
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27
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Nolan HR, Wagner ML, Jenkins T, Lim FY. Outcomes in the giant omphalocele population: A single center comprehensive experience. J Pediatr Surg 2020; 55:1866-1871. [PMID: 32475506 DOI: 10.1016/j.jpedsurg.2020.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 04/13/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Morbidity and mortality in the giant omphalocele population is complicated by large abdominal wall defects, physiologic aberrancies, and congenital anomalies. We hypothesized different anomalies and treatment types would affect outcomes. METHODS A 2009-2018 retrospective chart review of giant omphaloceles was performed. Exclusions included cloacal exstrophy, transfer after 3 weeks, surgery prior to transfer, conjoined twins, or not yet achieving fascial closure. Thirty-five patients met criteria and mortality and operative morbidity categorized them into favorable (n = 20) or unfavorable (n = 15) outcomes. Odds ratios analyzed potential predictors. Survivors were stratified into staged (n = 11), delayed (n = 8), and primary closure (n = 6) for subgroup analysis. RESULTS Unfavorable outcomes were associated with other major congenital anomalies, sac rupture, and major cardiac anomalies, but had significantly lower odds with increasing gestational age (p = 0.03) and birth weight (p < 0.001). In survivors, the primary group was younger at repair (p < 0.001) and had shorter length of stay (hospital p = 0.02, neonatal intensive care unit p = 0.005). There was no significant difference for sepsis, ventilator days, return to the operating room, or ventral hernia. CONCLUSIONS Predictions of overall outcomes in the giant omphalocele population require analysis of multiple variables. Our findings demonstrated increased odds of unfavorable outcomes in major cardiac anomalies, pulmonary hypertension, genetic diagnosis, other major anomalies, polyhydramnios, postnatal sac rupture, increasing omphalocele sac diameter, lower O/E TLV, lower gestational age at birth, lower birth weight, and repair other than primary. In those surviving to repair, surgical outcomes analyses demonstrated an earlier age of repair and a shorter length of stay for those patients able to be closed primarily; however further research is necessary to determine overall superiority between operative treatment types. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Heather R Nolan
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA.
| | - Monica L Wagner
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA
| | - Todd Jenkins
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA
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28
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Stuart WD, Guo M, Fink-Baldauf IM, Coleman AM, Clancy JP, Mall MA, Lim FY, Brewington JJ, Maeda Y. CRISPRi-mediated functional analysis of lung disease-associated loci at non-coding regions. NAR Genom Bioinform 2020; 2:lqaa036. [PMID: 32500120 PMCID: PMC7252574 DOI: 10.1093/nargab/lqaa036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 04/24/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023] Open
Abstract
Genome-wide association studies have identified lung disease-associated loci; however, the functions of such loci are not well understood in part because the majority of such loci are located at non-coding regions. Hi-C, ChIP-seq and eQTL data predict potential roles (e.g. enhancer) of such loci; however, they do not elucidate the molecular function. To determine whether these loci function as gene-regulatory regions, CRISPR interference (CRISPRi; CRISPR/dCas9-KRAB) has been recently used. Here, we applied CRISPRi along with Hi-C, ChIP-seq and eQTL to determine the functional roles of loci established as highly associated with asthma, cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). Notably, Hi-C, ChIP-seq and eQTL predicted that non-coding regions located at chromosome 19q13 or chromosome 17q21 harboring single-nucleotide polymorphisms (SNPs) linked to asthma/CF/COPD and chromosome 11p15 harboring an SNP linked to IPF interact with nearby genes and function as enhancers; however, CRISPRi indicated that the regions with rs1800469, rs2241712, rs12603332 and rs35705950, but not others, regulate the expression of nearby genes (single or multiple genes). These data indicate that CRISPRi is useful to precisely determine the roles of non-coding regions harboring lung disease-associated loci as to whether they function as gene-regulatory regions at a genomic level.
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Affiliation(s)
- William D Stuart
- Division of Neonatology, Perinatal and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Minzhe Guo
- Division of Neonatology, Perinatal and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Iris M Fink-Baldauf
- Division of Neonatology, Perinatal and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Alan M Coleman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - John P Clancy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Marcus A Mall
- Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, 13353, Germany.,Berlin Institute of Health, Berlin, 10178, Germany.,German Center for Lung Research, Berlin, 13353, Germany
| | - Foong-Yen Lim
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - John J Brewington
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Yutaka Maeda
- Division of Neonatology, Perinatal and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
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29
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Aydın E, Nolan H, Peiró JL, Burns P, Rymeski B, Lim FY. When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia? Pediatr Surg Int 2020; 36:485-491. [PMID: 32130491 DOI: 10.1007/s00383-020-04634-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Primary closure is often inadequate for large congenital diaphragmatic hernia (CDH) and necessitates repair by prosthetic patch or autologous muscle flap. Our aim was to evaluate outcomes of open patch versus flap repair, specifically diaphragmatic reherniation. METHODS A retrospective review (IRB #2017-6361) was performed on all CDH patients repaired from 2005 to 2016 at a single academic children's hospital. Patients were excluded from final analysis if they had primary or minimally invasive repair, expired, or were lost to follow-up. RESULTS Of 171 patients, 151 (88.3%) survived to discharge, 9 expired after discharge and 11 were lost to follow up, leaving 131 (86.8%) long-term survivors. Median follow-up was 5 years. Open repair was performed in 119 (90.8%) of which 28 (23.5%) underwent primary repair, 34 (28.6%) patch repair, and 57 (47.9%) flap repair. Overall, 6/119 (5%) patients reherniated, 1/28 (3.6%) in the primary group, 3/34 (8.8%) in the patch group, and 2/57 (3.5%) in the flap group. Comparing prosthetic patch to muscle flap repair, there was no significant difference in the number of patients who recurred nor time to reherniation (3 vs. 2, p = 0.295; 5.5 ± 0.00 months vs. 53.75 ± 71.06 months, p = 0.288). One patient in the patch group recurred twice. CONCLUSIONS Both muscle flap and patch repair of large CDH are feasible and durable with a relatively low risk of recurrence.
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Affiliation(s)
- Emrah Aydın
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA.
| | - Heather Nolan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose Luis Peiró
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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Abramov A, Fan W, Hernan R, Zenilman AL, Wynn J, Aspelund G, Khlevner J, Krishnan U, Lim FY, Mychaliska GB, Warner BW, Cusick R, Crombleholme T, Chung D, Danko ME, Wagner AJ, Azarow K, Schindel D, Potoka D, Soffer S, Fisher J, McCulley D, Farkouh-Karoleski C, Chung WK, Duron V. Comparative outcomes of right versus left congenital diaphragmatic hernia: A multicenter analysis. J Pediatr Surg 2020; 55:33-38. [PMID: 31677822 DOI: 10.1016/j.jpedsurg.2019.09.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) occurs in 1 out of 2500-3000 live births. Right-sided CDHs (R-CDHs) comprise 25% of all CDH cases, and data are conflicting on outcomes of these patients. The aim of our study was to compare outcomes in patients with right versus left CDH (L-CDH). METHODS We analyzed a multicenter prospectively enrolled database to compare baseline characteristics and outcomes of neonates enrolled from January 2005 to January 2019 with R-CDH vs. L-CDH. RESULTS A total of 588, 495 L-CDH, and 93 R-CDH patients with CDH were analyzed. L-CDHs were more frequently diagnosed prenatally (p=0.011). Lung-to-head ratio was similar in both cohorts. R-CDHs had a lower frequency of primary repair (p=0.022) and a higher frequency of need for oxygen at discharge (p=0.013). However, in a multivariate analysis, need for oxygen at discharge was no longer significantly different. There were no differences in long-term neurodevelopmental outcomes assessed at two year follow up. There was no difference in mortality, need for ECMO, pulmonary hypertension, or hernia recurrence. CONCLUSION In this large series comparing R to L-CDH patients, we found no significant difference in mortality, use of ECMO, or pulmonary complications. Our study supports prior studies that R-CDHs are relatively larger and more often require a patch or muscle flap for repair. TYPE OF STUDY Prognosis study LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Alexey Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rebecca Hernan
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Ariela L Zenilman
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Gudrun Aspelund
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Julie Khlevner
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Usha Krishnan
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Foong-Yen Lim
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Brad W Warner
- Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert Cusick
- Division of Pediatric Surgery, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA
| | - Timothy Crombleholme
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Dai Chung
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Amy J Wagner
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kenneth Azarow
- Pediatric Surgery Division, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - David Schindel
- Division of Pediatric Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Douglas Potoka
- Division of Pediatric Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Sam Soffer
- Department of Pediatric Surgery, Northwell Health, New York, NY, USA
| | - Jason Fisher
- Division of Pediatric Surgery, New York University Langone Medical Center, New York, NY, USA
| | - David McCulley
- Department of Pediatrics, Meriter-Unity Point Health, Madison, WI, USA
| | | | - Wendy K Chung
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA; Department of Medicine, Columbia University Medical Center, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Vincent Duron
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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French A, Le Q, DeFranco E, Habli M, Lim FY, McKinney D, Tabbah S. Reproductive Outcomes following Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2019; 47:464-470. [PMID: 31722342 DOI: 10.1159/000503993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are limited studies describing future reproductive outcomes in women who have had selective fetoscopic laser photocoagulation (SFLP) for twin-twin transfusion syndrome (TTTS). OBJECTIVE Our study aims to compare reproductive outcomes following monochorionic multiple gestational pregnancies complicated by TTTS requiring SFLP to those not requiring SFLP. METHODS This is a retrospective cohort study that analyzed records of patients who were evaluated at the Cincinnati Fetal Center (2007-2014) for monochorionic multiple gestations. A questionnaire regarding reproductive, obstetric, gynecologic, and psychological outcomes following the index pregnancy was administered to consented participants by electronic distribution. The data was compared between pregnancies with prior SFLP versus no prior SFLP. RESULTS There was a higher response rate in the SFLP group (219/474, 46.2%) versus the referent group (62/187, 33.2%). The median interval between the index pregnancy and survey completion was 74 months and 46 months in the SFLP and referent groups, respectively. Approximately 38 and 37% of the women in the SFLP and referent groups attempted conception after the index pregnancy with a >90% pregnancy success rate in both groups. Use of assisted reproductive technology was highly prevalent in both the index and subsequent pregnancies, with no significant difference between the groups. Over 60% of the women in each group did not attempt future pregnancy. Of those, approximately 1 in 3 cited the outcome of the index pregnancy as the primary reason for not pursuing future conception. There were no significant differences in selected maternal-fetal complications and new-onset gynecologic problems. More than 1 in 4 women in both groups were diagnosed with a mental health disorder following the index pregnancy. CONCLUSION SFLP does not appear to be associated with adverse reproductive, obstetric, or gynecologic outcomes. The data may help facilitate evidence-based counseling for this patient population.
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Affiliation(s)
- Ashley French
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Quoc Le
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Emily DeFranco
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mounira Habli
- Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, Ohio, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Foong-Yen Lim
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sammy Tabbah
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA, .,Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,
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Abstract
AIM With the advancement in the treatment strategies of congenital diaphragmatic hernia (CDH), there is an increase in the survival rates. This fact leads to an increase in the morbidity and extrapulmonary complications in the long term such as failure to thrive, hernia recurrence, neurodevelopmental delay, gastrointestinal problems, and musculoskeletal anomalies. Herein, we aim to investigate the association between the long-term musculoskeletal complications in CDH patients regarding the defect size, repair type, and perinatal parameters. METHODS After Institutional Review Board approval was obtained (2017-6361), a retrospective chart review was performed on CDH patients from 2003 to 2016. Patients who were operated due to left-sided isolated congenital diaphragmatic hernia and survived to date were included in the study. Data were collected on demographics, preoperative characteristics, operative interventions, and postoperative outcomes. Statistical analysis was performed with IBM SPSS Statistics 20.0.0 (Chicago, IL). RESULTS There were 98 patients with left CDH of whom 33 (33.7%) had primary repair, 25 (25.5%) had patch repair, and 40 (40.8%) had muscle flap repair. The median age of the patients was 6.00 ± 3.83 years. 45 patients (45.9%) had large diaphragmatic defects, 28 patients (28.6%) had at least one type of musculoskeletal deformities, 2 of which were pectus carinatum, 16 were pectus excavatum, and 18 were scoliosis. CDH patients who had small diaphragmatic defects and repaired with a patch were less likely develop musculoskeletal deformities while who had primary abdominal closure after ventral hernia significantly have more pectus excavatum. CONCLUSION Although there was a trend towards an increased risk of the pectus deformity and scoliosis in patients repaired with muscle flap, it did not reach statistical significance. There is a correlation between musculoskeletal deformities and the severity of the CDH.
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Affiliation(s)
- Emrah Aydın
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA. .,Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey.
| | - Oğuz Özler
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose Luis Peiró
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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Nolan H, Aydin E, Frischer JS, Peiro JL, Rymeski B, Lim FY. Hemorrhage after on-ECMO repair of CDH is equivalent for muscle flap and prosthetic patch. J Pediatr Surg 2019; 54:2044-2047. [PMID: 31103273 DOI: 10.1016/j.jpedsurg.2019.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE Prosthetic patch (patch) and muscle flap (flap) techniques are utilized for severe congenital diaphragmatic hernia (CDH) repair; however, when performed on extracorporeal membrane oxygenation (ECMO), the risk of hemorrhage increases. We sought to compare bleeding complications between repair types. METHODS We retrospectively reviewed 2010-2016 on-ECMO CDH repairs. RESULTS Twenty-nine patients met criteria: 13 patch (44.8%) and 16 flap (55.2%). Eight patch (61.5%) and 13 flap (81.2%) patients had left-sided defects (p = 0.223). All defects were Type C or D (Type C: patch 53.8%, flap 56.2%, p = 0.596). There was no difference in gestational age at delivery (patch 37.5 ± 0.9 weeks, flap 37.2 ± 1.3 weeks, p = 0.390) or age at repair (patch 7.46 ± 6.6 days, flap 6.00 ± 4.3 days, p = 0.476). Seven patch (53.8%) and 9 flap (56.2%) patients survived to discharge (p = 0.596). Estimated intraoperative blood loss was equivalent (patch 35.3 ± 53.9 mL, flap 24.2 ± 18.4 mL, p = 0.443). One patch patient (7.6%) and two (12.5%) flap patients required reoperation in the first 48 h for bleeding (p = 0.580). 48-h postoperative transfusions were the same for those that required reoperation (patch 282.0 mL/kg, flap 208.5 ± 21.9 mL/kg, p = 0.054) and those that did not (patch 120.7 ± 111.7 mL/kg, flap 118.4 ± 89.9 mL/kg, p = 0.561). CONCLUSIONS On-ECMO bleeding complications are equivalent for both flap and patch CDH repair. LEVEL OF EVIDENCE Type III (retrospective comparative study).
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Affiliation(s)
- Heather Nolan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Emrah Aydin
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Jason S Frischer
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Jose L Peiro
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Beth Rymeski
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Narayanasamy S, Adler E, Mahmoud M, Burkley M, Lim FY, Subramanyam R. Airway management of congenital pulmonary airway malformation resection in neonates and infants: A case cohort study. Paediatr Anaesth 2019; 29:808-813. [PMID: 31013391 DOI: 10.1111/pan.13648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/21/2019] [Accepted: 04/13/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anesthestic management of congenital pulmonary airway malformation has not been well described in the literature. It is not clear whether one-lung ventialtion is indicated during thoracoscopic lobectomy and if so, what is the best technique achieve it. AIMS We describe the variables with the two commonly performed surgical techniques, thoracoscopic lobectomy and open thoracotomy, from our institutional database to assess the role of lung isolation and the preferable method of lung isolation technique for congenital pulmonary airway malformation resections. METHODS After institutional review board approval, fetal center records were reviewed retrospectively from January 2010 to July 2016 for patients who underwent congenital pulmonary airway malformation resection. The primary goal was to describe the anesthesia induction-airway management techniques with emphasis on one-lung ventilation techniques. RESULTS Among the 65 resections, one-lung ventilation was performed in 30 resections (46%) and was primarily achieved by endobronchial intubation in most cases (80%). One-lung ventilation was performed in a greater number of resections with thoracoscopic lobectomy (96%) compared to open thoracotomies. CONCLUSION From our institution cohort, one-lung ventilation was more commonly used during thoracoscopic resections and was most commonly achieved with endobronchial intubation. Most patients were induced with inhalational anesthesia (sevoflurane), nondepolarizing neuromuscular blocker, and gentle positive pressure ventilation for intubation.
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Affiliation(s)
| | - Elena Adler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Mohamed Mahmoud
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Meghan Burkley
- Department of Anesthesiology, Le Bonheur Children's Hospital, Memphis, TN
| | - Foong-Yen Lim
- Department of Surgical Services, Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rajeev Subramanyam
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Riddle S, Huddle R, Lim FY, Stevenson C, Dean K, Sparling K, Fenchel M, Schibler K. Morbidity and cost burden of prenatal myelomeningocele repair. J Matern Fetal Neonatal Med 2019; 34:1651-1657. [PMID: 31345076 DOI: 10.1080/14767058.2019.1645827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study compared the morbidities and financial burden associated with prenatal open myelomeningocele repair versus postnatal repair. MATERIALS AND METHODS The retrospective study cohort included 23 mother-infant dyads undergoing prenatal repair and 30 with postnatal repair. Financial, demographic, and medical information were obtained for mother-infant dyads from each infant's birth through the first year of life. RESULTS Infants in the prenatal repair group were significantly affected by sequelae of prematurity, including apnea, bronchopulmonary dysplasia, and retinopathy of prematurity. Importantly, fewer of these infants required ventriculoperitoneal shunt procedures and the overall improved composite outcome of shunting or death. Infants in the postnatal repair group required more hospital readmissions in the first year of life. Financial costs for mother-infant dyads in the prenatal repair group were higher, driven by the length of stay in the neonatal intensive care unit and maternal hospital admissions. Kaplan-Meier curves analyzing the relative contributions of the length of stay and total charges in the population were constructed. The maternal contribution was markedly different between groups due to postoperative hospitalization, readmission, and close fetal surveillance required. Though these differences did not reach statistical significance, it highlights an important burden on families and the medical system. CONCLUSIONS This is the first study to report the contributions of prematurity in relation to maternal and infant morbidity and financial costs. The benefits of prenatal myelomeningocele repair include lower risk for ventriculoperitoneal shunting and fewer hospital readmissions. The risk of preterm birth and its neonatal sequelae continue to be a significant burden.
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Affiliation(s)
- Stefanie Riddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert Huddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Cincinnati Fetal Center, Cincinnati, OH, USA.,Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charles Stevenson
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristin Dean
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karen Sparling
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew Fenchel
- Division of Biostatistics and Epidemiology,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kurt Schibler
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Sanz Cortes M, Lapa DA, Acacio GL, Belfort M, Carreras E, Maiz N, Peiro JL, Lim FY, Miller J, Baschat A, Sepulveda G, Davila I, Gielchinsky Y, Benifla M, Stirnemann J, Ville Y, Yamamoto M, Figueroa H, Simpson L, Nicolaides KH. Proceedings of the First Annual Meeting of the International Fetoscopic Myelomeningocele Repair Consortium. Ultrasound Obstet Gynecol 2019; 53:855-863. [PMID: 31169957 DOI: 10.1002/uog.20308] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - D A Lapa
- Fetal Therapy Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G L Acacio
- Department of Obstetrics, Universidade de Taubate, São Paulo, Brazil
| | - M Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - E Carreras
- Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - N Maiz
- Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - J L Peiro
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - F Y Lim
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - J Miller
- Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - G Sepulveda
- Medicine Perinatal Alta Especialidad, Hospital Christus Muguerza Alta Especialidad, Monterrey, NL, Mexico
| | - I Davila
- Medicine Perinatal Alta Especialidad, Hospital Christus Muguerza Alta Especialidad, Monterrey, NL, Mexico
| | - Y Gielchinsky
- Department of Obstetrics & Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Obstetrics & Gynecology, Rabin Medical Center, Petach Tikva, Israel
| | - M Benifla
- Pediatric Neurosurgery Unit, Rambam Health Care Campus, Haifa, Israel
| | - J Stirnemann
- Department of Obstetrics and Gynecology, Necker-Enfants Malades Hospital, Paris, France
| | - Y Ville
- Department of Obstetrics and Gynecology, Necker-Enfants Malades Hospital, Paris, France
| | - M Yamamoto
- Universidad Los Andes, Santiago de Chile, Chile
| | - H Figueroa
- Universidad Los Andes, Santiago de Chile, Chile
| | - L Simpson
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York Presbyterian Hospital, New York City, NY, USA
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Goodnight WH, Bahtiyar O, Bennett KA, Emery SP, Lillegard JB, Fisher A, Goldstein R, Jatres J, Lim FY, McCullough L, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner AJ, Waqar LN, Zaretsky M. Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele. Am J Obstet Gynecol 2019; 220:494.e1-494.e7. [PMID: 30885769 PMCID: PMC6511319 DOI: 10.1016/j.ajog.2019.03.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. OBJECTIVE The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. STUDY DESIGN An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. RESULTS From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). CONCLUSION The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.
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Affiliation(s)
| | | | | | | | - J B Lillegard
- Midwest Fetal Care Center, Children's Hospital of Minnesota, Minneapolis, MN
| | | | - Ruth Goldstein
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | - KuoJen Tsao
- University of Texas Health Center, Houston, TX
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, WI
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Aydin E, Lim FY, Kingma P, Haberman B, Rymeski B, Burns P, Peiro JL. Congenital diaphragmatic hernia: the good, the bad, and the tough. Pediatr Surg Int 2019; 35:303-313. [PMID: 30680439 DOI: 10.1007/s00383-019-04442-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES We aim to determine factors that are associated with better outcomes of CDH patients. METHODS A retrospective review was performed on all CDH patients admitted to our institution between 2003 and 2016. This study was performed at a single institution which has a fetal care center. Patients admitted with CDH with at least 1-year follow-up during the analysis were included in the study. RESULTS Twenty-six (13.8%) patients had a hernia sac, 124 (59%) patients had liver herniation, and 56 (25.1%) patients had an accompanying syndrome. Overall survival to discharge was 73.1% while overall survival to date was 69.5%. The presence of a hernia sac, liver herniation, and accompanying syndromes showed as independent predictors influencing the survival, B 1.968, p = 0.04, OR 7.158, 95% CI 0.907-56.485, B - 1.178, p = 0.01, OR 3.932, 95% CI 1.798-8.602 and B - 1.032, p = 0.05, OR 2.795, 95% CI 0.976-7.764, respectively. CONCLUSION In our CDH cohort, the presence of a hernia sac was proven to be associated with better outcomes, while thoracic herniation of the liver was associated with worse outcomes. The accompanying syndromes although being more difficult to manage had a little effect on the outcome of the disease itself.
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Affiliation(s)
- Emrah Aydin
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA.
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Paul Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Haberman
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose L Peiro
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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Papanna R, Bahtiyar O, Bennett KA, Emery S, Lillegard J, Goldstein R, Goodnight W, Jatres J, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner A, Waqar LN, Zaretsky M, Fisher A. 229: Use of tissue grafts for in-utero spina bifida closure of large skin defects. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rossi RM, Tabbah S, McKinney D, Peiro J, Lim FY, Habli M. 230: Clinical factors associated with shorter latency after open fetal myelomeningocele repair. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Moldenhauer JS, Bahtiyar O, Bennett KA, Emery SP, Lillegard J, Fisher A, Goldstein R, Goodnight W, Jatres J, Lim FY, McCullough LB, Moehrlen U, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner AJ, Waqar LN, Zaretsky M. 213: Fetal myelomeningocele closure: outcomes from the fMMC consortium registry sponsored by NAFTNet. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Qi H, Yu L, Zhou X, Wynn J, Zhao H, Guo Y, Zhu N, Kitaygorodsky A, Hernan R, Aspelund G, Lim FY, Crombleholme T, Cusick R, Azarow K, Danko ME, Chung D, Warner BW, Mychaliska GB, Potoka D, Wagner AJ, ElFiky M, Wilson JM, Nickerson D, Bamshad M, High FA, Longoni M, Donahoe PK, Chung WK, Shen Y. De novo variants in congenital diaphragmatic hernia identify MYRF as a new syndrome and reveal genetic overlaps with other developmental disorders. PLoS Genet 2018; 14:e1007822. [PMID: 30532227 PMCID: PMC6301721 DOI: 10.1371/journal.pgen.1007822] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 12/20/2018] [Accepted: 11/08/2018] [Indexed: 12/24/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth defect that is often accompanied by other congenital anomalies. Previous exome sequencing studies for CDH have supported a role of de novo damaging variants but did not identify any recurrently mutated genes. To investigate further the genetics of CDH, we analyzed de novo coding variants in 362 proband-parent trios including 271 new trios reported in this study. We identified four unrelated individuals with damaging de novo variants in MYRF (P = 5.3x10(-8)), including one likely gene-disrupting (LGD) and three deleterious missense (D-mis) variants. Eight additional individuals with de novo LGD or missense variants were identified from our other genetic studies or from the literature. Common phenotypes of MYRF de novo variant carriers include CDH, congenital heart disease and genitourinary abnormalities, suggesting that it represents a novel syndrome. MYRF is a membrane associated transcriptional factor highly expressed in developing diaphragm and is depleted of LGD variants in the general population. All de novo missense variants aggregated in two functional protein domains. Analyzing the transcriptome of patient-derived diaphragm fibroblast cells suggest that disease associated variants abolish the transcription factor activity. Furthermore, we showed that the remaining genes with damaging variants in CDH significantly overlap with genes implicated in other developmental disorders. Gene expression patterns and patient phenotypes support pleiotropic effects of damaging variants in these genes on CDH and other developmental disorders. Finally, functional enrichment analysis implicates the disruption of regulation of gene expression, kinase activities, intra-cellular signaling, and cytoskeleton organization as pathogenic mechanisms in CDH.
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Affiliation(s)
- Hongjian Qi
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Applied Mathematics and Applied Physics, Columbia University, New York, New York, United States of America
| | - Lan Yu
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
| | - Xueya Zhou
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
| | - Julia Wynn
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
| | - Haoquan Zhao
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, United States of America
| | - Yicheng Guo
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
| | - Na Zhu
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
| | - Alexander Kitaygorodsky
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, United States of America
| | - Rebecca Hernan
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
| | - Gudrun Aspelund
- Department of Surgery, Columbia University Medical Center, New York, New York, United States of America
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, United States of America
| | | | - Robert Cusick
- Children's Hospital & Medical Center of Omaha, University of Nebraska College of Medicine, Omaha, Nebraska, United States of America
| | - Kenneth Azarow
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Melissa E Danko
- Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Dai Chung
- Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Brad W Warner
- Washington University, St. Louis Children's Hospital, St. Louis, Missouri, United States of America
| | - George B Mychaliska
- University of Michigan, CS Mott Children's Hospital, Ann Arbor, Michigan, United States of America
| | - Douglas Potoka
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Amy J Wagner
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Mahmoud ElFiky
- Department of Pediatric Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Jay M Wilson
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States of America
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Debbie Nickerson
- University of Washington, Seattle, Washington, United States of America
| | - Michael Bamshad
- University of Washington, Seattle, Washington, United States of America
| | - Frances A High
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States of America
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Mauro Longoni
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Patricia K Donahoe
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Wendy K Chung
- Department of Pediatrics Medical Center, Columbia University, New York, New York, United States of America
- Department of Medicine, Columbia University, New York, New York, United States of America
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York, United States of America
| | - Yufeng Shen
- Department of Systems Biology, Columbia University Medical Center, New York, New York, United States of America
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, United States of America
- JP Sulzberger Columbia Genome Center, Columbia University Medical Center, New York, New York, United States of America
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Nagaraj UD, Bierbrauer KS, Stevenson CB, Peiro JL, Lim FY, Zhang B, Kline-Fath BM. Spinal Imaging Findings of Open Spinal Dysraphisms on Fetal and Postnatal MRI. AJNR Am J Neuroradiol 2018; 39:1947-1952. [PMID: 30237301 DOI: 10.3174/ajnr.a5760] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/25/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Fetal MRI has become a valuable tool in the evaluation of open spinal dysraphisms making studies comparing prenatal and postnatal MRI findings increasingly important. Our aim was to determine the accuracy of predicting the level of the spinal dysraphic defect of open spinal dysraphisms on fetal MR imaging and to report additional findings observed when comparing fetal and postnatal MR imaging of the spine in this population. MATERIALS AND METHODS A single-center retrospective analysis was performed of fetal MRIs with open spinal dysraphisms from 2004 through 2016 with available diagnostic postnatal spine MR imaging. Images were reviewed by 2 board-certified fellowship-trained pediatric neuroradiologists. Corresponding clinical/operative reports were reviewed. RESULTS One hundred nineteen fetal MRIs of open spinal dysraphisms were included. The level of the osseous defect between fetal and postnatal MR imaging was concordant in 42.9% (51/119) of cases and was 1 level different in 39% (47/119) of cases. On postnatal MR imaging, type II split cord malformation was seen in 8.4% (10/119) of cases, with only 50% (5/10) of these cases identified prospectively on fetal MR imaging. Syrinx was noted in 3% (4/119) of prenatal studies, all cervical, all confirmed on postnatal MR imaging. CONCLUSIONS Fetal MR imaging is accurate in detecting the level of the spinal dysraphic defect, which has an impact on prenatal counseling, neurologic outcomes, and eligibility for fetal surgery. In addition, fetal MR imaging is limited in its ability to detect split cord malformations in patients with open spinal dysraphisms. Although rare, fetal MR imaging has a high specificity for detection of cervical spinal cord syrinx.
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Affiliation(s)
- U D Nagaraj
- From the Department of Radiology and Medical Imaging (U.D.N., B.Z., B.M.K.-F.)
| | | | - C B Stevenson
- Department of Pediatric Neurosurgery (K.S.B., C.B.S.)
| | - J L Peiro
- Department of Pediatric Surgery (J.L.P., F.Y.L.)
| | - F Y Lim
- Department of Pediatric Surgery (J.L.P., F.Y.L.)
| | - B Zhang
- From the Department of Radiology and Medical Imaging (U.D.N., B.Z., B.M.K.-F.)
- Department of Biostatistics and Epidemiology (B.Z.),University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center; Cincinnati, Ohio
| | - B M Kline-Fath
- From the Department of Radiology and Medical Imaging (U.D.N., B.Z., B.M.K.-F.)
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Aydin E, Joshi R, Oria M, Varisco BM, Lim FY, Peiro JL. Fetal tracheal occlusion in mice: a novel transuterine method. J Surg Res 2018; 229:311-315. [PMID: 29937007 DOI: 10.1016/j.jss.2018.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/29/2018] [Accepted: 04/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fetal tracheal occlusion (TO) is an emerging surgical therapy in congenital diaphragmatic hernia that improves the fetal lung growth. Different animal models of congenital diaphragmatic hernia and TO present advantages and disadvantages regarding ethical issues, cost, surgical difficulty, size, survival rates, and available genetic tools. We developed a minimally invasive murine transuterine TO model, which will be useful in defining how TO impacts lung molecular biology, cellular processes, and overall lung physiology. MATERIALS AND METHODS Time-mated C57BL/6 mice underwent laparotomy at embryonic day 16.5 (E16.5) with transuterine TO performed on two fetuses in each uterine horn. At E18.5, dams were sacrificed and fetuses harvested. The lungs of the TO fetuses were compared with the nonmanipulated counterparts by morphometric and histologic analysis. RESULTS Successful TO was confirmed in 16 of 20 TO fetuses. Twelve of them survived to E18.5 (75%). Fetal weights were comparable, but lung weights were significantly greater in TO (28.41 ± 5.87 versus 23.38 ± 3.09, P = 0.043). Lung to body weight ratio was also greater (0.26 ± 0.003 versus 0.22 ± 0.002, P = 0.006). E18.5 TO lungs demonstrated dilated central and distal airspaces with increased cellularity. DNA/protein and DNA/lung weight ratios were elevated while protein/lung weight ratio was lower in TO compared to control. CONCLUSIONS Mice fetal transuterine TO is feasible with comparable outcomes to other current animal models. The increase in the lung weight, lung to body weight ratio and the DNA/protein ratio indicate organized lung growth rather than edema or cell hypertrophy.
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Affiliation(s)
- Emrah Aydin
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Rashika Joshi
- The Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc Oria
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian Michael Varisco
- The Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Foong-Yen Lim
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jose Luis Peiro
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Taylor M, Lee M, Lim FY, Tabbah S, DeFranco E, McKinney D. 821: The influence of laser microseptostomy during selective fetoscopic laser photocoagulation on newborn survival of the recipient and donor twins in twin pregnancies complicated by twin-twin transfusion syndrome. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Radhakrishnan R, Merhar SL, Su W, Zhang B, Burns P, Lim FY, Kline-Fath BM. Prenatal Factors Associated with Postnatal Brain Injury in Infants with Congenital Diaphragmatic Hernia. AJNR Am J Neuroradiol 2017; 39:558-562. [PMID: 29269406 DOI: 10.3174/ajnr.a5500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/30/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Approximately 60% of infants with congenital diaphragmatic hernia have evidence of brain injury on postnatal MR imaging. It is unclear whether any brain injury is present before birth. In this study, we evaluated fetal MR imaging findings of brain injury and the association of congenital diaphragmatic hernia severity with postnatal brain injury. MATERIALS AND METHODS Fetal MR imaging and postnatal brain MR imaging were retrospectively evaluated in 36 cases of congenital diaphragmatic hernia (from 2009 to 2014) by 2 pediatric neuroradiologists. Brain injury on postnatal MR imaging and brain injury and congenital diaphragmatic hernia severity on fetal MR imaging were recorded. Correlations between brain abnormalities on fetal and postnatal brain MR imaging were analyzed. Postnatal brain injury findings correlating with the severity of congenital diaphragmatic hernia were also assessed. RESULTS On fetal MR imaging, enlarged extra-axial spaces (61%), venous sinus distention (21%), and ventriculomegaly (6%) were identified. No maturational delay, intracranial hemorrhage, or brain parenchymal injury was identified on fetal MR imaging. On postnatal MR imaging, 67% of infants had evidence of abnormality, commonly, enlarged extra-axial spaces (44%). Right-sided congenital diaphragmatic hernia was associated with a greater postnatal brain injury score (P = .05). Low observed-to-expected lung volume was associated with postnatal white matter injury (P = .005) and a greater postnatal brain injury score (P = .008). Lack of liver herniation was associated with normal postnatal brain MR imaging findings (P = .03). CONCLUSIONS Fetal lung hypoplasia is associated with postnatal brain injury in congenital diaphragmatic hernia, suggesting that the severity of lung disease and associated treatments affect brain health as well. We found no evidence of prenatal brain parenchymal injury or maturational delay.
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Affiliation(s)
- R Radhakrishnan
- From the Department of Radiology (R.R.), Riley Hospital for Children at Indiana University, Indianapolis, Indiana
| | | | - W Su
- Department of Mathematics (W.S.), University of Cincinnati, Cincinnati, Ohio
| | - B Zhang
- Division of Neonatology, Division of Biostatistics and Epidemiology (B.Z.)
| | - P Burns
- Fetal Care Center (P.B., F.Y.L.)
| | - F Y Lim
- Fetal Care Center (P.B., F.Y.L.)
| | - B M Kline-Fath
- Department of Radiology (B.M.K.-F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Farkouh-Karoleski C, Najaf T, Wynn J, Aspelund G, Chung WK, Stolar CJ, Mychaliska GB, Warner BW, Wagner AJ, Cusick RA, Lim FY, Schindel DT, Potoka D, Azarow K, Cotten CM, Hesketh A, Soffer S, Crombleholme T, Needelman H. A definition of gentle ventilation in congenital diaphragmatic hernia: a survey of neonatologists and pediatric surgeons. J Perinat Med 2017; 45:1031-1038. [PMID: 28130958 DOI: 10.1515/jpm-2016-0271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/28/2016] [Indexed: 01/30/2023]
Abstract
Ventilation practices have changed significantly since the initial reports in the mid 1980 of successful use of permissive hypercapnia and spontaneous ventilation [often called gentle ventilation (GV)] in infants with congenital diaphragmatic hernia (CDH). However, there has been little standardization of these practices or of the physiologic limits that define GV. We sought to ascertain among Diaphragmatic Hernia Research and Exploration; Advancing Molecular Science (DHREAMS) centers' GV practices in the neonatal management of CDH. Pediatric surgeons and neonatologists from DHREAMS centers completed an online survey on GV practices in infants with CDH. The survey gathered data on how individuals defined GV including ventilator settings, blood gas parameters and other factors of respiratory management. A total of 87 respondents, from 12 DHREAMS centers completed the survey for an individual response rate of 53% and a 92% center response rate. Approximately 99% of the respondents defined GV as accepting higher carbon dioxide (PCO2) and 60% of the respondents also defined GV as accepting a lower pH. There was less consensus about the use of sedation and neuromuscular blocking agents in GV, both within and across the centers. Acceptable pH and PCO2 levels are broader than the goal ranges. Despite a lack of formal standardization, the results suggest that GV practice is consistently defined as the use of permissive hypercapnia with mild respiratory acidosis and less consistently with the use of sedation and neuromuscular blocking agents. GV is the reported practice of surveyed neonatologists and pediatric surgeons in the respiratory management of infants with CDH.
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Chiu JS, Ma L, Wynn J, Krishnan U, Rosenzweig EB, Aspelund G, Arkovitz M, Warner BW, Lim FY, Mychaliska GB, Azarow K, Cusick RA, Chung DH, Chung WK. Mutations in BMPR2 are not present in patients with pulmonary hypertension associated with congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:1747-1750. [PMID: 28162765 DOI: 10.1016/j.jpedsurg.2017.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a prevalent major congenital anomaly with significant morbidity and mortality. Thirty to 40% mortality in CDH is largely attributed to pulmonary hypoplasia and pulmonary hypertension (PH). We hypothesized that the underlying genetic risk factors for hereditary PH are shared with CDH associated PH. METHODS Participants were recruited as part of the Diaphragmatic Hernia Research & Exploration; Advancing Molecular Science (DHREAMS) study, a prospective cohort of neonates with a diaphragmatic defect enrolled from 2005 to 2012. PH affected patients with available DNA for sequencing had one of the following: moderate or severe PH on echocardiography at 3months of age; moderate of severe PH at 1month of age with death occurring prior to the 3month echocardiogram; or on PH medications at 1month of age. We sequenced the coding regions of the hereditary PH genes bone morphogenetic protein receptor type II (BMPR2), caveolin 1 (CAV1) and potassium channel subfamily K, member 3 (KCNK3) to screen for mutations. RESULTS There were 29 CDH patients with PH including 16 males and 13 females. Sequencing of BMPR2, CAV1, and KCNK3 coding regions did not identify any pathogenic variants in these genes. TYPE OF STUDY Prognosis study LEVEL OF EVIDENCE: Level IV.
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Affiliation(s)
- Joanne S Chiu
- Department of Pediatrics, Division of Cardiology, Columbia University Medical Center, 3959 Broadway, 2-Babies North, New York, NY 10032, USA.
| | - Lijiang Ma
- Department of Pediatrics, Division of Molecular Genetics, Columbia University Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY 10032, USA
| | - Julia Wynn
- Department of Pediatrics, Division of Molecular Genetics, Columbia University Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY 10032, USA
| | - Usha Krishnan
- Department of Pediatrics, Division of Cardiology, Columbia University Medical Center, 3959 Broadway, 2-Babies North, New York, NY 10032, USA
| | - Erika B Rosenzweig
- Department of Pediatrics, Division of Cardiology, Columbia University Medical Center, 3959 Broadway, 2-Babies North, New York, NY 10032, USA
| | - Gudrun Aspelund
- Division of Pediatric Surgery, Columbia University Medical Center, 3959 Broadway, New York, NY 10032, USA
| | - Marc Arkovitz
- Department of Pediatric Surgery, Tel Hashomer Medical Center, Emek HaEla St 1, Ramat Gan, Israel
| | - Brad W Warner
- Division of Pediatric Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Foong-Yen Lim
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - George B Mychaliska
- Department of Surgery, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kenneth Azarow
- Division of Pediatric Surgery, Oregon Health & Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA
| | - Robert A Cusick
- Division of Pediatric Surgery, University of Nebraska Medical Center, College of Medicine, 42nd St and Emile St., Omaha, NE 68198, USA
| | - Dai H Chung
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Doctors' Office Tower, Suite 7100, Nashville, TN 37232-9780, USA
| | - Wendy K Chung
- Department of Pediatrics, Division of Molecular Genetics, Columbia University Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY 10032, USA
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Moldenhauer J, Lim FY, Miller R, Johnson A, Emery SP, Moon-Grady AJ, Wilkins-Haug L, Peterson E, Bahtiyar OM, Villa A, Zarrin H, Khalek N. 180: North American fetal therapy network: selective reduction in complicated monochorionic twins. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Clifford C, Polzin W, Lim FY, Peiro J, Shaaban A, Habli M. 225: Timing of fetal death and pregnancy outcome in twin twin transfusion syndrome after laser. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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