Fetal Endoscopic Tracheal Occlusion Research Articles

Congenital diaphragmatic hernia treated via fetal endoscopic tracheal occlusion improves outcome in a middle-income country.

A recent European randomized trial- Tracheal Occlusion To Accelerate Lung Growth- demonstrated that fetoscopic endoluminal tracheal occlusion (FETO) is associated with increased postnatal survival among infants with severe congenital diaphragmatic hernia (CDH). However, this differs in middle-income countries such as Brazil, where abortion is illegal and neonatal intensive care is inadequate. This study evaluated the effects of FETO on improving the survival of infants with moderate-to-severe CDH in isolated and non-isolated cases. This retrospective cohort study selected 49 fetuses with CDH, a normal karyotype, and a lung-to-head ratio (LHR) of <1 from a single national referral center for fetal surgery in São Paulo, Brazil, between January 2016 and November 2019. FETO was performed between 26 and 29weeks of gestation. The primary outcomes were infant survival until discharge from the neonatal intensive care unit and survival until six months of age. Forty-six women with singleton fetuses having severe CDH underwent prenatal intervention with FETO. Infant survival rates until discharge and at six months of age were both 38 %. The observed-to-expected LHR increased by 25 % after FETO in neonates who survived until discharge. Spontaneous intrauterine death occurred in four growth-restricted fetuses after FETO. Preterm birth in <37weeks and preterm rupture of membranes in <34weeks occurred in 56.5 % (26) and 26 % (12) cases, respectively. FETO may increase neonatal survival in fetuses with severe CDH, particularly in countries with limited neonatal intensive care.

Fetoscopic Tracheal Occlusion for Isolated Severe Left Diaphragmatic Hernia: A Systematic Review and Meta-Analysis.

Background: We aimed to conduct a systematic review and meta-analysis to evaluate the fetoscopic tracheal occlusion in patients with isolated severe and left-sided diaphragmatic hernia. Methods: Cochrane Library, Embase, and PubMed (Medline) databases were searched from inception to February 2024 with no filters or language restrictions. We included studies evaluating the outcomes of fetoscopic intervention compared to expectant management among patients with severe congenital diaphragmatic hernia exclusively on the left side. A random-effects pairwise meta-analysis was performed using RStudio version 4.3.1. Results: In this study, we included 540 patients from three randomized trials and five cohorts. We found an increased likelihood of neonatal survival associated with fetoscopic tracheal occlusion (Odds Ratio, 5.07; 95% Confidence Intervals, 1.91 to 13.44; p < 0.01) across general and subgroup analyses. Nevertheless, there were higher rates of preterm birth (OR, 5.62; 95% CI, 3.47-9.11; p < 0.01) and preterm premature rupture of membranes (OR, 7.13; 95% CI, 3.76-13.54; p < 0.01) in fetal endoscopic tracheal occlusion group compared to the expectant management. Conclusions: Our systematic review and meta-analysis demonstrated the benefit of fetoscopic tracheal occlusion in improving neonatal and six-month postnatal survival in fetuses with severe left-sided CDH. Further studies are still necessary to evaluate the efficacy of tracheal occlusion for isolated right-sided CDH, as well as the optimal timing to perform the intervention.

OP07.03: Refined technique for ultrasound‐guided balloon puncture to safely reverse fetal endoscopic tracheal occlusion in congenital diaphragmatic hernia

OP07.03: Refined technique for ultrasound‐guided balloon puncture to safely reverse fetal endoscopic tracheal occlusion in congenital diaphragmatic hernia

Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: systematic review and meta-analysis.

It is debated whether fetal endoscopic tracheal occlusion (FETO) is beneficial to fetuses with congenital diaphragmatic hernia (CDH) and whether FETO has different effects in moderate and severe CDH. We conducted a systematic review and meta-analysis including the latest evidence to assess the overall effects of FETO on clinical outcomes of CDH. We searched PubMed, EMBASE, The Cochrane Library, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang Database to retrieve eligible studies published before 8 September 2022. No language or study design restrictions were applied. Studies were included if CDH fetuses underwent FETO surgery and were compared with a cohort that underwent expectant management, with at least one outcome reported. The primary outcomes were mortality at 1, 6 and 12 months after birth, rates of pulmonary hypertension, use of extracorporeal membrane oxygenation (ECMO) and prematurity. Meta-analysis was conducted to obtain pooled odds ratios (ORs) and mean differences. The quality of included studies and pooled evidence was also assessed. A total of 1187 CDH fetuses from 20 studies were included in the quantitative synthesis. FETO significantly reduced 1-month (OR, 0.56 (95% CI, 0.34-0.93); P = 0.02, number needed to treat (NNT) = 7.67) and 6-month (OR, 0.34 (95% CI, 0.18-0.65); P = 0.0009, NNT = 5.26) CDH mortality (moderate/low quality of evidence). Subgroup analysis suggested that the effects of FETO on the rates of pulmonary hypertension and ECMO usage were significant in severe CDH (low/moderate quality of evidence) but not in moderate CDH (low/very low quality of evidence). FETO was also associated with an increased risk of preterm prelabor rupture of membranes before 37 weeks' gestation (OR, 4.94 (95% CI, 2.25-10.88); P < 0.0001, number needed to harm (NNH) = 3.13) and preterm birth before 37 weeks (OR, 5.24 (95% CI, 3.33-8.23); P < 0.00001, NNH = 2.79) (high/moderate quality of evidence). However, FETO was not associated with severe complications, such as preterm birth before 32 weeks, placental abruption or chorioamnionitis (very low/low quality of evidence). FETO is associated with a reduction in mortality, rate of pulmonary hypertension and ECMO usage in severe CDH, while it reduces only the risk of mortality in moderate CDH. Although FETO increases the risk of late prematurity, it does not result in extreme prematurity. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Development and internal validation of a prediction model to predict survival for congenital diaphragmatic hernia in the early postnatal period

Purpose To develop an easily applied predictive model to predict survival rate for infants with congenital diaphragmatic hernia (CDH) in the early postnatal period according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) guideline. Methods The retrospective study was conducted including 225 neonates with prenatal or postnatal diagnosed CDH between 2001 and 2018. Patients did not receive the therapy of fetal endoscopic tracheal occlusion and extracorporeal membrane oxygenation. The study took into consideration these variables that are easily available in most centers within the first 1 h after admission. A multivariable prediction model to predict the survival rate for CDH was generated and its performance was analyzed. Results The multiple logistic regression analysis was generated using five clinical variables that are routinely available in most centers, including birth weight, 1-min Apgar score, side of hernia, presence of liver herniation, and PaCO2 in the admission arterial blood analysis. The area under the receiver operating characteristic curve value for this model was 0.912, which was greater than that of a single biomarker in predicting the survival rate of CDH. This model had a sensitivity of 90.6% and a specificity of 74.6%. This model demonstrated good calibration (Hosmer–Lemeshow goodness-of-fit test, p = .410). Besides, the model had a better discriminative ability compared to the previously established predictive models of CDH. Conclusions The simple and generalizable model was developed by five predictors for CDH in the early period using the TRIPOD checklist. It demonstrated good performance in predicting the survival rate of infants with CDH, holding promise for future clinical application.

Fetal endoscopic tracheal occlusion for moderate and severe congenital diaphragmatic hernia: a systematic review and meta-analysis of randomized controlled trials.

Fetoscopic endoluminal tracheal occlusion (FETO) is considered to increase survival among fetuses with congenital diaphragmatic hernia (CDH). Data from high-quality trials had been lacking until the largest randomized controlled trials (the TOTAL trials) were completed. This study aimed to elucidate the efficacy and safety of FETO for increasing the survival of fetuses with moderate or severe CDH. Relevant studies published before August 1st, 2021 were identified by searching PubMed, Cochrane Library and Web of Science. Only randomized controlled trials (RCTs) reporting patients who underwent FETO versus patients who received standard perinatal care were included in the analysis. The primary outcome was survival in the FETO and control groups. The secondary aim was to evaluate complications during pregnancy, such as premature rupture of membranes (PROM) and preterm delivery, and neonatal complications, including the need for supplemental oxygen at birth and discharge and pulmonary hypertension in the FETO and control groups. The Mantel-Haenszel random effects model was applied, and risk ratios (RRs) or odds ratios (ORs) were calculated. Four RCTs were eligible for inclusion. The quality of these studies was high. The pooled estimate of survival for fetuses with moderate or severe CDH was higher in the FETO group than in the control group [odds ratio (OR), 3.43; 95% confidence interval (CI), 1.12-10.48; P = 0.03] with relatively strong evidence of between-study heterogeneity (I2 = 66%). Subgroup analysis revealed that in the severe CDH group, the pooled estimates of neonatal survival were significantly higher in the FETO group than in the control group (OR, 6.57; 95% CI, 1.39-31.06; P = 0.02). However, in the moderate CDH group, the pooled results of neonatal survival were only slightly higher in the FETO group than in the control group (OR, 1.65; 95% CI, 0.93-2.91; P = 0.08) and the difference was not significant. The risks of PROM and preterm delivery were both higher in the FETO group. No significant difference was found for the need for supplemental oxygen at birth and discharge or in pulmonary hypertension between the FETO group and matched controls. A limitation is that we were unable to calculate the effect of the second intervention on prematurity, which would have been meaningful for evaluating the risk of FETO for PROM or preterm delivery. FETO increases the survival rate in fetuses with moderate and severe CDH, especially in fetuses with severe CDH. However, FETO is associated with a higher risk of PROM and preterm delivery, and the optimal time of FETO should be carefully chosen.

Congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.

Improved survival for infants with severe congenital diaphragmatic hernia.

Survival for severe (observed to expected lung-head ratio (O:E LHR) < 25%) congenital diaphragmatic hernia (CDH) remains a challenge (15-25%). Management strategies have focused on fetal endoscopic tracheal occlusion (FETO) and/or extracorporeal membrane oxygenation therapy (ECMO) utilization. Describe single center outcomes for infants with severe CDH. Observational study of 13 severe CDH infants managed with ECMO, a protocolized DR algorithm, and early repair on ECMO with an innovative perioperative anticoagulation strategy. 13/140 (9.3%) infants met criteria and were managed with ECMO. 77% survived ECMO and 69% survived to discharge. 22% underwent tracheostomy. Median days on mechanical ventilation was 39 days (IQR 22:107.5) and length of stay 135 days (IQR 62.5:211.5). All infants received a gastrostomy tube (GT) and were discharged home on oxygen and pulmonary hypertension (PH) meds. Survival for infants with severe CDH can be optimized with early aggressive intervention and protocolized algorithms (149).

Imaging Assessment of Prognostic Parameters in Cases of Isolated Congenital Diaphragmatic Hernia: Integrative Review.

Antenatal recognition of severe cases of congenital diaphragmatic hernia (CDH) by ultrasound (US) and magnetic resonance imaging (MRI) may aid decisions regarding the indication of fetal endoscopic tracheal occlusion. An integrative review was performed. Searches in MEDLINE and EMBASE used terms related to CDH, diagnosis, MRI, and US. The inclusion criteria were reviews and guidelines approaching US and MRI markers of severity of CDH published in English in the past 10 years. The search retrieved 712 studies, out of which 17 publications were included. The US parameters were stomach and liver positions, lung-to-head ratio (LHR), observed/expected LHR (o/e LHR), and quantitative lung index. The MRI parameters were total fetal lung volume (TFLV), observed/expected TFLV, relative fetal or percent predicted lung volumes, liver intrathoracic ratio, and modified McGoon index. None of the parameters was reported to be superior to the others. The most mentioned parameters were o/e LHR, LHR, liver position, o/e TFLV, and TFLV.

Fetal Tracheal Occlusion Increases Lung Basal Cells via Increased Yap Signaling.

Fetal endoscopic tracheal occlusion (FETO) is an emerging surgical therapy for congenital diaphragmatic hernia (CDH). Ovine and rabbit data suggested altered lung epithelial cell populations after tracheal occlusion (TO) with transcriptomic signatures implicating basal cells. To test this hypothesis, we deconvolved mRNA sequencing (mRNA-seq) data and used quantitative image analysis in fetal rabbit lung TO, which had increased basal cells and reduced ciliated cells after TO. In a fetal mouse TO model, flow cytometry showed increased basal cells, and immunohistochemistry demonstrated basal cell extension to subpleural airways. Nuclear Yap, a known regulator of basal cell fate, was increased in TO lung, and Yap ablation on the lung epithelium abrogated TO-mediated basal cell expansion. mRNA-seq of TO lung showed increased activity of downstream Yap genes. Human lung specimens with congenital and fetal tracheal occlusion had clusters of subpleural basal cells that were not present in the control. TO increases lung epithelial cell nuclear Yap, leading to basal cell expansion.

Can fetal ultrasound and MRI predict outcome after fetal endoscopic tracheal occlusion for isolated severe congenital diaphragmatic hernia?

Can fetal ultrasound and MRI predict outcome after fetal endoscopic tracheal occlusion for isolated severe congenital diaphragmatic hernia?

Perinatal Outcomes after Fetal Endoscopic Tracheal Occlusion for Isolated Congenital Diaphragmatic Hernia: Rapid Review.

To compare the perinatal outcomes of fetuses with isolated congenital diaphragmatic hernia after fetal endoscopic tracheal occlusion (FETO) and antenatal expectant management. In this rapid review, searches were conducted in the MEDLINE, PMC, EMBASE and CENTRAL databases between August 10th and September 4th, 2020. Randomized controlled trials (RCTs), quasi-RCTs or cluster-RCTs published in English in the past ten years were included. We retrieved 203 publications; 180 studies were screened by abstract. Full-text selection was performed for eight studies, and 1 single center RCT met the inclusion criteria (41 randomized women; 20 in the FETO group, and 21 in the control group). Data collection was performed independently, by both authors, in two steps (title and abstract and full-text reading). There were no cases of maternal mortality. The mean gestational age at delivery was of 35.6 ± 2.4 weeks in the intervention group, and of 37.4 ± 1.9 weeks among the controls (p < 0.01). Survival until 6 months of age was reported in 50% of the intervention group, and in 5.8% of the controls (p < 0.01; relative risk: 10.5; 95% confidence interval [95%CI]: 1.5-74.7). Severe postnatal pulmonary hypertension was found in 50% of the infants in the intervention group, and in 85.7% of controls (p = 0.02; relative risk: 0.6; 95%CI: 0.4-0.9). An analysis of the study indicated some concerns of risk of bias. The quality of evidence was considered moderate to low. Current evidence is limited but suggests that FETO may be an effective intervention to improve perinatal outcomes.

A maChine and deep Learning Approach to predict pulmoNary hyperteNsIon in newbornS with congenital diaphragmatic Hernia (CLANNISH): Protocol for a retrospective study.

IntroductionOutcome predictions of patients with congenital diaphragmatic hernia (CDH) still have some limitations in the prenatal estimate of postnatal pulmonary hypertension (PH). We propose applying Machine Learning (ML), and Deep Learning (DL) approaches to fetuses and newborns with CDH to develop forecasting models in prenatal epoch, based on the integrated analysis of clinical data, to provide neonatal PH as the first outcome and, possibly: favorable response to fetal endoscopic tracheal occlusion (FETO), need for Extracorporeal Membrane Oxygenation (ECMO), survival to ECMO, and death. Moreover, we plan to produce a (semi)automatic fetus lung segmentation system in Magnetic Resonance Imaging (MRI), which will be useful during project implementation but will also be an important tool itself to standardize lung volume measures for CDH fetuses.Methods and analyticsPatients with isolated CDH from singleton pregnancies will be enrolled, whose prenatal checks were performed at the Fetal Surgery Unit of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Milan, Italy) from the 30th week of gestation. A retrospective data collection of clinical and radiological variables from newborns’ and mothers’ clinical records will be performed for eligible patients born between 01/01/2012 and 31/12/2020. The native sequences from fetal magnetic resonance imaging (MRI) will be collected. Data from different sources will be integrated and analyzed using ML and DL, and forecasting algorithms will be developed for each outcome. Methods of data augmentation and dimensionality reduction (feature selection and extraction) will be employed to increase sample size and avoid overfitting. A software system for automatic fetal lung volume segmentation in MRI based on the DL 3D U-NET approach will also be developed.Ethics and disseminationThis retrospective study received approval from the local ethics committee (Milan Area 2, Italy). The development of predictive models in CDH outcomes will provide a key contribution in disease prediction, early targeted interventions, and personalized management, with an overall improvement in care quality, resource allocation, healthcare, and family savings. Our findings will be validated in a future prospective multicenter cohort study.RegistrationThe study was registered at ClinicalTrials.gov with the identifier NCT04609163.

Fetal Surgery for Congenital Diaphragmatic Hernia

Research Article| September 01 2021 Fetal Surgery for Congenital Diaphragmatic Hernia AAP Grand Rounds (2021) 46 (3): 33. https://doi.org/10.1542/gr.46-3-33 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Fetal Surgery for Congenital Diaphragmatic Hernia. AAP Grand Rounds September 2021; 46 (3): 33. https://doi.org/10.1542/gr.46-3-33 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: fetal surgery, hernia, congenital diaphragmatic, fetal endoscopic tracheal occlusion Source: Deprest JA, Nicolaides KH, Benachi A, et al. Randomized trial of fetal surgery for severe left diaphragmatic hernia. N Engl J Med. 2021;385(2):107-118; doi: https://doi.org/10.1056/NEJMoa2027030Google Scholar Investigators from multiple international institutions conducted an open-label randomized controlled trial to assess the efficacy of fetal endoluminal tracheal obstruction (FETO) in fetuses with severe pulmonary hypoplasia secondary to left-sided diaphragmatic hernia. With FETO, a balloon is inserted into the trachea of an affected fetus prior to 30 weeks’ gestation and inflated; the balloon is deflated at a later point. The study was conducted at 10 FETO centers and 26 NICUs in multiple countries. Women >18 years old with a fetus with a left diaphragmatic hernia and severe pulmonary hypoplasia (fetal lung-to-head ratio <25% of predicted based on gestational age) who were <33 weeks, 6 days gestation... You do not currently have access to this content.

Effectiveness Of Fetal Endoscopic Tracheal Occlusion Therapy In The Prenatal Period Of Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia is one of the rare malformations (0.8-5 / 10000). Although there are many treatment options in the postnatal period, as the severity of the malformation increases, the response to treatment decreases. Lung development is restricted by the compression of intraabdominal organs passing through the diaphragmatic defect. The severity of pulmonary hypertension due to hypoplasia in the lung tissue is closely related to postnatal morbidity and mortality. In addition to the lung tissue, left ventricular hypoplasia may also occur due to pressure on the heart. For all these reasons, treatment options have begun to be investigated even in the prenatal period, before tissue hypoplasia develops. In the last 20 years, there have been serious developments in ultrasound and magnetic resonance devices in parallel with the developments in technology. Accordingly, lung development of fetuses with diaphragmatic hernia during prenatal period has been better followed. Fetal endoscopic tracheal occlusion is the only method that can give treatment options to patients who are found to have severely decreased lung tissue in the prenatal period, in order to increase postpartum life expectancy. With this procedure, it is aimed to collect the fluids released from the lung with a balloon placed in the trachea in the prenatal period. Because of these accumulated fluids, the lung volume expands, tissue hypoplasia decreases, and the degree of pulmonary hypertension decreases. Although the fetal tracheal occlusion procedure has improved neonatal outcomes, there is a possibility of complications depending on the way the procedure is applied. Various complications such as premature rupture of membranes and preterm labor can be seen depending on the procedure. For this reason, it is necessary to choose the candidates for the tracheal occlusion procedure well and to calculate the profit-loss ratio well. In this study, current publications of fetal endoscopic tracheal occlusion procedure were reviewed. It was investigated on which patients the procedure could be applied and what the benefits and harms might be if it was applied.

Impact of fetal endoscopic tracheal occlusion in fetuses with congenital diaphragmatic hernia and moderate lung hypoplasia.

To assess the effect of Fetal Endoscopic Tracheal Occlusion (FETO) on neonatal survival in fetuses with left congenital diaphragmatic hernia (CDH) and moderate lung hypoplasia. CDH fetuses with moderate pulmonary hypoplasia (observed/expected lung area to head ratio between 26% and 35%, or between 36% and 45% with liver herniation) were prospectively recruited. Included patients were matched to a control group who were ineligible for FETO. Primary outcomes were survival at 28days, at discharge, and at 6months of age, respectively. 58 cases were recruited, 29 treated with FETO and 29 matched controls. Median gestational age (GA) at balloon placement and removal were 29.6 and 33.6weeks, respectively. FETO group showed significantly lower GA at delivery (35.2 vs. 37.1weeks, respectively, p<0.01), higher survival at 28days (51.7 vs. 24.1%, respectively, p=0.03), at discharge (48.3 vs. 24.1%, respectively, p=0.06), and at six months of age (41.4 vs. 24.1%, respectively, p=0.16), and significantly lower length of ventilatory support (17.8 vs. 32.3days, p=0.01) and NICU stay (34.2 vs. 58.3days, p=<0.01) compared to controls. FETO was associated with a non-significant increase in survival and significantly lower neonatal respiratory morbidity among CDH fetuses with moderate lung hypoplasia.

Extracellular Vesicles and Their miRNA Content in Amniotic and Tracheal Fluids of Fetuses with Severe Congenital Diaphragmatic Hernia Undergoing Fetal Intervention.

Infants with congenital diaphragmatic hernia (CDH) are at high risk of postnatal mortality due to lung hypoplasia and arterial pulmonary hypertension. In severe cases, prenatal intervention by fetal endoscopic tracheal occlusion (FETO) can improve survival by accelerating lung growth. However, postnatal mortality remains in the range of about 50% despite fetal treatment, and there is currently no clear explanation for this different clinical response to FETO. We evaluated the concentration of extracellular vesicles (EVs) and associated microRNA expression in amniotic and tracheal fluids of fetuses with CDH undergoing FETO, and we examined the association between molecular findings and postnatal survival. We observed a higher count of EVs in the amniotic fluid of non-survivors and in the tracheal fluid sampled in utero at the time of reversal of tracheal occlusion, suggesting a pro-inflammatory lung reactivity that is already established in utero and that could be associated with a worse postnatal clinical course. In addition, we observed differential regulation of four EV-enclosed miRNAs (miR-379-5p, miR-889-3p; miR-223-3p; miR-503-5p) in relation to postnatal survival, with target genes possibly involved in altered lung development. Future research should investigate molecular therapeutic agents targeting differentially regulated miRNAs to normalize their expression and potentially improve clinical outcomes.

Fetal endoscopic tracheal occlusion and pulmonary hypertension in moderate congenital diaphragmatic hernia

Objective To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmonary hypertension (PH) in fetuses with isolated moderate left-sided diaphragmatic hernia (CDH). Methods This retrospective study included fetuses with CDH evaluated between February 2004 and July 2017. Using the tracheal occlusion to accelerate lung growth (TOTAL) trial definition, we classified fetuses into moderate left CDH if O/E-LHR (observed/expected-lung head ratio) was 25–34.9% regardless of liver position or O/E-LHR of 35–44.9% if liver was in the chest. Postnatal echocardiograms were used to diagnose PH. Logistic regression analyses were performed to determine the relationship of FETO with study outcomes. Results Of 184 cases with no other major anomalies, 30 (16%) met criteria. There were nine FETO and 21 non-FETO cases. By hospital discharge, a higher proportion of infants in the FETO group had resolution of PH (87.5 (7/8) vs. 40% (8/20); p=.013). FETO was associated with adjusted odds ratio of 17.3 (95% CI: 1.75–171; p=.015) to resolve PH by hospital discharge. No significant differences were noted in need for ECMO or survival to discharge between groups. Conclusions Infants with moderate left-sided CDH according to O/E-LHR, FETO is associated with resolution of PH by the time of hospital discharge.

Инновационная модель эндотрахеального катетера (ФЭТО-баллон) для эндоскопической окклюзии трахеи при тяжелой врожденной диафрагмальной грыже плода

Инновационная модель эндотрахеального катетера (ФЭТО-баллон) для эндоскопической окклюзии трахеи при тяжелой врожденной диафрагмальной грыже плода

Prenatal stomach position predicts gastrointestinal morbidity at 2 years in fetuses with left-sided congenital diaphragmatic hernia.

The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH. This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables. Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years. In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.