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18539

Repair of Congenital Diaphragmatic Hernias On Extracorporeal Membrane Oxygenation (ECMO): Does Early Repair Improve Patient Survival?

Saturday, October 20, 2012
Napoleon Ballroom (Hilton Riverside)
Sara C. Fallon, MD1, Darrell L. Cass, MD1, Oluyinka O. Olutoye, MD, PhD1, Irving J. Zamora, MD1, David A. Lazar, MD1, Emily L. Larimer, BA1, Stephen Welty, MD2, Alicia A. Moise, MD2, Ann B. Demny, RN2 and Timothy C. Lee, MD1, (1)Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, (2)Pediatrics, Division of Neonatology, Baylor College of Medicine - Texas Children's Hospital, Hosuton, TX

Purpose

The optimal timing of repair for those infants with congenital diaphragmatic hernia (CDH) that require ECMO remains a matter of debate.  Early repair on ECMO theoretically allows for restoration of normal thoracic anatomy. However, serious bleeding from repair performed early in the ECMO course may necessitate premature decannulation. The purpose of this study was to examine the complication rates and outcomes of infants undergoing early CDH repair on ECMO.  

Methods

Following IRB approval, the medical records of all infants with CDH who were treated with ECMO at our institution between 2001 and 2011 were reviewed.  Data collected included fetal imaging prognostic factors, pre-ECMO characteristics, ECMO data, operative details, and post ECMO course.  Data were analyzed using parametric and non-parametric tests where appropriate. "Early" repair was defined as repair <72 hours after ECMO initiation. 

Results

During the study period, 53 infants with CDH received ECMO support with an overall survival of 53%. Twenty-nine patients were repaired on ECMO while 17 patients had repair post-decannulation. Seven died on ECMO without being repaired.  Survival was 73%, 50% and 64% for those repaired early, late, or post-decannulation, respectively (Table 1).  Despite a significantly worse prenatal prognostic factor  (LHR), patients repaired early on ECMO had survival similar to those repaired post decannulation. Furthermore, when comparing only patients repaired on ECMO, the early repair group had a 23% higher survival rate than the late repair group and also were able to be decannulated almost 8 days earlier than the late repair group (p-value = 0.001), with the need for a circuit change was also significantly lower (p=0.001) in the early repair group. However, infants repaired on ECMO tended to have more bleeding complications.

Conclusion

In conclusion, early repair on ECMO was associated with decreased ECMO duration and a trend towards improved survival in comparison to similar severity CDH patients who were repaired late on ECMO. Larger patient cohorts are needed to convincingly address this question and may warrant a prospective multi-institutional study.

Early(<72 hrs)

Late(>72hrs)

Post-Decannulation

p

Number of Patients

11

18

17

Male

73%

67%

53%

0.525

Left-sided Hernia

73%

77%

59%

0.513

Isolated

82%

83%

94%

0.540

Gestational Age

37.9±0.89

37.9±1.9

37.9±1.8

0.992

Birth Weight (g)

2774±537

2981±588

3174±570

0.202

Observed-to-expected Total Fetal Lung Volume

23%±5.7

25%±6.7

33%±11.5

0.068

LHR

1.2±0.32^

1.3±0.26

1.8±0.77^

0.016

Liver up

100%

89%

73%

0.136

Patch repair

100%

95%

87%

0.396

Survival

73%(8/11)

50%(9/18)

64%(11/17)

0.439

Days on ECMO (mean+/-SD)

12±7.5

18±6.1*

10±3.5

0.001

Days of Intubation

42±27

67±49

38±27

0.289

Days in Hospital

110±55

144±81

64±53

0.193

Total # circuit changes

27% (3/11)

72% (13/18)*

17% (3/17)

0.001

Major bleeding complications

36%

44%

12%

0.098

* significant compared to early and post-decannulation

^significant compared to each other