Research: Fetoscopic endoluminal tracheal occlusion versus expectant management for fetuses with severe left-sided congenital diaphragmatic hernia

Am J Obstet Gynecol MFM

. 2023 Dec 7:101248.

 doi: 10.1016/j.ajogmf.2023.101248. Online ahead of print.

Fetoscopic endoluminal tracheal occlusion versus expectant management for fetuses with severe left-sided congenital diaphragmatic hernia

Vivien Dütemeyer 1Thomas Schaible 2Dominique A Badr 1Anne-Gael Cordier 3Meike Weis 4Alba Perez-Ortiz 2Diane Carriere 5Mieke M Cannie 6Aline Vuckovic 7Nicola Persico 8Giacomo Cavallaro 9Alexandra Benachi 3Jacques C Jani 10

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Background: The therapy of fetuses with congenital diaphragmatic hernia (CDH) is challenging, but there is evidence that fetoscopic endoluminal tracheal occlusion (FETO) has a benefit over expectant care. Additionally, standardisation and expertism have a great impact on survival, probably the key of centers relying on expectant management and extracorporeal membrane oxygenation (ECMO) after birth.

Objective: To examine the survival and morbidity rates of fetuses with severe isolated left-sided CDH (LCDH) who underwent FETO versus expectant management in high-volume centers.

Study design: This was a multicenter retrospective study including all consecutive fetuses with severe isolated LCDH who were expectantly managed in a German center or underwent FETO in three other European centers (Belgium, France and Italy). Severe CDH was defined as observed-expected total fetal lung volume (o/e TFLV) ≤35% with intrathoracic position of the liver, using magnetic resonance images (MRI). All MRI were centralized and lung volumes were measured by two experienced operators, who were blinded to the pre- and postnatal data. Multiple logistic regression analyses were performed to examine the effect of the management in the two groups on the short- and long-term outcomes.

Results: 147 patients with expectant management and 47 patients who underwent FETO were analyzed. Fetuses who were expectantly managed had lower o/e TFLV (20.6% ± 7.5% versus 23.7% ± 6.8%, p=0.013), higher gestational age at delivery (median weeks of gestation: 37.4 [IQR: 36.6, 38.00] versus 35.1 [IQR: 33.1, 37.2], p<0.001) and a more frequent use of ECMO (55.8% versus 4.3%, p<0.001) in comparison to the fetuses who underwent FETO. The survival rates at discharge and at two years of age of the expectant management group were higher compared to the survival rates of the FETO group (74.3% versus 44.7%, p=0.001 and 72.8% versus 42.5%, p=0.001, respectively). After adjustment for maternal age, gestational age at birth, o/e TFLV and birthweight Z-score, the odds ratios were 4.65 (95%CI: 1.9-11.9, p=0.001) and 4.37 (95%CI: 1.8-11.0, p=0.001) respectively. The morbidity was comparable between both groups.

Conclusion: Fetuses with severe isolated LCDH had a higher survival rate when treated in an experienced center in Germany with an antenatal expectant management and frequent use of ECMO during the postnatal period in comparison to fetuses treated with FETO in Belgium, France and Italy, without the expense of higher morbidity.

Keywords: congenital diaphragmatic hernia; extracorporeal membrane oxygenation; fetoscopic endoluminal tracheal occlusion; magnetic resonance imaging; survival rate.

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