Surgical Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation Cannulation

Abstract

Objective: To determine the optimal timing of congenital diaphragmatic hernia (CDH) repair after extracorporeal membrane oxygenation (ECMO) cannulation Summary Background Data: The timing of CDH repair after ECMO cannulation remains a controversial topic due to studies with low power or strong selection bias. Methods: This is a 2-aim retrospective cohort study based on the CDH Study Group registry for the period of 2007-2017. Aim 1-Compare On versus After ECMO repair. Aim 2-Compare Early versus Late repair on ECMO. In order to minimize selection bias and account for non-repairs, subjects in each aim were stratified into study groups based on their treatment center's characteristics. In each aim, the study groups were matched based on propensity score (PS). The main outcomes included mortality rate and incidence of non-repair. Results: In aim 1, 136 patients remained in each group after PS matching. Compared to the After ECMO group, patients in the On ECMO group demonstrated a lower mortality rate, hazard ratio (HR) 0.54 (0.38, 0.77) (P < 0.001), and lower incidence of non-repair, 5.9% versus 33.8% (P < 0.001). In aim 2, 77 patients remained in each group after PS matching. Compared to the Late group, Early repair of CDH on ECMO was associated with a lower mortality rate, HR 0.51 (0.33, 0.77) (P ¼ 0.002), and lower incidence of non-repair, 9.1% versus 44.2% (P < 0.001). Conclusions: The approach of early repair after ECMO cannulation is associated with improved survival compared to delayed surgical correction.

Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study

“…Gentili et al found a stabilization interval of 43.9 ± 38.7 hours (range 22e168 hours) before patients underwent surgical correction [37]. It is possible that the lack of a standardized treatment protocol before surgical repair might contribute to infant mortality within the first week of life [35,38].…”

Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

“…For patients who undergo surgical repair while on ECMO, early repair could not only reduce ECMOassociated bleeding risk at the time of repair but could theoretically permit earlier compensatory lung growth while resting on ECMO, although outcomes have been mixed [6,[11][12][13]. Robertson et al found that survival was not significantly different between those repaired before and after 5 days following cannulation at 43.3% and 41.2%, respectively [6].…”

“…Where possible, for those patients needing ECMO, repair after ECMO is preferred [5][6][7][8]; however for highrisk patients, repair on ECMO is often necessary to minimize the risk of non-repair, allow for compensatory lung growth, and improve the chance of survival [9,10]. The optimal timing of CDH repair on ECMO, whether early or late after cannulation, is yet to be established; however, published reports to date suggest benefit with early repair [6,[9][10][11][12][13]. In a recent study, Dao et al reported that for centers that perform mostly on ECMO repairs, mortality is improved with early repair on ECMO when compared to repair after weaning from ECMO [11].…”

“…The optimal timing of CDH repair on ECMO, whether early or late after cannulation, is yet to be established; however, published reports to date suggest benefit with early repair [6,[9][10][11][12][13]. In a recent study, Dao et al reported that for centers that perform mostly on ECMO repairs, mortality is improved with early repair on ECMO when compared to repair after weaning from ECMO [11]. While counter to many studies that suggest improvement in survival when repair is delayed until after ECMO decannulation, this report adds to the controversy and debate as to optimal timing of repair for the subset of CDH patients requiring ECMO.…”

“…While counter to many studies that suggest improvement in survival when repair is delayed until after ECMO decannulation, this report adds to the controversy and debate as to optimal timing of repair for the subset of CDH patients requiring ECMO. What is clearly outlined in the literature is salvage repair late when patients fail to wean from ECMO is associated with the worst outcomes [9][10][11]. This could be secondary to disease severity in these patients, but may also be related to increased complications with late repair on ECMO.…”