title: Congenital diaphragmatic hernia repair on extracorporeal life support: a decade of lessons learned.
abstract: Congenital diaphragmatic hernia (CDH) is a vexing anomaly that manifests with variable pulmonary compromise in neonates. More than one-third of neonates with CDH require extracorporeal membrane oxygenation (ECMO) for refractory pulmonary hypertension (PHN). To assess the outcome of neonates having CDH repair on ECMO, we reviewed our experience for babies treated between 1992 and 2003. Of 97 neonates with CDH, 40 required ECMO, and 30 were repaired on bypass. Eighteen were supported by veno-venous bypass (VV) and 12 by veno-arterial bypass (VA). While on ECMO, transfusion requirements increased twofold postoperatively (15 to 33 cc x kg(-1) day(-1), P = 0.03) and then significantly decreased after decannulation (1.5 cc x kg(-1) x day(-1), P < 0.01). Non-intracranial hemorrhage occurred in 7 (23%) infants and intracranial hemorrhage in 3 (10%). Twelve (40%) infants died; one (3%) on ECMO secondary to refractory PHN. The mean length of stay for the 18 (60%) survivors was 48 days. Comparisons between survivors and nonsurvivors showed a significantly increased mortality for infants placed on VA bypass (P < 0.01). However, no other variable was predictive of survival. We conclude that CDH repair on ECMO is technically feasible, shows similar survival to the Extracorporeal Life Support Organization (ELSO) registry, and is associated with few bleeding complications.
authors.affiliation: Department of General Surgery, Vanderbilt University Medical Center and Vanderbilt Children's Hospital, Nashville, Tennessee 37212, USA.
authors.forename: Mary T
authors.initials: MT
authors.lastname: Austin
authors.forename: Harold N
authors.initials: HN
authors.lastname: Lovvorn
authors.forename: Irene D
authors.initials: ID
authors.lastname: Feurer
authors.forename: Joshua
authors.initials: J
authors.lastname: Pietsch
authors.forename: T Mark
authors.initials: TM
authors.lastname: Earl
authors.forename: R
authors.initials: R
authors.lastname: Bartilson
authors.forename: Wallace W
authors.initials: WW
authors.lastname: Neblett
authors.forename: John B
authors.initials: JB
authors.lastname: Pietsch
mesh_terms: D000046:Academic Medical Centers; D001034:Apgar Score; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000150:complications / Q000401:mortality / Q000601:surgery*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000209:etiology; D007231:Infant, Newborn; D020300:Intracranial Hemorrhages / Q000209:etiology; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011237:Predictive Value of Tests; D012008:Recurrence; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013714:Tennessee / Q000453:epidemiology; D016896:Treatment Outcome