title: Fetal pulmonary response after fetoscopic tracheal occlusion for severe isolated congenital diaphragmatic hernia.
abstract: OBJECTIVE
  To estimate the response in lung growth and vascularity after fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia in the prediction of neonatal survival.
  
  
  METHODS
  Between January 2006 and December 2010, fetal lung parameters (observed-to-expected lung-to-head ratio; observed-to-expected lung volume; and contralateral lung vascularization index) were evaluated before fetal tracheal occlusion and were evaluated longitudinally every 2 weeks in 72 fetuses with severe isolated congenital diaphragmatic hernia. Thirty-five fetuses underwent fetal endoscopic tracheal occlusion and 37 cases did not.
  
  
  RESULTS
  Survival rate was significantly higher in the fetal endoscopic tracheal occlusion group (54.3%) than in the no fetal endoscopic tracheal occlusion group (5.4%, P<.01). Fetal endoscopic tracheal occlusion resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with fetuses that did not go to the fetal intervention (increase of the observed-to-expected lung-to-head ratio, observed-to-expected total lung volume, and contralateral pulmonary vascularization index 56.2% compared with 0.3%, 37.9% compared with 0.1%, and 98.6% compared with 0.0%, respectively; P<.01). Receiver operating characteristic curves indicated that the observed-to-expected total fetal lung volume was the single best predictor of neonatal survival before fetal endoscopic tracheal occlusion (cutoff 0.23, area under the curve [AUC] 0.88, relative risk 5.3, 95% confidence interval [CI] 1.4-19.7). However, the contralateral lung vascularization index at 4 weeks after fetal endoscopic tracheal occlusion was more accurate in the prediction of neonatal outcome (cutoff 24.0%, AUC 0.98, relative risk 9.9, 95% CI 1.5-66.9) with the combination of observed-to-expected lung volumes and contralateral lung vascularization index at 4 weeks being the best predictor of outcome (AUC 0.98, relative risk 16.6, 95% CI 2.5-112.3).
  
  
  CONCLUSIONS
  Fetal endoscopic tracheal occlusion improves survival rate by increasing the lung size and pulmonary vascularity in fetuses with severe congenital diaphragmatic hernia. The pulmonary response after fetal endoscopic tracheal occlusion can be used to predict neonatal survival.
authors.affiliation: Obstetrics Department and Pediatric Surgery, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil. rodrigoruano@hotmail.com
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Ruano
authors.forename: Marcos Marques
authors.initials: MM
authors.lastname: da Silva
authors.forename: Juliana Alvares Duarte Bonini
authors.initials: JA
authors.lastname: Campos
authors.forename: Ramesha
authors.initials: R
authors.lastname: Papanna
authors.forename: Kenneth
authors.initials: K
authors.lastname: Moise
authors.forename: Uenis
authors.initials: U
authors.lastname: Tannuri
authors.forename: Marcelo
authors.initials: M
authors.lastname: Zugaib
mesh_terms: D000328:Adult; D001938:Brazil / Q000453:epidemiology; D005260:Female; D005332:Fetoscopy; D005333:Fetus / Q000473:pathology*; D006548:Hernia, Diaphragmatic / Q000401:mortality / Q000473:pathology / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008168:Lung / Q000098:blood supply / Q000196:embryology / Q000473:pathology*; D011247:Pregnancy; D011446:Prospective Studies; D055815:Young Adult