Y. D. Sevilmis1,2, O. O. Olutoye1, M. A. Belfort1,5,6, C. J. Rhee3,4, J. A. Garcia-Prats3,4, A. M. Vogel1,2, T. C. Lee1,2, S. G. Keswani1,2, A. King1,2 1Baylor College Of Medicine, Michael E. DeBakey Department Of Surgery, Houston, TX, USA 2Texas Children’s Hospital, Department Of Surgery, Division Of Pediatric Surgery, Houston, TX, USA 3Baylor College Of Medicine, Department Of Pediatrics, Houston, TX, USA 4Texas Children’s Hospital, Department Of Pediatrics, Section Of Neonatology, Houston, TX, USA 5Texas Children’s Hospital, Department Of Obstetrics And Gynecology, Houston, TX, USA 6Baylor College Of Medicine, Department Of Obstetrics And Gynecology, Houston, TX, USA
Introduction: Congenital diaphragmatic hernia (CDH) is a complex pathology characterized by pulmonary hypertension and hypoplasia. Surfactant (SURF) use in CDH is controversial and maybe complicated by fetoscopic endoluminal tracheal occlusion (FETO), which is associated with prematurity in clinical trials and surfactant deficiency in animal models. The purpose of this study is to evaluate the characteristics and outcomes in CDH neonates who receive SURF.
Methods: A retrospective review of all fetuses with prenatally diagnosed unilateral CDH born at a single comprehensive fetal care center from 9/2015 to 5/2022 was performed. Prenatal imaging features, perinatal management (including FETO and extracorporeal membranous oxygenation [ECMO]), and outcomes were collected. Data was analyzed with descriptive statistics, two-sample t-test or chi-squared analysis.
Results: Of 102 prenatally diagnosed fetuses with unilateral CDH, 18/102 (18%) underwent FETO. FETO patients were more likely to be younger and receive SURF than non-FETO patients (gestational age (GA), weeks: FETO 35.3 [34.3-37.1] vs non-FETO 38.4 [36.9-39.1], p<0.005; SURF administration: FETO+SURF (10/18) 56% vs non-FETO+SURF (11/84) 13%, p<0.001). Regardless of FETO intervention, patients that received SURF were more likely to be younger with lower birthweights (GA, weeks: non-FETO+SURF 36.3 [33.1-38] vs non-FETO-SURF 38.6 [37.3-39.1] p<0.05; FETO+SURF 34.7 [32.9-36.1] vs. FETO-SURF 37 [35.1-38.9] p<0.05; and birthweight: non-FETO+SURF 2.3kg [2.1-2.8] vs non-FETO-SURF 3.1kg [2.8-3.5] p=0.01; FETO+SURF 2.3kg [2.1-2.8] vs. FETO-SURF 2.9kg [2.7-3.4kg] p<0.05). In those who did not undergo FETO, patients who received SURF had more severe prenatal prognostic indicators (observed/expected total fetal lung volumes: non-FETO+SURF 0.2 [0.16-0.3] vs non-FETO-SURF 0.35 [0.26-0.46] p<0.001) and were associated with decreased survival to discharge (p<0.001) and increased ECMO use (p<0.05). All FETO patients had severe prenatal prognostic indicators. FETO+SURF trended towards lower rates of ECMO use (FETO+SURF 50%) compared with non-FETO severe (type C/D defect) CDH (non-FETO severe CDH 67%, non-FETO severe+SURF 81.8%; p>0.05).
Conclusion: FETO is correlated with increased surfactant use, however, lower GA and birthweight are associated with increased SURF administration in CDH regardless of FETO treatment. While surfactant administration is associated with more severe prognostic indictors and worse outcomes in non-FETO CDH patients, this association is notably absent with FETO. Further evaluation of the effects of FETO and surfactant administration on perinatal respiratory outcomes are needed to improve clinical care of severe CDH patients who undergo fetal intervention.
