Elsevier

Journal of Pediatric Surgery

Volume 44, Issue 9, September 2009, Pages 1691-1701
Journal of Pediatric Surgery

Original article
Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation

https://doi.org/10.1016/j.jpedsurg.2009.01.017Get rights and content

Abstract

Purpose

Venoarterial extracorporeal membrane oxygenation (ECMO) (VA) is used more commonly in neonates with congenital diaphragmatic hernia (CDH) than venovenous ECMO (VV). We hypothesized that VV may result in comparable outcomes in infants with CDH requiring ECMO.

Methods

We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) database (1991-2006). Multivariate logistic regression analyses were used to compare VV- and VA-associated mortality.

Results

Four thousand one hundred fifteen neonates required ECMO, with an overall mortality rate of 49.6%. Venoarterial ECMO was used in 82% and VV in 18% of neonates. Pre-ECMO inotrope use and complications were equivalent between VA and VV. The mortality rate for VA and VV was 50% and 46%, respectively. After adjusting for birth weight, gestational age, prenatal diagnosis, ethnicity, Apgar scores, pH less than 7.20, Paco2 greater than 50, requiring high-frequency ventilation, and year of ECMO, there was no difference in mortality between VV vs VA. Renal complications and on-ECMO inotrope use were more common with VV, whereas neurologic complications were more common with VA. The conversion rate from VV to VA was 18%; conversion was associated with a 56% mortality rate.

Conclusion

The short-term outcomes of VV and VA are comparable. Patients with CDH who fail VV may be predisposed to a worse outcome. Nevertheless, VV offers equal benefit to patients with CDH requiring ECMO while preserving the native carotid.

Section snippets

Data source

The ELSO registry database was used to compare VV and VA. Since 1976, the average number of VA cases per year increased steadily and peaked in 1990 (Fig. 1). Therefore, we limited our analysis to 15 years from 1991 to 2006 because, before 1991, VV accounted for less than 1% of the total ECMO cases (Fig. 1). The ELSO registry is composed of more than 170 centers and collects pre-ECMO, on-ECMO, and post-ECMO clinical data, as well as the patient's final disposition (intensive care unit discharge

Study population

We identified 4115 neonates with CDH from the ELSO registry between 1991 and 2006. Venoarterial ECMO was performed in 3347 (81%) neonates, whereas VV was performed in 768 (19%), including VV-VA conversions. We excluded 209 (0.05%) patients (n = 50 VV and n = 159 VA) with missing BWs from all of the analyses.

Patient demographics and characteristics are described in Table 1. Mean GA was near term, and the average BW was more than 3000 g. Most (65%) of the neonates were of white racial/ethnic

Discussion

Our current inability to predict which ECMO modality would be more advantageous for infants with CDH is partly because of the fact that no randomized trials have ever been designed to test or assess this issue, and by default, current predictive modeling must rely on retrospective data [8], [9], [10], [19]. The objective of this study was to compare the outcomes of infants with respiratory failure associated with CDH treated with VV or VA after adjusting for disease severity. Using the ELSO

Conclusion

The ELSO registry is the largest and most complete dataset compiled to increase our understanding and allow the study of extracorporeal life support. Clearly, VA is more commonly used in infants with CDH, but the data suggest that VV is being used in sick neonates with increasing frequency, and the difference in unadjusted mortality becomes insignificant after controlling for initial severity of illness. Venoarterial ECMO remains a well-established and accepted method; however, there are

References (34)

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