Changes in management of FETO-treated infants with severe CDH

This study aims to evaluate changes in outcomes and management of infants with severe congenital diaphragmatic hernia (CDH) undergoing fetoscopic endoluminal tracheal occlusion (FETO) across two eras, and to compare outcomes by side of defect over the last decade. Retrospective review of liveborn infants with severe CDH (observed to expected lung to head ratio [O/E LHR] < 0.25 left-sided; < 0.45 right-sided) who underwent FETO at King's College Hospital, London, UK, and survived to delivery. Fifty-eight infants were included across two 5-year periods (2002-2007 and 2020-2025). Survival improved from 44.1% to 70.8% (p = 0.044). Right-sided defects were more common in the second epoch (9% versus 54%, p < 0.001). All infants in the second era had echocardiography-guided inotropic and ventilatory management, which was not universally available earlier. In the second epoch surgical repair occurred later (4.0 versus 6.5 days, p = 0.018), repair by two-stage abdominal closure (laparostomy) increased from 0% to 77.8% (p < 0.001) and recurrence fell from 33 to 0% (p = 0.042). Mechanical ventilation, oxygen therapy and admission were longer latterly. In thirty-one infants delivered between 2015 and 2025, preterm prelabour rupture of membranes (PPROM) occurred in 67% of left-versus 92% of right-sided CDH, but at an earlier gestational age in left (p = 0.032). Left CDH infants had longer duration of mechanical ventilation (p = 0.04) and hospital stay (p = 0.006) with no mortality difference (exploratory).

Survival of FETO-treated severe CDH infants improved from 44 to 71% alongside later repair, staged abdominal closure and echocardiography-guided management. Left-sided defects had greater respiratory morbidity and longer admission than right-sided defects without changing survival.

• FETO improves survival in severe left-sided CDH, but postnatal management has changed substantially since its introduction.

• Survival of FETO-treated severe CDH rose from 44 to 71% over two decades despite more right-sided defects. Repair occurred later, following haemodynamic and respiratory stabilisation (as guided by echocardiography) with staged abdominal closure in 77.8% of recent repairs; recurrence decreased from 33 to 0%. • Left-sided CDH infants had greater respiratory morbidity and length of stay than right-sided CDH infants, without a significant difference in mortality.