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Survival of patients with congenital diaphragmatic hernia during the ECMO era: an 11-year experience
N Ssemakula1, D L Stewart, L J Goldsmith
1Department of Pediatrics, University of Louisville School of Medicine and Kosair Children's Hospital, Kentucky 40202-3830, USA.
Background/Purpose:
Congenital diaphragmatic hernia (CDH) is associated with significant mortality and morbidity. To evaluate the impact of extracorporeal membrane oxygenation (ECMO) on survival, a review of our experience with CDH patients was initiated.
Methods:
The authors performed a retrospective nonrandomized analysis of 98 consecutive CDH patients who were ECMO candidates, and were symptomatic within the first day of life, and underwent repair between May 1985 and May 1996. The patients were divided into three groups: Group 1 (n = 38) refers to patients who were clinically stable and underwent repair before 48 hours of age and did not need ECMO rescue; Group 2 (n = 29) consists of patients who underwent repair but required ECMO rescue; and Group 3 (n = 31) refers to patients who met ECMO criteria preoperatively and required ECMO for stabilization and later underwent repair on ECMO. The Kaplan-Meier survival graph was used for survival analysis.
Results:
During the 11-year span, the overall survival rate of all CDH patients was 72% (71 of 98). The survival rate of patients who did not require ECMO support was 92% (35 of 38), whereas patients who required ECMO after repair had a 72% (21 of 29) survival rate. These were compared with a 48% (15 of 31) survival rate for those undergoing repair on ECMO. The differences in survival among the three groups were statistically significant using the log-rank test (P = .0018).
Conclusions:
Survival was significantly better for infants who underwent successful repair without ECMO than those who required ECMO rescue pre- or postrepair. The overall improved survival of CDH patients to 72% compared with historical controls of 38% to 58% may be attributed to ECMO, but the requirement of ECMO before repair, as well as the presence of congenital anomalies (P < .01), prematurity (P < .01), the need for a Gore-Tex patch at repair (P < .05), prenatal diagnosis at less than 25 weeks' gestation (P < .01), and the occurrence of an intracranial hemorrhage (P < .01), decreases the chances of survival.