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Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach.
J Pediatr Surg. 2018 Nov; 53(11):2092-2099.JP

Abstract

PURPOSE

Previous studies comparing extracorporeal membrane oxygenation (ECMO) modality for congenital diaphragmatic hernia (CDH) have not accounted for confounding by indication. We therefore hypothesized that using a propensity score (PS) approach to account for selection bias may identify outcome differences based on ECMO modality for infants with CDH.

METHODS

We utilized ELSO Registry data (2000-2016). Patients with CDH were divided to either venoarterial (VA) or venovenous (VV) ECMO. Patients were matched by PS to control for nonrandom treatment assignment. Subgroup analyses were conducted based on timing of CDH repair relative to ECMO. Primary analysis was the "intent-to-treat" cohort based on the initial ECMO mode. Mortality was the primary outcome, and severe neurologic injury (SNI) was a secondary outcome.

RESULTS

PS matching (3:1) identified 3304 infants (VA = 2470, VV = 834). In the main group, mortality was not different between VA and VV ECMO (OR = 1.01, 95% CI: 0.86-1.18) and there was no difference in SNI between VA and VV (OR = 0.80; 95% CI: 0.63-1.01). For the pre-ECMO CDH repair subgroup, 175 VA cases were matched to 70 VV. In these neonates, mortality was higher for VV compared to VA (OR = 2.10, 95% CI: 1.19-3.69), without any difference in SNI (OR = 1.48; 95% CI: 0.59-3.71). For the subgroup that did not have pre-ECMO CDH repair, 2030 VA cases were matched to 683 VV cases. In this subgroup, VV was associated with 27% lower risk of SNI relative to VA (OR = 0.73, 95% CI: 0.56-0.95) without any difference in mortality (OR = 0.94, 95% CI: 0.79-1.11).

CONCLUSION

This study revalidates that ECMO mode does not significantly affect mortality or SNI in infants with CDH. In the subset of infants who require pre-ECMO CDH repair, VA favors survival, whereas, in the subgroup of infants that did not have pre-ECMO CDH repair, VV favors lower rates of SNI. We conclude that neither mode appears consistently superior across all situations, and clinical judgment should remain a multifactorial decision.

LEVEL OF EVIDENCE

Level III.

Authors+Show Affiliations

Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA. Electronic address: yguner@uci.edu.Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX.Community Memorial Hospital, Department of Surgery, Ventura, CA.University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital Los Angeles, Department of Pediatric Surgery.University of California Irvine Biostatistics, Institute for Clinical and Translational Science Irvine, CA.University of California Irvine Biostatistics, Institute for Clinical and Translational Science Irvine, CA.Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.Children's Hospital of Orange County, Division of Neonatalogy, Orange, CA.Children's Hospital Los Angeles, Department of Pediatric Surgery.Columbia University College of Physicians and Surgeons, New York City, New York; California Pediatric Surgical Group, Santa Barbara.University of California, Irvine School of Medicine, Department of Medicine, Orange, CA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

30318280

Citation

Guner, Yigit S., et al. "Outcomes of Infants With Congenital Diaphragmatic Hernia Treated With Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: a Propensity Score Approach." Journal of Pediatric Surgery, vol. 53, no. 11, 2018, pp. 2092-2099.
Guner YS, Harting MT, Fairbairn K, et al. Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach. J Pediatr Surg. 2018;53(11):2092-2099.
Guner, Y. S., Harting, M. T., Fairbairn, K., Delaplain, P. T., Zhang, L., Chen, Y., Kabeer, M. H., Yu, P., Cleary, J. P., Stein, J. E., Stolar, C., & Nguyen, D. V. (2018). Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach. Journal of Pediatric Surgery, 53(11), 2092-2099. https://doi.org/10.1016/j.jpedsurg.2018.06.003
Guner YS, et al. Outcomes of Infants With Congenital Diaphragmatic Hernia Treated With Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: a Propensity Score Approach. J Pediatr Surg. 2018;53(11):2092-2099. PubMed PMID: 30318280.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach. AU - Guner,Yigit S, AU - Harting,Matthew T, AU - Fairbairn,Kelly, AU - Delaplain,Patrick T, AU - Zhang,Lishi, AU - Chen,Yanjun, AU - Kabeer,Mustafa H, AU - Yu,Peter, AU - Cleary,John P, AU - Stein,James E, AU - Stolar,Charles, AU - Nguyen,Danh V, Y1 - 2018/06/07/ PY - 2017/11/21/received PY - 2018/04/18/revised PY - 2018/06/03/accepted PY - 2018/10/16/entrez PY - 2018/10/16/pubmed PY - 2018/12/12/medline KW - CDH KW - ECMO KW - Propensity score KW - Venoarterial KW - Venovenous SP - 2092 EP - 2099 JF - Journal of pediatric surgery JO - J Pediatr Surg VL - 53 IS - 11 N2 - PURPOSE: Previous studies comparing extracorporeal membrane oxygenation (ECMO) modality for congenital diaphragmatic hernia (CDH) have not accounted for confounding by indication. We therefore hypothesized that using a propensity score (PS) approach to account for selection bias may identify outcome differences based on ECMO modality for infants with CDH. METHODS: We utilized ELSO Registry data (2000-2016). Patients with CDH were divided to either venoarterial (VA) or venovenous (VV) ECMO. Patients were matched by PS to control for nonrandom treatment assignment. Subgroup analyses were conducted based on timing of CDH repair relative to ECMO. Primary analysis was the "intent-to-treat" cohort based on the initial ECMO mode. Mortality was the primary outcome, and severe neurologic injury (SNI) was a secondary outcome. RESULTS: PS matching (3:1) identified 3304 infants (VA = 2470, VV = 834). In the main group, mortality was not different between VA and VV ECMO (OR = 1.01, 95% CI: 0.86-1.18) and there was no difference in SNI between VA and VV (OR = 0.80; 95% CI: 0.63-1.01). For the pre-ECMO CDH repair subgroup, 175 VA cases were matched to 70 VV. In these neonates, mortality was higher for VV compared to VA (OR = 2.10, 95% CI: 1.19-3.69), without any difference in SNI (OR = 1.48; 95% CI: 0.59-3.71). For the subgroup that did not have pre-ECMO CDH repair, 2030 VA cases were matched to 683 VV cases. In this subgroup, VV was associated with 27% lower risk of SNI relative to VA (OR = 0.73, 95% CI: 0.56-0.95) without any difference in mortality (OR = 0.94, 95% CI: 0.79-1.11). CONCLUSION: This study revalidates that ECMO mode does not significantly affect mortality or SNI in infants with CDH. In the subset of infants who require pre-ECMO CDH repair, VA favors survival, whereas, in the subgroup of infants that did not have pre-ECMO CDH repair, VV favors lower rates of SNI. We conclude that neither mode appears consistently superior across all situations, and clinical judgment should remain a multifactorial decision. LEVEL OF EVIDENCE: Level III. SN - 1531-5037 UR - https://www.unboundmedicine.com/medline/citation/30318280/Outcomes_of_infants_with_congenital_diaphragmatic_hernia_treated_with_venovenous_versus_venoarterial_extracorporeal_membrane_oxygenation:_A_propensity_score_approach_ DB - PRIME DP - Unbound Medicine ER -