O. Moreno-Alvarez

Contribution of intrapulmonary artery Doppler to improve prediction of survival in fetuses with congenital diaphragmatic hernia treated with fetal endoscopic tracheal occlusion

To evaluate the contribution of intrapulmonary artery Doppler in predicting the survival of fetuses with congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO).

Learning curve for lung area to head circumference ratio measurement in fetuses with congenital diaphragmatic hernia

To assess the learning curve for the fetal lung area to head circumference ratio (LHR) calculation in fetuses with congenital diaphragmatic hernia (CDH).

Changes in Lung Tissue Perfusion in the Prediction of Survival in Fetuses with Congenital Diaphragmatic Hernia Treated with Fetal Endoscopic Tracheal Occlusion

Objective: To assess the impact of lung perfusion by fractional moving blood volume (FMBV) for the prediction of survival in fetuses with congenital diaphragmatic hernia (CDH) treated with fetal endoscopic tracheal occlusion (FETO). Study Design: Lung perfusion by FMBV (%) and the observed/expected lung-to-head ratio (o/e LHR) were evaluated 1 day before and 7–14 days after FETO in a cohort of 62 CDH fetuses, and their isolated and combined values to predict survival was assessed. Results: Preoperative lung perfusion did not show association with survival. However, after FETO, an increase in 30% of the preoperative lung FMBV and an increase in 50% of the LHR was significantly associated with the probability of survival. A model combining the changes in FMBV and o/e LHR after therapy allowed discrimination of cases with poor (10% survival), moderate (40–70% survival) and very good prognosis (100% survival). Conclusion:Changes in lung tissue perfusion, evaluated by FMBV after FETO, improved the prediction of survival in fetuses with CDH.

Lung tissue perfusion in congenital diaphragmatic hernia and association with the lung‐to‐head ratio and intrapulmonary artery pulsed Doppler

To evaluate lung tissue perfusion in fetuses with congenital diaphragmatic hernia (CDH) and to explore the association of lung tissue perfusion with the lung area to head circumference ratio (LHR) and intrapulmonary artery pulsed Doppler.

Prognostic value of pulmonary Doppler to predict response to tracheal occlusion in fetuses with congenital diaphragmatic hernia.

Pulmonary Doppler may play an important role in the prediction of survival and postnatal morbidity in fetuses with congenital diaphragmatic hernia treated with fetoscopic tracheal occlusion (FETO). Spectral Doppler indexes such as pulsatility index and peak early diastolic reversed flow could help to refine the selection of fetuses that might benefit from fetal therapy. When combined with lung-to-head ratio (LHR), these Doppler indices allow to discriminate cases with moderate-to-high survival rates from fetuses with extremely low chances to survive after FETO. In addition, they discriminate groups with a high or low risk of serious neonatal morbidity in surviving fetuses. After therapy, the combined evaluation of the relative increase of LHR with the increase in lung tissue perfusion by power Doppler seems to improve the prediction of fetal survival. In conclusion, while LHR remains the strongest predictive index, Doppler measurements allow to substantially improve the accuracy in the prediction of the chances of survival of fetuses with congenital diaphragmatic hernia treated with FETO.

Usefulness of lung-to-head ratio and intrapulmonary arterial Doppler in predicting neonatal morbidity in fetuses with congenital diaphragmatic hernia treated with fetoscopic tracheal occlusion

To explore the potential value of intrapulmonary artery Doppler velocimetry in predicting neonatal morbidity in fetuses with left‐sided congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO).

Lung Tissue Blood Perfusion Changes Induced by in utero Tracheal Occlusion in a Rabbit Model of Congenital Diaphragmatic Hernia

Objective: To analyze the impact of in utero tracheal occlusion (TO) on lung tissue blood perfusion, as measured by fractional moving blood volume (FMBV) and conventional spectral Doppler, in a rabbit model of congenital diaphragmatic hernia (CDH). Methods: In 50 fetal rabbits, a left CDH was surgically created at 23 days of gestational age (GA). At 28 days of GA, the surviving CDH fetuses were randomly assigned to undergo either TO (CDH+TO group) or a sham operation (CDH group). Twenty littermates, which were not operated on, served as internal normal controls. At 30 days of GA, lung perfusion estimated by FMBV and spectral Doppler of the proximal intrapulmonary artery were evaluated in the right lung during cesarean section. Doppler waveform analysis included the pulsatility index (PI), peak early diastolic reverse flow and peak systolic velocity. Results: Eleven CDH fetuses, 9 CDH+TO and 20 controls were suitable for the study. CDH fetuses showed a significantly higher PI [8.0 (SD 1.8) vs. 5.22 (SD 1.1), p < 0.001] and lower FMBV [13.5% (SD 4.6) vs. 23.0% (SD 2.1), p < 0.001] than the controls. In contrast, CDH+TO fetuses had a significantly lower PI [5.8 (SD 2.3) vs. 8.0 (SD 1.8), p = 0.015] and higher FMBV [27.6% (SD 7.1) vs. 13.5% (SD 4.6), p < 0.001] than CDH fetuses, with values similar to the controls. Peak early diastolic reverse flow and peak systolic velocity showed nonsignificant differences among the study groups. The lung to body weight ratio at necropsy correlated positively with lung FMBV (r = 0.60, p < 0.001) and negatively with the pulmonary artery PI (r = –0.48, p < 0.01). Conclusion: Tracheal occlusion is consistently associated with increased lung tissue perfusion and decreased intrapulmonary impedance in a rabbit model of CDH.

Fetal Endoscopic Tracheal Intubation: A New Fetoscopic Procedure to Ensure Extrauterine Tracheal Permeability in a Case with Congenital Cervical Teratoma

Congenital neck masses are associated with high perinatal mortality and morbidity secondary to airway obstruction due to a mass effect of the tumor with subsequent neonatal asphyxia and/or neonatal death. Currently, the only technique designed to establish a secure neonatal airway is the ex utero intrapartum treatment (EXIT) procedure, which involves neonatal tracheal intubation while fetal oxygenation is maintained by the uteroplacental circulation in a partial fetal delivery under maternal general anesthesia. We present a case with a giant cervical teratoma and huge displacement and compression of the fetal trachea that was treated successfully at 35 weeks of gestation with a novel fetoscopic procedure to ensure extrauterine tracheal permeability by means of a fetal endoscopic tracheal intubation (FETI) before delivery. The procedure consisted of a percutaneous fetal tracheoscopy under maternal epidural anesthesia using an 11-Fr exchange catheter covering the fetoscope that allowed a conduit to introduce a 3.0-mm intrauterine orotracheal cannula under ultrasound guidance. After FETI, a conventional cesarean section was performed uneventfully with no need for an EXIT procedure. This report is the first to illustrate that in cases with large neck tumors involving fetal airways, FETI is feasible and could potentially replace an EXIT procedure by allowing prenatal airway control.

OC35: Changes in lung blood perfusion in congenital diaphragmatic hernia treated with FETO and association with clinical outcome

cage perimeter (RCP), lung area (LA), heart area (HA), right lung diameter (RLD), lung length, abdominal circumference (AC), and femur length (FL) were measured by 2DUS. Pulmonary hypoplasia was confirmed by: 1) lung/body weight ratio ≤ 0.015 < 28 weeks, or ≤ 0.012 ≥ 28 weeks of gestation, and/or 2) autopsy. Sensitivity, specificity, positiveand negative predictive values (PPV/NPV), and diagnostic efficiency of 3DUS and 2DUS parameters to detect lethal pulmonary hypoplasia were compared. 44 fetuses were excluded for lack of a suitable volume dataset to measure (n = 30) or impossibility to confirm the neonatal diagnosis [(n = 14)]. Results: Lethal pulmonary hypoplasia was diagnosed in 34.1% of cases (14/41). The diagnostic efficiency of biometric parameters in predicting lethal pulmonary hypoplasia is shown in the Table.

Airway and vascular maturation stimulated by tracheal occlusion do not correlate in the rabbit model of diaphragmatic hernia.

Background:In animal models of congenital diaphragmatic hernia (CDH), tracheal occlusion (TO) has induced maturation of both airway spaces and vascular structures. Airway and vascular response to TO are assumed to occur in parallel. This study aims to describe and measure the relationship between airway and vascular maturation induced by TO.Methods:A rabbit model of CDH on gestational day (GD) 23 and TO on GD 28 (term = GD 31) has been used. Two study groups have been defined: DH (diaphragmatic hernia) and TO (DH treated with TO). Animals were collected on GD 30 and blood flow data of the pulmonary artery (pulsatility index (PI) and fractional moving blood volume) were ultrasonographically measured. Lung morphometry consisted of measurements of radial alveolar count (RAC) and arterial muscular thickness.Results:Animals in the DH group (n = 9) had the worst hemodynamic parameters; their lungs were hypoplastic and had the thickest arterial muscular layer. Animals in the TO group (n = 10) had all these effects reversed. There were no correlations among hemodynamic, airway, and vascular parameters, except for RAC and PI (r = −0.528, P = 0.043).Conclusion:Airway and vascular maturation after TO appear to be uncorrelated effects. TO could trigger several pathways that separately regulate airway and vascular responses.