Link: https://www.ncbi.nlm.nih.gov/pubmed/30318280

J Pediatr Surg. 2018 Nov;53(11):2092-2099. doi: 10.1016/j.jpedsurg.2018.06.003. Epub 2018 Jun 7.
Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach.
Guner YS1, Harting MT2, Fairbairn K3, Delaplain PT4, Zhang L5, Chen Y5, Kabeer MH6, Yu P6, Cleary JP7, Stein JE8, Stolar C9, Nguyen DV10.
Author information
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: 0.86-1.1 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.

Copyright © 2018 Elsevier Inc. All rights reserved.

KEYWORDS:
CDH; ECMO; Propensity score; Venoarterial; Venovenous

PMID: 30318280 PMCID: PMC6192269 [Available on 2019-11-01] DOI: 10.1016/j.jpedsurg.2018.06.003
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