MCACS - Does the EXIT to ECMO Procedure Change Outcomes for High-Risk CDH Patients?

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Does the EXIT to ECMO Procedure Change Outcomes for High-Risk CDH Patients?
Alexander P. Stoffan, MD¹, Jay M. Wilson,MD^1,2, Russell W. Jennings, MD^1,2, Louise Wilkins-Haug, MD^2,3, Terry L. Buchmiller, MD^1,2
¹Children�s Hospital Boston, Department of Surgery � Harvard Medical School, Boston, MA; ²Advanced Fetal Care Center, Children�s Hospital Boston � Harvard Medical School, Boston, MA; ³Department of Obstetrics and Gynecology, Brigham and Women�s Hospital - Harvard Medical School, Boston, MA

Purpose: In the most severe cases of CDH, significant barotrauma or death can occur before advanced therapies such as ECMO can be initiated. We have previously examined the use of the EXIT to ECMO procedure (ex utero intrapartum treatment with placement on extracorporeal membrane oxygenation) in high-risk infants and reported a survival advantage. We report our experience with EXIT to ECMO in a more recent cohort of our most severe CDH patients.
Methods: Every patient with less than 15% predicted lung volume during January 2005 to December 2010 was included. We obtained data on prenatal imaging, size and location of the defect, and survival.
Results: 17 high-risk infants were identified. All 17 (100%) received ECMO and required a patch. Six children were delivered by EXIT to ECMO and only 2 survived (33%). An additional patient was delivered by EXIT to intubation with ECMO on standby and died. Five of the ten children that did not receive EXIT survived (50%).
Conclusions: No clear survival benefit with the use of the EXIT to ECMO procedure was demonstrated in this updated report of our high-risk CDH population. The general application of EXIT to ECMO for CDH is not supported by our results.

Table 1. Demographics. Variables are separated by EXIT group and the non-EXIT group. There is similar birth weight, gestational age at birth and predicted lung volume between both groups. There were fewer right-sided defects in the EXIT group, and there was more cardiac disease in the EXIT group. There were no significant p values in this small sample size.
*One patient with hypoplastic left heart and one with ASD/VSD
**One patient with ASD.

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