Fetal MR Lung Volumetry in Congenital Diaphragmatic Hernia (CDH): Prediction of Clinical Outcome and the Need for Extracorporeal Membrane Oxygenation (ECMO)

Abstract

Background: Despite the ultrasound (US) based lung-to-head ratio (LHR) and first results of fetal lung volume (FLV) determination in magnetic resonance imaging (MRI), there is no reliable prenatal parameter for the clinical course and outcome of fetuses with congenital diaphragmatic hernia (CDH), in particular for the need of extracorporeal membrane oxygenation (ECMO).

Patients and Method: MR FLV measurement was evaluated in 36 fetuses with CDH using T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) imaging. FLV and liver herniation, respectively, were correlated with survival and the need for ECMO therapy. A total of 18 healthy fetuses served as controls. MR FLV measurement was applied to predict survival and the need for neonatal ECMO therapy and to assess liver herniation as a prognostic parameter.

Results: On MRI there was a highly significant correlation of the FLV and patients’ survival (p=0.0001) and ECMO requirement, respectively (p=0.0029). Compared to normal controls mean FLV in infants who died was 10% (9.4±5.8 ml) and 32% in surviving infants (25±9.7 ml). Liver herniation significantly decreased lung volume and negatively impacted clinical outcome (p<0.0005).

Conclusion: The MR FLV is a strong predictor of survival in CDH patients. MR FLV measurements are also valuable to identify patients who may benefit from ECMO therapy. Upward liver herniation is the most important additional prognostic parameter.

Zusammenfassung

Hintergrund: Trotz der Nutzung der sonografischen (US) ‘lung to head’ ratio (LHR) und ersten Ergebnissen der Bestimmung des fetalen Lungenvolumens (FLV) in der Magnetresonanztomografie (MR), existiert kein zuverlässiger pränataler Parameter für den klinischen Verlauf von Feten mit einer kongenitalen Zwerchfellhernie (CDH), insbesondere nicht für die Notwendigkeit einer extrakorporalen Membranoxygenierungs- (ECMO)-Therapie.

Patienten und Methoden: Die Quantifizierung des MR-FLV wurde bei 36 Feten mit einer CDH untersucht. Benutzt zur MR-Bildgebung wurde eine T2-gewichtete ,half-Fourier acquisition single-shot turbo spin echo'-(HASTE)-Sequenz. Das FLV und die Verlagerung der Leber wurden mit dem Überleben der Kinder und der Notwendigkeit einer ECMO-Therapie korreliert. 18 gesunde Feten dienten als altersentsprechende Kontrollgruppe. Die Messung des MR-FLV wurde zur Prognosebeurteilung für Überleben und Notwendigkeit einer ECMO-Therapie benutzt. Die Verlagerung der Leber wurde als prognostischer Parameter beurteilt.

Ergebnisse: Die Magnetresonanztomografie zeigte eine hochsignifikante Korrelation zwischen FLV und dem Überleben der Patienten (p=0,0001) und der Notwendigkeit einer ECMO-Therapie (p=0,0029). Verglichen mit normalen Kontrollen beträgt das mittlere FLV von verstorbenen Kindern 10% (9,4±5,8 ml) und für überlebende Kinder 32% (25±9,7 ml). Die Hernierung der Leber führt zu einer signifikanten Reduktion des FLVs und verschlechtert den klinischen Verlauf (p<0,0005).

Schlussfolgerung: Das MR-FLV ist ein höchst valider Parameter zur Vorhersage des Überlebens bei Patienten mit einer CDH. Die Messung des MR-FLV ist wertvoll, um Patienten zu identifizieren, die von einer ECMO-Therapie profitieren können. Die Hernierung der Leber nach intrathorakal ist der wichtigste zusätzliche prognostische Parameter.

Key words

congenital diaphragmatic hernia - extracorporeal membrane oxygenation - fetal lung volume measurement - magnetic resonance imaging

Schlüsselwörter

kongenitale Zwerchfellhernie - extrakorporale Membranoxygenierung - fetales Lungenvolumen - Magnetresonanztomografie

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