PREFERENTIAL USE OF VENOVENOUS EXTRACORPOREAL MEMBRANE-OXYGENATION FOR CONGENITAL DIAPHRAGMATIC-HERNIA

Acute respiratory failure (ARF) secondary to congenital diaphragmatic hernia (CDH), unresponsive to maximal medical management, has traditio nally been treated with venoarterial (VA) extracorporeal membrane oxyg enation (ECMO). Venovenous (VV) ECMO offers several benefits over VA E CMO including preserved pulmonary blood flow, preservation of the caro tid artery, and pulsatile flow. However, use of the VV modality has no t been widespread because of concerns of cardiac instability during by pass, and because only one double-lumen (DL) catheter size is availabl e in the United States. The authors hypothesize that VV ECMO is a safe and effective treatment for CDH, symptomatic at birth, and report a s ingle institution experience of preferential VV use for CDH. Over an 1 8-month period, 14 patients with CDH were placed on ECMO after maximal medical management failed, including high frequency ventilation and n itric oxide in some cases. Ability to place the 14 Fr DL catheter was the sole criteria for VA or VV selection. Nine patients were successfu lly placed on VV and 5 on VA; no VV patient required conversion to VA. The two groups of patients were similar with respect to degree of ill ness, birth weight, EGA, time on and age at start of ECMO. Overall sur vival for this series was 64%: 66% in the VV group and 60% in the VA g roup. Two patients in the VV group were found to have congenital heart disease incompatible with life, were withdrawn from therapy and allow ed to die, and are listed as treatment failures. The authors conclude that CDH patients receive adequate oxygenation and show hemodynamic st ability on VV ECMO. This experience suggests that VV ECMO is a safe an d acceptable method of respiratory support for neonatal CDH. The advan tages of VV ECMO should make this modality the preferred method of ECM O support in CDH. Copyright (C) 1995 by W.B. Saunders Company