O2185: Congenital Diaphragmatic Hernia repair and ECLS – anticoagulation and repair timing

Background: Extracorporeal life support (ECLS) is frequently used in managing congenital diaphragmatic hernia (CDH), but its use complicates surgical decision-making, particularly due to hemorrhagic risk. The timing of surgical repair and choice of anticoagulation are key factors contributing to this risk and remain subjects of ongoing debate. This study aims to assess trends in diaphragmatic repair with ECLS, comparing blood loss and outcomes based on repair timing and anticoagulation type.

Methods: This retrospective cohort study of the CDH Study Group included patients born 2021-2024, with data on anticoagulation use and estimated blood loss (EBL) recorded during this period. Patients not receiving ECLS were excluded. Analysis included Chi-square, Kruskal-Wallis, and Mann-Whitney U where appropriate.

Results: A total of 1,325 CDH patients were identified, with 302 (22.8%) receiving ECLS. The median gestational age was 38 (IQR: 37-39) weeks, birth weight was 2.98 (2.7-3.4) kg, and 5-minute Apgar scores were 6 (4-8). Diaphragm repair occurred in 90.8%, with varying CDHSG stages identified (A: 1.8%, B: 11.1%, C: 54.2%, D: 32.8%). Rate of repair (survival) were: on ECLS: 70.7% (50.8%), before in 11.0% (50.0%), and after in 18.3% (78.0%, p< 0.001). Those repaired before ECLS had higher Apgar scores (p=0.009), while those repaired on ECLS had greater EBL (p=0.0003), higher rates of reoperation for bleeding (p=0.04), and longer ECLS duration (p=0.001) (Table).

Specifically, for patients repaired on ECLS (vs after), median EBL was 15cc; range 0-300 (vs 5 (5-15). EBL distribution for on ECLS repair was: 45.6% (0-10), 27.9% (11-25), 16.9% (25-100), and 9.6% (≥100), with survival rates of 62.9%, 44.7%, 52.2%, and 53.8%, respectively.

Regarding anticoagulation, bivalirudin use has increased over time (Figure). Bivalirudin (vs. heparin) was associated with a median EBL of 15 ml (10-30) vs. 10 (5-25), neurologic complication rate (47.7% vs. 50.0%), and survival rate (58.5% vs. 50.0%), with similar ECLS duration (12 days vs 11 days) and reoperation rates (14.6% vs 14.8%) (all p=NS).

Conclusion: Repair timing and anticoagulation impact outcomes in CDH patients on ECLS. On ECLS repair results in increased EBL and increased rate of reoperation for bleeding, though infrequent and with equivalent or better survival. Bivalirudin use has increased over time, though no statistically significant improvements in outcome were identified.