The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data

B. Van Calster, A. Benachi, K. H. Nicolaides, E. Gratacos, C. Berg, N. Persico, G. J. Gardener, M. Belfort, Y. Ville, G. Ryan, A. Johnson, H. Sago, P. Kosiński, P. Bagolan, T. Van Mieghem, P. L. J. DeKoninck, F. M. Russo, S. B. Hooper, J. A. Deprest*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

26 Citations (Scopus)

Abstract

Background: Two randomized controlled trials compared the neonatal and infant outcomes after fetoscopic endoluminal tracheal occlusion with expectant prenatal management in fetuses with severe and moderate isolated congenital diaphragmatic hernia, respectively. Fetoscopic endoluminal tracheal occlusion was carried out at 27 +0 to 29 +6 weeks’ gestation (referred to as “early”) for severe and at 30 +0 to 31 +6 weeks (“late”) for moderate hypoplasia. The reported absolute increase in the survival to discharge was 13% (95% confidence interval, −1 to 28; P=.059) and 25% (95% confidence interval, 6–46; P=.0091) for moderate and severe hypoplasia. Objective: Data from the 2 trials were pooled to study the heterogeneity of the treatment effect by observed over expected lung-to-head ratio and explore the effect of gestational age at balloon insertion. Study Design: Individual participant data from the 2 trials were reanalyzed. Women were assessed between 2008 and 2020 at 14 experienced fetoscopic endoluminal tracheal occlusion centers and were randomized in a 1:1 ratio to either expectant management or fetoscopic endoluminal tracheal occlusion. All received standardized postnatal management. The combined data involved 287 patients (196 with moderate hypoplasia and 91 with severe hypoplasia). The primary endpoint was survival to discharge from the neonatal intensive care unit. The secondary endpoints were survival to 6 months of age, survival to 6 months without oxygen supplementation, and gestational age at live birth. Penalized regression was used with the following covariates: intervention (fetoscopic endoluminal tracheal occlusion vs expectant), early balloon insertion (yes vs no), observed over expected lung-to-head ratio, liver herniation (yes vs no), and trial (severe vs moderate). The interaction between intervention and the observed over expected lung-to-head ratio was evaluated to study treatment effect heterogeneity. Results: For survival to discharge, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion was 1.78 (95% confidence interval, 1.05–3.01; P=.031). The additional effect of early balloon insertion was highly uncertain (adjusted odds ratio, 1.53; 95% confidence interval, 0.60–3.91; P=.370). When combining these 2 effects, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion with early balloon insertion was 2.73 (95% confidence interval, 1.15–6.49). The results for survival to 6 months and survival to 6 months without oxygen dependence were comparable. The gestational age at delivery was on average 1.7 weeks earlier (95% confidence interval, 1.1–2.3) following fetoscopic endoluminal tracheal occlusion with late insertion and 3.2 weeks earlier (95% confidence interval, 2.3–4.1) following fetoscopic endoluminal tracheal occlusion with early insertion compared with expectant management. There was no evidence that the effect of fetoscopic endoluminal tracheal occlusion depended on the observed over expected lung-to-head ratio for any of the endpoints. Conclusion: This analysis suggests that fetoscopic endoluminal tracheal occlusion increases survival for both moderate and severe lung hypoplasia. The difference between the results for the Tracheal Occlusion To Accelerate Lung growth trials, when considered apart, may be because of the difference in the time point of balloon insertion. However, the effect of the time point of balloon insertion could not be robustly assessed because of a small sample size and the confounding effect of disease severity. Fetoscopic endoluminal tracheal occlusion with early balloon insertion in particular strongly increases the risk for preterm delivery.

Original languageEnglish
Pages (from-to)560.e1-560.e24
JournalAmerican Journal of Obstetrics and Gynecology
Volume226
Issue number4
DOIs
Publication statusPublished - Apr 2022

Bibliographical note

Funding Information:
The setup of the Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials was funded by the European Commission through its sixth framework program in Life Sciences & Health (CT2006-37409) and later, by the KU Leuven (Belgium; C32/17/054) (both to J.A.D.), the Wellcome Trust (WT101957) and from the Engineering and Physical Sciences Research Council (NS/A000027/1) of the United Kingdom for the “Image-Guided Intrauterine Minimally Invasive Fetal Diagnosis and Therapy” study (both to J.A.D. and K.H.N.), and the Unité de Recherche Clinique Paris APHP Centre, Université de Paris, France (to A.B.) for data management and monitoring. B.V.C. was supported by Internal Funds KU Leuven (C24M/20/064). The funding sources had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the article for publication.

Publisher Copyright:
© 2021 Elsevier Inc.

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