In this session from the 12th Annual Update Course in Pediatric Surgery, Drs. Rebecca Stark and Steven Lee from Seattle Children’s Hospital walk through the timing, technique, and controversies surrounding ECMO in severe congenital diaphragmatic hernia (CDH) cases.

Key Highlights:

• VV vs VA ECMO: While venovenous (VV) ECMO is gaining traction with improved cannulas, venoarterial (VA) ECMO remains the predominant choice for most centers treating CDH.
• When to initiate ECMO: Early intervention is often favored in high-risk CDH cases, especially when prenatal imaging suggests severe compromise.
• SPHERE protocol in decision-making: A structured approach from Michigan offers criteria for ECMO vs comfort care, but outcome prediction remains unreliable—50% of decisions based on early data may be incorrect.
• Controversy in selection: Dr. Stark advocates for offering ECMO to all infants with isolated unilateral CDH, emphasizing the importance of treating every case as a potential survivor.
• Role of prenatal counseling: Early, transparent discussions with families are critical for navigating high-stakes decisions and aligning on care pathways.

This session underscores both the technical and ethical complexity in managing severe CDH—and the need for thoughtful protocols paired with clinical flexibility.