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 evolving protocols for performing ECMO and surgical repair in cases of severe congenital diaphragmatic hernia (CDH).

Key Highlights:

• VA ECMO with bivalirudin: The presenters advocate for bivalirudin as a preferred anticoagulant over heparin due to its short half-life, predictable response, and ease of control—making it ideal for ECMO patients requiring surgery.
• Dilute thrombin time for monitoring: They highlight a lab-friendly technique for monitoring bivalirudin using dilute thrombin time—5x more specific and sensitive than PTT and easily implementable in any lab.
• Safe and timely surgical repair on ECMO: Early CDH repair (within 8–24 hours of ECMO initiation) can be performed with minimal bleeding and less tissue edema when using bivalirudin and meticulous technique.
• Institutional buy-in for early repair: The team underscores the importance of cross-disciplinary collaboration—including neonatologists, anesthesiologists, and weekend OR availability—to enable early ECMO repair protocols.
• Risk-stratified vs early repair strategy: Some centers risk-stratify ECMO patients, but Stark and Lee favor universal early repair to avoid complications associated with delayed surgery in non-weanable patients.
• Evolving national practices: As of this year, over 80% of CDH Study Group centers are now performing early repair on ECMO—showing how rapidly clinical protocols can shift with strong supporting data.

This session emphasizes the role of proactive planning, team-based decision-making, and flexible protocol development in improving outcomes for neonates with severe CDH requiring ECMO.