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de Carvalho Nunes G, Wutthigate P, Simoneau J, Beltempo M, Sant'Anna GM, Altit G. Natural evolution of the patent ductus arteriosus in the extremely premature newborn and respiratory outcomes. J Perinatol 2022; 42:642-648. [PMID: 34815521 DOI: 10.1038/s41372-021-01277-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/21/2021] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate spontaneous closure of the patent ductus arteriosus (PDA) in extremely preterm infants and their respiratory outcomes, especially at <26 weeks gestational age (GA). STUDY DESIGN Retrospective study in <29 weeks, admitted within 24 h after birth (Feb 2015 and Dec 2019). Infants without any intervention to promote ductal closure, ≥1 echocardiography, and alive at discharge were included. RESULTS Two hundred and fourteen infants (average GA 26.3 ± 1.5 weeks) were included; 84 (39%) <26 weeks. PDA closed spontaneously in 194 (91%); 76/84 (90%) for infants <26 weeks. PDA closure was ascertained on an echocardiography performed at a median age of 36.4 [34.4-40.1] weeks. Rate of moderate-to-severe bronchopulmonary dysplasia decreased throughout the study period (OR for year of birth: 0.70 [95% CI: 0.57-0.87], p = 0.001). CONCLUSION Majority of extremely preterm infants, including <26 weeks, had spontaneous closure of the ductus before term corrected age. There was a concomitant improvement of respiratory outcomes.
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Affiliation(s)
- Gabriela de Carvalho Nunes
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Punnanee Wutthigate
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Jessica Simoneau
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Marc Beltempo
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Guilherme Mendes Sant'Anna
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Gabriel Altit
- Neonatology-McGill University Health Centre-Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, QC, Canada.
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Sankar MN, Bhombal S, Benitz WE. PDA: To treat or not to treat. CONGENIT HEART DIS 2019; 14:46-51. [DOI: 10.1111/chd.12708] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/16/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Meera N. Sankar
- Division of Neonatal and Developmental Medicine; Stanford University School of Medicine; Palo Alto California
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine; Stanford University School of Medicine; Palo Alto California
| | - William E. Benitz
- Division of Neonatal and Developmental Medicine; Stanford University School of Medicine; Palo Alto California
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Michihata N, Matsui H, Fushimi K, Yasunaga H. Hospital volume and mortality due to preterm patent ductus arteriosus. Pediatr Int 2016; 58:1171-1175. [PMID: 27062220 DOI: 10.1111/ped.13008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 10/07/2015] [Accepted: 04/01/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Preterm patent ductus arteriosus (PDA) requires neonatal intensive care. The relationship between hospital volume and mortality of PDA remains poorly understood. METHODS This was a retrospective observational study, using a national inpatient database in Japan. We identified patients who were diagnosed with PDA; exclusion criteria were as follows: (i) other cardiac complications; (ii) mild PDA treated without oral/i.v. indomethacin, surgery, or catheter intervention; (iii) age >1 year at admission; (iv) gestational age ≥32 weeks; (v) death within 3 days of admission; and (vi) transferal to other hospitals. Information was collected using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2013. Hospital volume was defined as the average annual number of neonates with gestational age <32 weeks at each hospital. The outcome measure was in-hospital mortality. RESULTS A total of 2437 eligible patients treated at 199 hospitals were included. Low, medium, and high volume were defined as average annual number of preterm infants <34, 34-65, and >65, respectively. There were no significant differences in in-hospital mortality according to hospital volume. In-hospital mortality was identical in patients who received indomethacin alone, surgical or catheter intervention, or both after adjustment for patient background. CONCLUSIONS There was no significant relationship between hospital volume and in-hospital mortality due to preterm PDA. Centralization of patients with this condition may not be necessary.
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Affiliation(s)
- Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
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Backes CH, Cheatham SL, Deyo GM, Leopold S, Ball MK, Smith CV, Garg V, Holzer RJ, Cheatham JP, Berman DP. Percutaneous Patent Ductus Arteriosus (PDA) Closure in Very Preterm Infants: Feasibility and Complications. J Am Heart Assoc 2016; 5:JAHA.115.002923. [PMID: 26873689 PMCID: PMC4802484 DOI: 10.1161/jaha.115.002923] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous closure of patent ductus arteriosus (PDA) in term neonates is established, but data regarding outcomes in infants born very preterm (<32 weeks of gestation) are minimal, and no published criteria exist establishing a minimal weight of 4 kg as a suitable cutoff. We sought to analyze outcomes of percutaneous PDA occlusion in infants born very preterm and referred for PDA closure at weights <4 kg. METHODS AND RESULTS Retrospective analysis (January 2005-January 2014) was done at a single pediatric center. Procedural successes and adverse events were recorded. Markers of respiratory status (need for mechanical ventilation) were determined, with comparisons made before and after catheterization. A total of 52 very preterm infants with a median procedural weight of 2.9 kg (range 1.2-3.9 kg) underwent attempted PDA closure. Twenty-five percent (13/52) of infants were <2.5 kg. Successful device placement was achieved in 46/52 (88%) of infants. An adverse event occurred in 33% of cases, with an acute arterial injury the most common complication. We observed no association between weight at time of procedure and the risk of an adverse event. No deaths were attributable to the PDA closure. Compared to precatheterization trends, percutaneous PDA closure resulted in improved respiratory status, including less exposure to mechanical ventilation (mixed effects logistic model, P<0.01). CONCLUSIONS Among infants born very preterm, percutaneous PDA closure at weights <4 kg is generally safe and may improve respiratory health, but risk of arterial injury is noteworthy. Randomized clinical trials are needed to assess clinically relevant differences in outcomes following percutaneous PDA closure versus alternative (surgical ligation) management strategies.
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Affiliation(s)
- Carl H Backes
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Sharon L Cheatham
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Grace M Deyo
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Scott Leopold
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Molly K Ball
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Developmental Therapeutics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Vidu Garg
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Ralf J Holzer
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - John P Cheatham
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Darren P Berman
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH The Heart Center, Nationwide Children's Hospital, Columbus, OH Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
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Elhoff JJ, Ebeling M, Hulsey TC, Atz AM. Potential Unintended Consequences of a Conservative Management Strategy for Patent Ductus Arteriosus. CONGENIT HEART DIS 2015; 11:52-7. [PMID: 26193967 DOI: 10.1111/chd.12287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND A recent review supports a strategy of deferring treatment of patent ductus arteriosus (PDA) in the preterm neonate until at least the second week after birth. In light of previous suggestion that later initiation of treatment may be less efficacious for closing PDAs it is reasonable to question if delayed treatment may be less effective. DESIGN We conducted a single center retrospective review of a neonatal intensive care unit database of infants ≤37 weeks gestation with the diagnosis of PDA and treated with indomethacin from 1999 to 2007. We determined gestational age (GA), timing of indomethacin initiation, and status of the PDA at hospital discharge. Treatment failure was defined as neonates requiring further intervention to close their PDA or those who died without echo-proven PDA closure. RESULTS Of the 341 infants meeting the study criteria, 77 (23%) had defined treatment failure. The failure group had a younger median GA of 25 weeks (interquartile range [IQR], 24-26) vs. 28 weeks (IQR, 26-30) for the successful group (P < .0001). The failure group had a median treatment initiation on day of life (DOL) 4 (IQR, 1-8) compared with DOL 3 (IQR, 1-6) for those in the successful group (P = .15). Taken as a whole, infants treated after DOL 5 were significantly more likely to have treatment failure (30.1% vs. 19.3% for those treated DOL 1-5, P = .03). CONCLUSIONS Our study confirms that younger GA at birth is correlated with increased likelihood of failed PDA closure. We also show a trend indicating that later initiation of treatment may decrease the chances of successfully closing a PDA. Future examination of PDA management should consider the potential unintended consequences that may accompany a delayed treatment strategy.
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Affiliation(s)
- Justin J Elhoff
- Divisions of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Myla Ebeling
- Epidemiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas C Hulsey
- Epidemiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew M Atz
- Divisions of Cardiology, Medical University of South Carolina, Charleston, SC, USA
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Lee JH, Shin JH, Park KH, Rhie YJ, Park MS, Choi BM. Can early B-type natriuretic peptide assays predict symptomatic patent ductus arteriosus in extremely low birth weight infants? Neonatology 2013. [PMID: 23182972 DOI: 10.1159/000343034] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Earlier and more accurate identification of a high-risk group of preterm infants that are likely to develop a hemodynamically significant patent ductus arteriosus (hsPDA) would allow specific targeting of early treatment and thus possibly minimize the morbidity and mortality associated with a PDA in extremely low birth weight (ELBW) infants. OBJECTIVE To investigate the predictability of B-type natriuretic peptide (BNP) for early targeted treatment of hsPDA in ELBW infants. METHODS 73 ELBW infants that underwent echocardiographic evaluation and plasma BNP measurement after birth were enrolled. 31 infants developed hsPDA (HsPDA group) and 42 infants did not develop hsPDA (nPDA group). RESULTS BNP levels of the HsPDA group were significantly higher than those of the nPDA group at 24 h of age (921 [318-2,133] vs. 152 [91-450] pg/ml) but not different at 12 h of age. BNP levels at 24 h of age were significantly correlated with the magnitudes of the ductal shunt but not at 12 h of age. The area under the receiver operator characteristic curve of BNP levels for prediction of hsPDA at 24 h of age was 0.830. At the cutoff BNP levels of 200 and 900 pg/ml at 24 h of age, sensitivity was 83.9 and 54.8% and specificity was 61.9 and 95.2%, respectively. CONCLUSIONS BNP levels at 24 h of age can be used as a guide for early targeted treatment of hsPDA and avoid the unnecessary use of cyclooxygenase inhibitors in ELBW infants.
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Affiliation(s)
- Jang Hoon Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
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Saldeño YP, Favareto V, Mirpuri J. Prolonged persistent patent ductus arteriosus: potential perdurable anomalies in premature infants. J Perinatol 2012; 32:953-8. [PMID: 22460543 DOI: 10.1038/jp.2012.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Patent ductus arteriosus (PDA) is a common condition among preterm infants. Controversy exists regarding the risk-benefit ratio of early closure of PDAs by either medical or surgical treatments. On the other hand, potential morbidities associated with no or delayed closure has not been well studied. The objective of the study was to determine if there is an association of prolonged persistent PDA (PP-PDA) with various morbidities in infants ≤28 weeks or 1250 g. STUDY DESIGN This matched case-control analysis includes preterm infants with a diagnosis of PDA over a period of 28 months in a single level III center in the USA. The predictive variable was the presence of a PP-PDA (PDA>3 weeks). Cases were infants with PP-PDA and controls were those with PDA but not PP-PDA (two controls for each case). Outcome variables included days on mechanical ventilation and with oxygen treatment, length of hospital stay, bronchopulmonary dysplasia (BPD), retinopathy of prematurity stage III-V (ROP) necrotizing enterocolitis grade II or more (NEC), delayed growth, direct hyperbilirubinemia >4 mg dl(-1) and osteopenia of prematurity. Data was obtained from database collected prospectively and from the review of clinical records when necessary. Statistics included ANOVA, Kaplan-Meier curves and χ (2). Significance was set at P<0.05. RESULT PP-PDA was associated with a significant increase in the number of days of mechanical ventilation, oxygen treatment and length of hospital stay, and in the rates of BPD (60% vs 4.5%), NEC (29% vs 5%), ROP (43% vs 5%), direct hyperbilirubinemia (41% vs 3%), osteopenia (44% vs 6%), parenteral nutrition for >40 days (70% vs 21%), tracheostomy during the hospitalization (15% vs 0%) and delayed growth (70% vs 21%), were also significantly higher in babies with PP-PDA. CONCLUSION A prolonged exposure to PDA does not seem to be inconsequential for some infants and is associated with an increase prevalence of severe morbidities with potential long lasting effects.
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Affiliation(s)
- Y P Saldeño
- Division of Neonatal-Perinatal Medicine, BC Children's Hospital, Vancouver, BC, Canada.
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Noori S. Pros and cons of patent ductus arteriosus ligation: hemodynamic changes and other morbidities after patent ductus arteriosus ligation. Semin Perinatol 2012; 36:139-45. [PMID: 22414885 DOI: 10.1053/j.semperi.2011.09.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although surgical ligation of a persistent patent ductus arteriosus resolves the adverse hemodynamic consequences of the systemic-to-pulmonary shunt and may confer some long-term benefits, it is also associated with both immediate and long-term negative effects. The population that benefits from or is harmed by the procedure is not clearly defined. Although indiscriminate ligation of the patent ductus arteriosus in all patients is not supported by the available information, the recent suggestion declaring the ductus harmless is not supported either. As we await the results of appropriately designed randomized control studies to define the indications for ligation, we must use clinical and echocardiographic indicators of a hemodynamically significant ductus arteriosus and thoughtful assessment of each individual patient to help guide us in addressing this complex problem.
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Affiliation(s)
- Shahab Noori
- Division of Neonatology and Center for Fetal and Neonatal Medicine, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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Tauzin L, Joubert C, Noel AC, Bouissou A, Moulies ME. Effect of persistent patent ductus arteriosus on mortality and morbidity in very low-birthweight infants. Acta Paediatr 2012; 101:419-23. [PMID: 22133090 DOI: 10.1111/j.1651-2227.2011.02550.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Because New Caledonia is geographically isolated from the nearest cardiac surgical centre, surgical closure of ductus arteriosus is not performed in very low-birthweight (VLBW) infants who have a persistent patent ductus in spite of having undergone treatment with ibuprofen. This study aimed at investigating the possible effect of persistent patent ductus in VLBW infants. METHODS The study included 177 VLBW infants born at 25-31 weeks of gestation from January 2006 to May 2011. Mortality and major morbidities were compared between infants with a persistent patent ductus (n = 33) and those without it (n = 104). Statistical associations between potential neonatal risk factors and significant morbidities were identified using multivariate regression analyses. RESULTS Rates of mortality and major morbidities, including the rate of bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular haemorrhage grades I-II and III-IV, periventricular leucomalacia, late-onset infections and failure of hearing screening, were insignificantly higher in VLBW infants with a persistent patent ductus than in those without it. CONCLUSION This study adds further evidence that persistent patent ductus arteriosus has no significant effect on mortality and morbidity in VLBW infants born at ≥25 weeks' gestational age.
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Affiliation(s)
- Laurent Tauzin
- Neonatal Intensive Care Unit, Territorial Hospital Centre, New Caledonia, France.
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Tosse V, Pillekamp F, Verde P, Hadzik B, Sabir H, Mayatepek E, Hoehn T. Urinary NT-proBNP, NGAL, and H-FABP may predict hemodynamic relevance of patent ductus arteriosus in very low birth weight infants. Neonatology 2012; 101:260-6. [PMID: 22222353 DOI: 10.1159/000334826] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 11/02/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hemodynamically significant patent ductus arteriosus (hsPDA) is the most common functional cardiovascular disease in preterm infants. The necessity to treat hsPDA can neither be derived solely from clinical nor from echocardiographic criteria. OBJECTIVE The aim of this study was to establish non-invasive parameters which can differentiate hsPDA from non-hsPDA. METHODS Urinary protein levels of NT-proBNP, NGAL, and H-FABP were measured and correlated with the necessity of therapy for PDA. In 37 neonates (<1,500 g), urinary protein concentrations were tested on days 0, 2, and 7 by ELISA methodology. Of 37 infants, 12 required therapeutic interventions according to current treatment standards. RESULTS Infants receiving an intervention for PDA showed significantly higher levels of pro-BNP, NGAL, and H-FABP at all time points except for NT-proBNP on day 0. Infants requiring a second or third course of ibuprofen had significantly higher levels of H-FABP and NGAL. In all samples, the concentration of the three proteins correlated positively with each other. CONCLUSIONS The present study shows that measurement of urinary proteins is a powerful and non-invasive method to quantify the effect of PDA on systemic perfusion in preterm infants. Furthermore, NGAL and H-FABP may be used to indicate the necessity of pharmacological or surgical treatment of PDA.
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Affiliation(s)
- Veronika Tosse
- Neonatology and Pediatric Intensive Care Medicine, Department of General Pediatrics, Heinrich Heine University, Düsseldorf, Germany
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El-Khuffash AF, McNamara PJ. The patent ductus arteriosus ligation decision. J Pediatr 2011; 158:1037-8; author reply 1038-9. [PMID: 21349543 DOI: 10.1016/j.jpeds.2010.12.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 12/30/2010] [Indexed: 11/28/2022]
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Fanos V, Pusceddu M, Dessì A, Marcialis MA. Should we definitively abandon prophylaxis for patent ductus arteriosus in preterm new-borns? Clinics (Sao Paulo) 2011; 66:2141-9. [PMID: 22189742 PMCID: PMC3226612 DOI: 10.1590/s1807-59322011001200022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 08/12/2011] [Indexed: 12/30/2022] Open
Abstract
Although the prophylactic administration of indomethacin in extremely low-birth weight infants reduces the frequency of patent ductus arteriosus and severe intraventricular hemorrhage, it does not appear to provide any long-term benefit in terms of survival without neurosensory and cognitive outcomes. Considering the increased drug-induced reduction in renal, intestinal, and cerebral blood flow, the use of prophylaxis cannot be routinely recommended in preterm neonates. However, a better understanding of the genetic background of each infant may allow for individualized prophylaxis using NSAIDs and metabolomics.
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Affiliation(s)
- Vassilios Fanos
- Neonatal Intensive Care Unit, Puericulture Institute And Neonatal Section, AOU University of Cagliari, Italy
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