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Mitra S, Bischoff AR, Sathanandam S, Lakshminrusimha S, McNamara PJ. Procedural closure of the patent ductus arteriosus in preterm infants: a clinical practice guideline. J Perinatol 2024:10.1038/s41372-024-02052-9. [PMID: 38997403 DOI: 10.1038/s41372-024-02052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/29/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024]
Abstract
IMPORTANCE Transcatheter closure of the patent ductus arteriosus (PDA) is being increasingly adopted as an alternative to surgical PDA closure in preterm infants. OBJECTIVE To develop rigorous clinical practice guideline recommendations on procedural PDA closure in preterm infants. METHODS The principles of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence-to-Decision (EtD) framework were used to develop the guideline recommendations. An e-Delphi survey of 45 experts was conducted and recommendations that reached ≥75% agreement were accepted as consensus. MAIN RECOMMENDATIONS Procedural PDA closure may be considered in extremely preterm infants (<28 weeks gestational age) requiring invasive mechanical ventilation >10 postnatal days and confirmed to have a large hemodynamically significant PDA, at centers with high local rates of death and/or bronchopulmonary dysplasia (conditional recommendation). If sufficient institutional expertise is available and patient characteristics are suitable, transcatheter PDA closure may be considered as the preferred approach over PDA ligation (conditional recommendation).
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Affiliation(s)
- Souvik Mitra
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, USA
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, USA.
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Söderström F, Sindelar R, Olsson KW, Yousef S, Todorova D, Pestalozzi J, Mellander M, Raaijmakers R. Active versus restrictive ligation strategy for patent ductus arteriosus - A retrospective two-center study of extremely preterm infants born between 22 + 0 and 25 + 6 weeks of gestational age. Early Hum Dev 2024; 191:105976. [PMID: 38452632 DOI: 10.1016/j.earlhumdev.2024.105976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) in premature infants is associated with adverse clinical outcomes. Mode and timing of treatment are still controversial. Data are limited in the most extremely premature infants <26 weeks of gestational age (GA), where clinical problems are most significant and patients are most vulnerable. AIMS To investigate whether different approaches to surgical closure of PDA in two large Swedish centers has an impact on clinical outcomes including mortality in extremely preterm infants born <26 weeks GA. STUDY DESIGN Retrospective, two-center, cohort study. SUBJECTS Infants born at 22+0-25+6 weeks GA between 2010 and 2016 at Uppsala University Children's Hospital (UUCH; n = 228) and Queen Silvia Children's Hospital Gothenburg (QSCHG; n = 220). MAIN OUTCOME MEASURES Survival, bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). RESULTS Surgical closure of PDA was more common and performed earlier at QSCHG (50 % vs 16 %; median age 11 vs 44 days; p < 0.01). Survival was similar in both centres. There was a higher incidence of severe BPD and longer duration of mechanical ventilation at UUCH (p < 0.01). There was a higher incidence of ROP, IVH and sepsis at QSCH (p < 0.05, p < 0.01 and p < 0.01). A sub-group analysis matching all surgically treated infants at QSCHG with infants at UUCH with the same GA showed similar results as the total cohort. CONCLUSION Earlier and higher rate of surgical PDA closure in this cohort of extremely preterms born <26 weeks GA did not impact mortality but was associated with lower rates of severe BPD and higher rates of severe ROP.
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Affiliation(s)
- Fanny Söderström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Neonatal Intensive Care Unit, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Neonatal Intensive Care Unit, Uppsala University Children's Hospital, Uppsala, Sweden
| | | | - Sawin Yousef
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Daniela Todorova
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Neonatal Intensive Care Unit, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joanna Pestalozzi
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mats Mellander
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Children's Heart Center, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Renske Raaijmakers
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Neonatal Intensive Care Unit, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
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3
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Cervera SB, Saeed S, Luu TM, Gorgos A, Beltempo M, Claveau M, Basso O, Lapointe A, Tremblay S, Altit G. Evaluation of the association between patent ductus arteriosus approach and neurodevelopment in extremely preterm infants. J Perinatol 2024; 44:388-395. [PMID: 38278962 DOI: 10.1038/s41372-024-01877-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Assess if unit-level PDA management correlates with neurodevelopmental impairment (NDI) at 18-24 months corrected postnatal age (CPA) in extremely preterm infants. STUDY DESIGN Retrospective analysis of infants born at <29 weeks (2014-2017) across two units having distinct PDA strategies. Site 1 utilized an echocardiography-based treatment strategy aiming for accelerated closure (control). Site 2 followed a conservative approach. PRIMARY ENDPOINT NDI, characterized by cerebral palsy, any Bayley-III composite score <85, sensorineural/mixed hearing loss, or at least unilateral visual impairment. RESULTS 377 infants were evaluated. PDA treatment rates remained unchanged in Site 1 but eventually reached 0% in Site 2. Comparable rates of any/significant NDI were seen across both sites (any NDI: 38% vs 36%; significant NDI: 13% vs 10% for Site 1 and 2, respectively). After adjustments, NDI rates remained similar. CONCLUSION PDA management strategies in extremely preterm newborns showed no significant impact on neurodevelopment outcomes at 18-24 months CPA.
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Affiliation(s)
- Soledad Belén Cervera
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Sahar Saeed
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Thuy Mai Luu
- Neonatal Follow-Up, Department of Paediatrics, Université de Montréal, Montreal, QC, Canada
| | - Andrea Gorgos
- Neonatal Follow-Up, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Martine Claveau
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Olga Basso
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Anie Lapointe
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Sophie Tremblay
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Gabriel Altit
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada.
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Surak A, Sidhu A, Ting JY. Should we "eliminate" PDA shunt in preterm infants? A narrative review. Front Pediatr 2024; 12:1257694. [PMID: 38379909 PMCID: PMC10876852 DOI: 10.3389/fped.2024.1257694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
The patent ductus arteriosus frequently poses a significant morbidity in preterm infants, subjecting their immature pulmonary vascular bed to substantial volume overload. This, in turn, results in concurrent hypoperfusion to post-ductal organs, and subsequently alters cerebral blood flow. In addition, treatment has not demonstrated definitive improvements in patient outcomes. Currently, the optimal approach remains a subject of considerable debate with ongoing research controversy regarding the best approach. This article provides a comprehensive review of existing literature.
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Affiliation(s)
- Aimann Surak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Amneet Sidhu
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Joseph Y. Ting
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Kikuchi N, Goto T, Katsumata N, Murakami Y, Shinohara T, Maebayashi Y, Sakakibara A, Saito C, Hasebe Y, Hoshiai M, Nemoto A, Naito A. Correlation between the Closure Time of Patent Ductus Arteriosus in Preterm Infants and Long-Term Neurodevelopmental Outcome. J Cardiovasc Dev Dis 2024; 11:26. [PMID: 38248896 PMCID: PMC10816731 DOI: 10.3390/jcdd11010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/09/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
In patent ductus arteriosus (PDA) in preterm infants, the relationship between treatment timing and long-term developmental prognosis remains unclear. The purpose of this study was to clarify the relationship between the age in days when ductus arteriosus closure occurred and long-term development. Preterm infants with a birth weight of less than 1500 g who were admitted to our NICU over a period of 9 years (2011-2019) and were diagnosed with PDA were included. A new version of the K-type developmental test for corrected ages of 1.5 and 3 years was used as an index of development. The relationship between the duration of PDA and the developmental index was evaluated using Pearson's correlation coefficient, and multiple regression analysis was performed. Development quotient (DQ) at the ages of 1.5 and 3 years showed a correlation with the PDA closure date and the standard deviation (SD) value of the term birth weight. Multiple regression analysis showed a positive correlation of the DQ at 1.5 and 3 years with the SD value of the term birth weight and a negative correlation with the PDA closure date. In addition, a stronger correlation was found in the "posture/motor" sub-item at 3 years. On the other hand, the analysis including preterm infants without PDA showed that preterm infants with PDA closure on the 6th day or later after birth had a significantly lower 3-year-old DQ than preterm infants with a PDA exposure within 5 days. In conclusion, it is suggested that the decrease in cerebral blood flow due to PDA in preterm infants has an adverse effect on long-term neurodevelopment. Appropriate interventions, including surgical treatment for PDA in preterm infants without delay, ideally within 5 days of birth, may be effective in improving the developmental prognosis.
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Affiliation(s)
- Natsumi Kikuchi
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
- Department of Pediatrics, School of Medicine, Yamanashi University, Kofu 409-3821, Japan;
| | - Taichiro Goto
- Lung Cancer and Respiratory Disease Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan
| | - Nobuyuki Katsumata
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Yasushi Murakami
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Tamao Shinohara
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Yuki Maebayashi
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Aiko Sakakibara
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Chisato Saito
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Yohei Hasebe
- Department of Pediatrics, School of Medicine, Yamanashi University, Kofu 409-3821, Japan;
| | - Minako Hoshiai
- Cardiovascular Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan;
| | - Atsushi Nemoto
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
| | - Atsushi Naito
- Department of Neonatology, Perinatal Center, Yamanashi Prefectural Central Hospital, Kofu 400-8506, Japan; (N.K.); (N.K.); (Y.M.); (T.S.); (Y.M.); (A.S.); (C.S.); (A.N.); (A.N.)
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Honnorat M, Perouse-De-Montclos T, Bakloul M, Walton C, Butin M, Vo Van P. Transcatheter closure of patent ductus arteriosus in preterm infants: results from a single-center cohort. Front Pediatr 2023; 11:1292623. [PMID: 38178913 PMCID: PMC10765538 DOI: 10.3389/fped.2023.1292623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
Objective To assess the success rate of patent ductus arteriosus (PDA) transcatheter closure in preterm infants and to describe the nature of procedural adverse events and short-term clinical status. Study design All the preterm infants with PDA transcatheter closure were evaluated retrospectively between July 2019 and March 2023 in a single level III neonatal intensive care unit in France. The procedure was performed in the catheterization laboratory using venous canulation. We retrospectively collected data about the patients' characteristics, procedural outcomes and complications. Results Twenty-five infants born between 23.4 and 32.0 weeks of gestational age (mean ± SD 26.3 ± 1.9 weeks) underwent transcatheter PDA closure. Their mean age and weight at the time of the procedure were 52 days (range 22-146 days) and 1,620 g (range 890-3,700 g), respectively. Successful closure was achieved in all but one patient. Procedure related complications were reported in 10 infants (40%), including 6 left pulmonary artery stenosis one of which required a balloon dilatation, two cardiac tamponades and two inferior vena cava thrombosis. Only two post-ligature syndromes occurred after the procedure. Two infants died one of which was related to the procedure. Conclusion Transcatheter closure of a PDA is a valid alternative to surgical ligation due to its high success rate and low incidence of post-ligature syndrome. Nevertheless, we also report rare, although serious complications.
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Affiliation(s)
- Marion Honnorat
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France
| | | | - Mohamed Bakloul
- Service de Cardiologie Pédiatrique, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Camille Walton
- Cardiologie pédiatrique, Hôpital Privé Natécia, Lyon, France
| | - Marine Butin
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France
- INSERM U1111, CNRS UMR 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Centre International de Recherche en Infectiologie, Equipe “Pathogénie des Infections à Staphylocoques”, Lyon, France
| | - Philippe Vo Van
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France
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Castaldo MP, Neary E, Bischoff AR, Resende MHF, Weisz DE, Jain A, Giesinger RE, McNamara PJ. Rectal Acetaminophen Improves Shunt Volume and Reduces Patent Ductus Arteriosus Ligation in Extremely Preterm Infants. Am J Perinatol 2023; 40:1223-1231. [PMID: 34583409 DOI: 10.1055/s-0041-1735214] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE An alternative therapy for preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA) is needed when cyclooxygenase inhibitors fail or where treatment is contraindicated due to coexisting renal failure, necrotizing enterocolitis, and/or intestinal perforation. No studies have evaluated the efficacy of per rectum (PR) acetaminophen. The study aimed to evaluate the efficacy of PR acetaminophen in modulating the risk of PDA ligation. STUDY DESIGN A retrospective matched case-control study was conducted to compare neonates born <29 weeks' gestation with evidence of hsDA, in an era when rescue rectal acetaminophen was used (January 2014-March 2018) as a treatment strategy, versus historical controls (July 2006-August 2012). All patients underwent comprehensive echocardiography assessment of ductal shunt volume according to a standardized protocol. Acetaminophen treated neonates were matched according to demographics, gestation, preintervention echocardiography features, and comorbidities. Control patients were selected when an echocardiography was performed at an equivalent postnatal age. Infants with a genetic syndrome, severe congenital malformation, or major forms of congenital heart disease excluding small atrial septal defect or ventricular septal defect, PDA, or patent formale ovale were excluded. The primary outcome was surgical ligation of the PDA. Secondary outcomes included echocardiography indices of hemodynamic significance, the composite of death, or severe BPD (defined by ventilator dependence at 36 weeks postmenstrual age). Descriptive statistics and univariate (t-tests, Fisher's exact test, and Mann-Whitney U test) analyses were used to evaluate clinical and echocardiography characteristics of the groups and compare outcomes. RESULTS Forty infants (20 cases and 20 controls), with similar demographic and echocardiography features, were compared. Cases received 6.8 ± 0.7 days (60 mg/kg/day) of PR acetaminophen. Responders (n = 12, 60%) had echocardiography evidence of reduced ductal diameter (2.2 mm [1.9-2.6] to 1.1 mm [0-1.7], p = 0.002), left ventricular output (363 ± 108-249 ± 61 mL/min/kg; p = 0.002) and left atrium to aortic root ratio (1.7 ± 0.3-1.3 ± 0.2; p = 0.002) following treatment. The rate of PDA ligation was 50% lower (p = 0.02) and composite outcome of death or severe bronchopulmonary dysplasia was reduced (p = 0.04) in the acetaminophen group. CONCLUSION Rectal acetaminophen was associated with improvement in echocardiography indices of PDA shunt volume, a 50% reduction in PDA ligation rates and a reduction in the composite outcome of death or severe BPD. Pharmacologic and further prospective clinical studies are needed. KEY POINTS · Many preterm infants encounter the clinical consequences of a hemodynamically significant PDA.. · The merits and optimal timing of PDA ligation remains an area of controversy amongst neonatologists.. · Cyclooxygenase inhibitors are associated with adverse events or are often contraindicated..
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Affiliation(s)
- Michael P Castaldo
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elaine Neary
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Adrianne R Bischoff
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maura H F Resende
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Regan E Giesinger
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Newborn and Developmental Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Pandey R, Youmans L, Aneji C, Bell C, Breinholt J, Khan A. Extremely premature infants with patent ductus arteriosus closure: Comparative analysis of surgical ligation versus cardiac catheterization-based closure. Medicine (Baltimore) 2022; 101:e29103. [PMID: 35357352 DOI: 10.1097/md.0000000000029103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/26/2022] [Indexed: 11/25/2022] Open
Abstract
Our objective was to compare postprocedure hemodynamic decompensation in extremely premature infants who had their patent ductus arteriosus (PDA) closed with surgical ligation (SL) versus cardiac catheter-based closure (CCC).This is a single-center retrospective review of extremely premature ( < 28 weeks) infants who had their PDA closed by SL or CCC.Of the total of 69 infants, 53 underwent SL, and 16 had CCC. Infants in 2 groups were comparable at birth. However, at the time of the procedure, infants in the SL group were smaller, less mature, and had higher respiratory support. Vasopressor use, both pre- and postprocedure, was more common in the SL group. Nineteen percent of the infants in the SL group, compared to 6% in the CCC group (P = .34), required dose escalation or use of vasopressors after the PDA closure.There was no significant difference between the 2 groups in postoperative hemodynamic decompensation. Large, multicenter, prospective study or randomized control trial will help to confirm our findings.
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Affiliation(s)
- Rajesh Pandey
- McGovern School of Medicine, University of Texas, Health Science Center at Houston, Houston, TX
| | - Lydia Youmans
- McGovern School of Medicine, University of Texas, Health Science Center at Houston, Houston, TX
| | - Chiamaka Aneji
- McGovern School of Medicine, University of Texas, Health Science Center at Houston, Houston, TX
| | - Cynthia Bell
- McGovern School of Medicine, University of Texas, Health Science Center at Houston, Houston, TX
| | | | - Amir Khan
- McGovern School of Medicine, University of Texas, Health Science Center at Houston, Houston, TX
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Abstract
Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.
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Levy PT, Pellicer A, Schwarz CE, Neunhoeffer F, Schuhmann MU, Breindahl M, Fumagelli M, Mintzer J, de Boode W. Near-infrared spectroscopy for perioperative assessment and neonatal interventions. Pediatr Res 2021:10.1038/s41390-021-01791-1. [PMID: 34716423 DOI: 10.1038/s41390-021-01791-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
Perioperative applications of near-infrared spectroscopy (NIRS) to monitor regional tissue oxygenation and perfusion in cardiac and noncardiac surgery are of increasing interest in neonatal care. Complex neonatal surgery can impair adequate oxygen delivery and tissue oxygen consumption and increase the risk of neurodevelopmental delay. Coupled with conventional techniques, NIRS monitoring may enable targeted hemodynamic management of the circulation in both cardiac and noncardiac surgical procedures. In this narrative review, we discuss the application of perioperative NIRS in specific neonatal interventions, including surgical intervention for congenital heart defects, definitive closure of the patent ductus arteriosus, neurological and gastrointestinal disorders, and use of extracorporeal membrane oxygenation. We identified areas for future research within disease-specific indications and offer a roadmap to aid in developing evidence-based targeted diagnostic and management strategies in neonates. IMPACT: There is growing recognition that perioperative NIRS monitoring, used in conjunction with conventional monitoring, may provide critical hemodynamic information that either complements clinical impressions or delivers novel physiologic insight into the neonatal circulatory and perfusion pathways.
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Affiliation(s)
- Philip T Levy
- Department of Pediatrics, Harvard Medical School and Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christoph E Schwarz
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
- Infant Research centre, University College Cork Ireland, Cork, Ireland
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Monica Fumagelli
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Jonathan Mintzer
- Division of Newborn Medicine, Department of Pediatrics, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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Adams M, Schulzke SM, Natalucci G, Schneider J, Riedel T, Tolsa CB, Pfister R, Bassler D. Outcomes for Infants Born in Perinatal Centers Performing Fewer Surgical Ligations for Patent Ductus Arteriosus: A Swiss Population-Based Study. J Pediatr 2021; 237:213-220.e2. [PMID: 34157348 DOI: 10.1016/j.jpeds.2021.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess patent ductus arteriosus treatment variation between Swiss perinatal centers and to determine its effect on outcome in a population-based setting. STUDY DESIGN This was a retrospective cohort study of infants born less than 28 weeks of gestation between 2012 and 2017. Outcomes between surgically ligated and pharmacologically treated infants as well as infants born in centers performing ≤10% ligation ("low" group) and >10% ("high" group) were compared using logistic regression and 1:1 propensity score matching. Matching was based on case-mix and preligation confounders: intraventricular hemorrhages grades 3-4, necrotizing enterocolitis, sepsis, and ≥28 days' oxygen supply. RESULTS Of 1389 infants, 722 (52%) had pharmacologic treatment and 156 (11.2%) received surgical ligation. Compared with infants who received pharmacologic treatment, ligated infants had greater odds for major morbidities (OR 2.09, 95% CI 1.44-3.04) and 2-year neurodevelopmental impairment (OR 1.81, 95% CI 1.15-2.84). Mortality was comparable after restricting the cohort to infants surviving at least until day 10 to avoid survival bias. In the "low" group, 34 (4.9%) of 696 infants were ligated compared with 122 (17.6%) of 693 infants in the "high" group. Infants in the "high" group had greater odds for major morbidities (OR 1.49, 95% CI 1.11-2.0). CONCLUSIONS Our analysis identified a burden on infants receiving surgical ligation vs pharmacologic treatment in a population-based setting where there was no agreed-on common procedure. These results may guide a revision of patent ductus arteriosus treatment practice in Switzerland.
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Affiliation(s)
- Mark Adams
- Newborn Research, Department of Neonatology, University of Zurich and University Hospital Zurich, Zurich, Switzerland; Swiss Neonatal Network & Follow-up Group, Zurich, Switzerland.
| | - Sven M Schulzke
- Department of Neonatology, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Giancarlo Natalucci
- Newborn Research, Department of Neonatology, University of Zurich and University Hospital Zurich, Zurich, Switzerland; Swiss Neonatal Network & Follow-up Group, Zurich, Switzerland; Larsson-Rosenquist Centre for Neurodevelopment, Growth and Nutrition of the Newborn, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Juliane Schneider
- Clinic of Neonatology, Department Woman-Mother-Child, University Hospital Lausanne, Lausanne, Switzerland
| | - Thomas Riedel
- Paediatric and Neonatal Intensive Care Unit, Department of Paediatrics, Cantonal Hospital Graubuenden, Chur, Switzerland
| | | | - Riccardo Pfister
- Department of Woman, Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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12
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Wang H, Jain A, Weisz DE, Moraes TJ. Trends in patent ductus arteriosus ligation in neonates and changes in outcomes: A 10-year multicenter experience. Pediatr Pulmonol 2021; 56:3250-3257. [PMID: 34288596 DOI: 10.1002/ppul.25576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 11/09/2022]
Abstract
RATIONALE The management of neonates with patent ductus arteriosus (PDA) has changed over time. METHODS We conducted a single-city, retrospective review of neonates who underwent PDA ligation over a 10-year time period and compared infants from the first 5 years to the second 5 years to evaluate how clinical characteristics changed over this time. RESULTS Infants from the second 5-year epoch were older at time of ligation (38 vs. 30 days), had a higher ligation weight (1432 vs. 1121 g) and a lower incidence of postligation cardiac syndrome (1.9% vs. 11.5%). No differences in mortality, length of hospital-stay or major morbidities were seen. Compared to neonates who underwent PDA ligation at ≤28 days of life, those with a ligation age >28 days had a higher ligation weight (1421 vs. 1039 g), a higher proportion of COX inhibitor use (92.5% vs. 83.8%), and a higher incidence of moderate-severe bronchopulmonary dysplasia (BPD) (60.4% vs. 44.4%). Only 10.7% (25/233) patients were evaluated by laryngoscopy, in which the incidence of vocal cord paralysis (VCP) was 36.0%; 2 patients were clinically diagnosed with VCP for a total 4.7% incidence of VCP (11/233). CONCLUSIONS Over the 10 years examined, neonates underwent PDA ligation at an older age in the second 5-year time period; this change was not associated with a change in the incidence of major morbidities. Ligation age >28 days was associated with an increase incidence of moderate-severe BPD. The overall incidence of documented VCP post-PDA ligation was relatively low but was seen in over 1/3 who were evaluated by laryngoscopy.
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Affiliation(s)
- Huanhuan Wang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Amish Jain
- Division of Neonatal/Perinatal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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13
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Sarda SP, Sarri G, Siffel C. Global prevalence of long-term neurodevelopmental impairment following extremely preterm birth: a systematic literature review. J Int Med Res 2021; 49:3000605211028026. [PMID: 34284680 PMCID: PMC8299900 DOI: 10.1177/03000605211028026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective Neurodevelopmental impairment (NDI) is a major complication of extreme prematurity. This systematic review was conducted to summarize the worldwide long-term prevalence of NDI associated with extreme prematurity. Methods Embase and MEDLINE databases were searched for epidemiologic and observational/real-world studies, published in English between 2011 and 2016, reporting long-term prevalence of NDI (occurring from 1 year) among extremely preterm infants born at gestational age (GA) ≤28 weeks. Results Of 2406 articles identified through searches, 69 met the protocol NDI definition (24 North America, 25 Europe, 20 Rest of World). Prevalence of any severity NDI in North America was 8%–59% at 18 months to 2 years, and 11%–37% at 2–5 years; prevalence of moderate NDI in Europe was 10%–13% at 18 months to 2 years, 3% at 2–5 years, and 9%–19% at ≥5 years; prevalence of any NDI in Rest of World was 15%–61% at 18 months to 2 years, and 42% at 2–5 years (no North America/Rest of World studies reported any NDI at ≥5 years). A trend toward higher prevalence of NDI with lower GA at birth was observed. Conclusions Extreme prematurity has a significant long-term worldwide impact on neurodevelopmental outcomes.
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Affiliation(s)
- Sujata P Sarda
- Global Evidence and Outcomes, Takeda, Lexington, MA, USA
| | - Grammati Sarri
- Evidence Synthesis, Modeling & Communication, Evidera, London, UK
| | - Csaba Siffel
- Global Evidence and Outcomes, Takeda, Lexington, MA, USA.,College of Allied Health Sciences, 1421Augusta University, 1421Augusta University, Augusta, GA, USA
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14
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Godin R, Rodriguez JC, Kahn DJ. Oral Versus Intravenous Medications for Treatment of Patent Ductus Arteriosus in Preterm Neonates: A Cost-Saving Initiative. J Pediatr Pharmacol Ther 2021; 26:291-299. [PMID: 33833632 DOI: 10.5863/1551-6776-26.3.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/18/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The purpose of the study was to quantify cost savings after promoting oral pharmacotherapy for the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). METHODS This was a retrospective before-and-after time series quality improvement study. Oral ibuprofen and acetaminophen use criteria were developed and recommended, rather than the more costly intravenous equivalents. There were 24-month medication use reports generated for both the pre-criteria (Era-1) and the post-criteria (Era-2) implementation phases to identify neonates prescribed hsPDA medications in order to assess cost differences. RESULTS Era-1 had 190 treatment courses in 110 neonates for a total medication cost of $171,260.70. Era-2 had 210 courses in 109 patients for a total medication cost of $47,461.49, yielding savings of $123,799.21 ($61,899.61 annually) after criteria implementation. The reduction in intravenous ibuprofen use in Era-2 accounted for all the savings. CONCLUSION Preferentially prescribing lower-cost oral medications to treat hsPDA led to significant cost savings.
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15
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Aldecoa-Bilbao V, García-Catalán MJ, Gaixa M, Clotet Caba J, Teodoro S, Figaró Voltà C. Neurodevelopmental Impairment at Two Years in Premature Infants with Prolonged Patency of Ductus Arteriosus after a Conservative Approach. Am J Perinatol 2021; 38:449-455. [PMID: 31600790 DOI: 10.1055/s-0039-1697674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The study aims to assess the impact on neurodevelopmental outcomes of a prolonged hemodynamically significant patent ductus arteriosus (PDA) after a conservative treatment. STUDY DESIGN This involves the study of two cohorts of preterm infants 23 to 29 weeks gestation, before (n = 29) and after (n = 54) a conservative approach of PDA. We compared survival, major outcomes, and neurodevelopmental impairment (NDI) at 2 years and analyzed NDI in the conservative cohort according to the duration of the PDA. RESULTS Conservative cohort received less medical (31.5%) and surgical treatment (7.4%) and had more days of PDA (59 days in 24-26 weeks and 22 days in 27-29 weeks; p < 0.001) in comparison with control cohort (19 days in 24-26 weeks and 11 days in 27-29 weeks; p = 0.688). Mortality, survival-without-morbidity at discharge, and NDI at 2 years were similar between the two groups (p = 0.732). In the multivariate analysis PDA >28 days was not related to worse outcomes at discharge (p = 0.296) or less survival-without-NDI at 2 years (p = 0.498). CONCLUSION Until randomized trials prove the benefit of attempting to close the PDA with ibuprofen in the first week of life, conservative management may be a reasonable option.
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Affiliation(s)
- Victoria Aldecoa-Bilbao
- Department of Neonatology, Hospital Clínic Barcelona, ICGON, BCNatal, Universitat de Barcelona, Barcelona, Spain
| | - Maria-Jesús García-Catalán
- Department of Pediatrics, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Marta Gaixa
- Department of Pediatric, Centre Desenvolupament Infantil i Atenció Precoç, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Jordi Clotet Caba
- Department of Neonatology, Hospital Clínic Barcelona, ICGON, BCNatal, Universitat de Barcelona, Barcelona, Spain
| | - Silvia Teodoro
- Department of Pediatric Cardiology, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carme Figaró Voltà
- Department of Neonatology, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
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16
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Gudmundsdottir A, Broström L, Skiöld B, Källén K, Serenius F, Norman M, Aden U, Bonamy AE. The type and timing of patent ductus arteriosus treatment was associated with neurodevelopment when extremely preterm infants reached 6.5 years. Acta Paediatr 2021; 110:510-520. [PMID: 32603514 DOI: 10.1111/apa.15452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 05/24/2020] [Accepted: 06/23/2020] [Indexed: 11/30/2022]
Abstract
AIM This study investigated patent ductus arteriosus (PDA) treatment and neurodevelopmental outcomes when extremely preterm born children reached 6.5 years. METHOD Our cohort was 435 children with neonatal PDA treatment data and neurodevelopmental follow-up data, born in 2004-2007, who participated in the Extremely Preterm Infants in Sweden Study. Pharmacological or surgical PDA treatment and the age at PDA treatment, were investigated in relation to the risks of moderate to severe neurodevelopmental impairment (NDI) and full-scale intelligence quotient (FSIQ) at 6.5 years. RESULTS The children who received PDA drug treatment, including those who also had surgery, had the same risk of moderate to severe NDI or lower FSIQ as untreated children. However, children who had primary PDA surgery faced increased risks of NDI, with an adjusted incidence rate ratio of 1.62 (95% confidence interval [CI] 1.28-2.06) and a lower adjusted mean difference FSIQ of -7.1 (95% CI -11 to -3.2). Surgery at less than 10 days of life was associated with a significantly increased risk of moderate to severe NDI and lower FSIQ than surgery after 20 days. CONCLUSION Drug treatment followed by deferred surgery appeared to be a safer option for extremely preterm infants severely affected by PDA.
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Affiliation(s)
- Anna Gudmundsdottir
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Lina Broström
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Beatrice Skiöld
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Karin Källén
- Department of Obstetrics and Gynecology Institute of Clinical Sciences University of Lund Lund Sweden
| | - Fredrik Serenius
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
| | - Ulrika Aden
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Anna‐Karin Edstedt Bonamy
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
- Clinical Epidemiology Unit Department of Medicine Solna Karolinska Institutet Stockholm Sweden
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Clyman RI, Kaempf J, Liebowitz M, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A. Prolonged Tracheal Intubation and the Association Between Patent Ductus Arteriosus and Bronchopulmonary Dysplasia: A Secondary Analysis of the PDA-TOLERATE trial. J Pediatr 2021; 229:283-288.e2. [PMID: 32979387 PMCID: PMC7855529 DOI: 10.1016/j.jpeds.2020.09.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/16/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022]
Abstract
In the PDA-TOLERATE trial, persistent (even for several weeks) moderate to large patent ductus arteriosus (PDA) was not associated with an increased risk of BPD when the infant required <10 days of intubation. However, in infants requiring intubation for ≥10 days, prolonged PDA exposure (≥11 days) was associated with an increased risk of moderate/severe BPD.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco,Department of Cardiovascular Research Institute, University of California San Francisco
| | - Joseph Kaempf
- Department of Pediatrics of Providence St. Vincent Medical Center, Portland, OR
| | | | - Omer Erdeve
- Department of Pediatrics of Ankara University School of Medicine Children’s Hospital, Ankara, Turkey
| | - Ali Bulbul
- Department of Pediatrics of Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | | | | | - Aijaz Farooqi
- Department of Pediatrics of Umea University Hospital, Umea, Sweden
| | - Anup Katheria
- Department of Pediatrics of Sharp Mary Birch Hospital, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics of Sharp Mary Birch Hospital, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics of University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics of University of Chicago, Chicago, IL
| | - Andrea Wickremasinghe
- Department of Pediatrics of Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Lawrence Dong
- Department of Pediatrics of Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | - Susan W. Aucott
- Department of Pediatrics of Johns Hopkins University, Baltimore, MD
| | - Madoka Hayashi
- Department of Pediatrics of Johns Hopkins University, Baltimore, MD
| | - Anne Marie Heuchan
- Department of Pediatrics of University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, UK
| | | | - Matthew Derrick
- Department of Pediatrics of Northshore University Health System, Evanston, IL
| | - Erika Fernandez
- Department of Pediatrics of University of California San Diego and Rady Children’s Hospital, San Diego, CA
| | - Meera Sankar
- Department of Pediatrics of Good Samaritan Hospital, San Jose, CA
| | - Tina Leone
- Department of Pediatrics of Columbia University Medical Center, New York, NY
| | - Jorge Perez
- Department of Pediatrics of South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics of South Miami Hospital/Baptist Health South Florida, Miami, FL
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18
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Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
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Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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19
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Su BH, Lin HY, Chiu HY, Tsai ML, Chen YT, Lu IC. Therapeutic strategy of patent ductus arteriosus in extremely preterm infants. Pediatr Neonatol 2020; 61:133-141. [PMID: 31740267 DOI: 10.1016/j.pedneo.2019.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/15/2019] [Accepted: 10/21/2019] [Indexed: 01/29/2023] Open
Abstract
The ductus arteriosus is likely to close without treatment in most infants born at gestational age (GA) > 28 weeks (73%), and those with birth weight > 1000 g (94%). However, the rates of spontaneous ductal closure among less mature or smaller infants with respiratory distress syndrome are not known. Extremely preterm infants born at GA < 28 weeks are associated with a high risk of severe intraventricular hemorrhage (IVH) or pulmonary hemorrhage, which usually occur within 72 h after birth and affect mortality and long-term neurological development. These serious hemorrhagic complications may be closely related to hemodynamic changes caused by a hemodynamically significant patent ductus arteriosus (hs-PDA). While prophylactic indomethacin has been shown to reduce the rates of PDA, PDA ligation, severe IVH and early pulmonary hemorrhage, the available evidence does not support its prophylactic use in preterm infants. Symptomatic or late treatment is associated with lower success rate, and increased complications of a hs-PDA. The issue of "to treat or not to treat a PDA" is controversial. Considering the relationship between the effectiveness and timing of pharmacological treatment, early targeted treatment may be an alternative approach for the early identification of a hs-PDA in specific high-risk patient population, especially infants <26 weeks GA who are at the highest risk of severe IVH or pulmonary hemorrhage. Serial echocardiographic studies can be used to select patients who are candidates for early targeted medical treatment of hs-PDA. Surgical ligation of PDA, and transcatheter closure if proven to be safe, can be used as back-up therapy for patients who fail medical treatment and continue to have cardiopulmonary compromise.
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Affiliation(s)
- Bai-Horng Su
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - I-Chun Lu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
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20
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Yan H, Ma F, Li Y, Zhou K, Hua Y, Wan C. The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19356. [PMID: 32118777 PMCID: PMC7478603 DOI: 10.1097/md.0000000000019356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a particularly common problem in preterm infants. Although surgical ligation is rarely performed in many contemporary neonatal intensive care units, it remains a necessary treatment option for preterm infants with a large hemodynamically significant PDA under strict clinical criteria, and it can reduce mortality in preterm infants. However, the optimal timing of surgical ligation is still controversial. We conducted this systematic review and meta-analysis to compare the mortality and morbidity of early and late surgical ligation of PDA in preterm or very-low-birth-weight (VLBW) infants. METHODS This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019133686). We searched the databases of PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform up to May 2019. RESULTS This review included 6 retrospective studies involving 397 premature or VLBW infants with PDA. Pooled analysis showed that compared with the late ligation group, the early ligation group had a lower fraction of inspired oxygen (FiO2) at 24 hours postoperatively (mean difference [MD] -6.34, 95% confidence interval [CI] -9.45 to -3.22), fewer intubation days (MD -19.69, 95% CI -29.31 to -10.07), earlier date of full oral feeding (MD -22.98, 95% CI -28.63 to -17.34) and heavier body weight at 36 weeks of conceptional age (MD 232.08, 95% CI 57.28 to 406.88). No significant difference in mortality or other complications was found between the early and late groups. CONCLUSION Our meta-analysis implies that compared with late surgical ligation, early ligation might have a better respiratory outcome and nutritional status for PDA in preterm or VLBW infants. There was no difference in mortality or postoperative complications between early and late ligation. A randomized prospective clinical trial with a possible large sample size is urgently needed to reinvestigate this conclusion. PROSPERO REGISTRATION NUMBER CRD42019133686.
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Affiliation(s)
- Hualin Yan
- Department of Medical Ultrasound, West China Hospital, Sichuan University
- West China School of Medicine, Sichuan University
| | - Fan Ma
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chaomin Wan
- West China School of Medicine, Sichuan University
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
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21
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Fraisse A, Bautista-Rodriguez C, Burmester M, Lane M, Singh Y. Transcatheter Closure of Patent Ductus Arteriosus in Infants With Weight Under 1,500 Grams. Front Pediatr 2020; 8:558256. [PMID: 33072674 PMCID: PMC7536298 DOI: 10.3389/fped.2020.558256] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/24/2020] [Indexed: 11/23/2022] Open
Abstract
Persistent patent ductus arteriosus (PDA) is very common in preterm infants, especially in extremely preterm infants. Despite significant advances in management of these vulnerable infants, there has been no consensus on management of PDA-when should we treat, who should we treat, how should we treat and in fact there is no agreement on how we should define a hemodynamically significant PDA. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) remains the first line of therapy with moderate success rate in closing the PDA. Paracetamol has been reported to be a safe and equally effective medical therapy for closure of PDA. However, additional studies on its long-term safety and efficacy in extremely low birth weight infants are needed before paracetamol can be recommended as standard treatment for a PDA in preterm infants. Surgical ligation of PDA is not without an increased risk of mortality and co-morbidities. Recently, there has been a significant interest in percutaneous transcatheter closure of PDA in preterm infants, including extremely low birth weight infants. Transcatheter PDA closure in preterm ELBW infants is technically feasible with high PDA occlusion success rates and acceptable complication rates as compared to surgical ligation. Many centers have reported promising early- and mid-term follow-up results. However, they need to be further tested in the prospective well-designed studies and randomized controlled trials comparing the results and outcomes of this technique with current treatment strategies including medical treatment before they can be used as the new standard of care for PDA closure in extremely low birth weight infants.
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Affiliation(s)
- Alain Fraisse
- Pediatric Cardiology Services, Royal Brompton Hospital, London, United Kingdom.,National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Carles Bautista-Rodriguez
- Pediatric Cardiology Services, Royal Brompton Hospital, London, United Kingdom.,National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Margarita Burmester
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Pediatric Cardiac Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Mary Lane
- Pediatric Cardiology Services, Royal Brompton Hospital, London, United Kingdom.,National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Yogen Singh
- Department of Pediatrics-Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
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22
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Kemmochi M, Senzaki H, Miyaji K, Hashimoto M, Yamaguchi A, Ooka M, Yokozeki Y, Ishii M. Optimal timing of video-assisted thoracoscopic surgery for patent ductus arteriosus in preterm infants born at ≤ 28 weeks of gestation. Pediatr Int 2019; 61:792-796. [PMID: 31199535 DOI: 10.1111/ped.13909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 01/09/2019] [Accepted: 03/01/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery for patent ductus arteriosus (VATS-PDA) is an alternative surgical procedure to open chest surgery, even in premature infants. This study investigated whether the timing of VATS-PDA has a prognostic impact in premature infants whose operative indication was determined according to the symptomatic PDA and the ineffectiveness of or contraindication to indomethacine therapy. METHODS We studied 49 infants born at or before 28 weeks of gestation who were admitted to the neonatal intensive care unit between January 2004 and June 2016, and who underwent VATS-PDA. The patients were divided into two groups according to median age at the time of surgery (early group, 24 infants who underwent surgery at ≤ 24 days of life; late group, 25 infants who underwent surgery at ≥ 25 days of life). RESULTS No significant differences were found in bodyweight at 30 days of age and 40 weeks of corrected gestational age between the groups. The timing of surgery did not affect the operative procedure or postoperative complications. In addition, no differences were observed between the early and late groups in terms of complications associated with prematurity, including intraventricular hemorrhage, incidence and severity of bronchopulmonary dysplasia, and necrotizing enteropathy. CONCLUSION Video-assisted thoracoscopic surgery for patent ductus arteriosus can be safely performed in premature infants without a preferential timing for the intervention, suggesting that this procedure allows for an elective basis approach after heart failure management with conservative and/or drug therapy in premature infants with PDA.
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Affiliation(s)
- Manabu Kemmochi
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Hideaki Senzaki
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Megumi Hashimoto
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Ayano Yamaguchi
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Mari Ooka
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yuuichirou Yokozeki
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Masahiro Ishii
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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23
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Clyman RI, Liebowitz M, Kaempf J, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A. PDA-TOLERATE Trial: An Exploratory Randomized Controlled Trial of Treatment of Moderate-to-Large Patent Ductus Arteriosus at 1 Week of Age. J Pediatr 2019; 205:41-48.e6. [PMID: 30340932 PMCID: PMC6502709 DOI: 10.1016/j.jpeds.2018.09.012] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 08/11/2018] [Accepted: 09/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare early routine pharmacologic treatment of moderate-to-large patent ductus arteriosus (PDA) at the end of week 1 with a conservative approach that requires prespecified respiratory and hemodynamic criteria before treatment can be given. STUDY DESIGN A total of 202 neonates of <28 weeks of gestation age (mean, 25.8 ± 1.1 weeks) with moderate-to-large PDA shunts were enrolled between age 6 and 14 days (mean, 8.1 ± 2.2 days) into an exploratory randomized controlled trial. RESULTS At enrollment, 49% of the patients were intubated and 48% required nasal ventilation or continuous positive airway pressure. There were no differences between the groups in either our primary outcome of ligation or presence of a PDA at discharge (early routine treatment [ERT], 32%; conservative treatment [CT], 39%) or any of our prespecified secondary outcomes of necrotizing enterocolitis (ERT, 16%; CT, 19%), bronchopulmonary dysplasia (BPD) (ERT, 49%; CT, 53%), BPD/death (ERT, 58%; CT, 57%), death (ERT,19%; CT, 10%), and weekly need for respiratory support. Fewer infants in the ERT group met the rescue criteria (ERT, 31%; CT, 62%). In secondary exploratory analyses, infants receiving ERT had significantly less need for inotropic support (ERT, 13%; CT, 25%). However, among infants who were ≥26 weeks gestational age, those receiving ERT took significantly longer to achieve enteral feeding of 120 mL/kg/day (median: ERT, 14 days [range, 4.5-19 days]; CT, 6 days [range, 3-14 days]), and had significantly higher incidences of late-onset non-coagulase-negative Staphylococcus bacteremia (ERT, 24%; CT,6%) and death (ERT, 16%; CT, 2%). CONCLUSIONS In preterm infants age <28 weeks with moderate-to-large PDAs who were receiving respiratory support after the first week, ERT did not reduce PDA ligations or the presence of a PDA at discharge and did not improve any of the prespecified secondary outcomes, but delayed full feeding and was associated with higher rates of late-onset sepsis and death in infants born at ≥26 weeks of gestation. TRIAL REGISTRATION ClinicalTrials.gov: NCT01958320.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA,Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Melissa Liebowitz
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Joseph Kaempf
- Department of Pediatrics, Providence St. Vincent Medical Center, Portland, OR
| | - Omer Erdeve
- Department of Pediatrics, Ankara University School of Medicine Children’s Hospital, Ankara
| | - Ali Bulbul
- Department of Pediatrics, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | | | | | - Aijaz Farooqi
- Department of Pediatrics, Umea University Hospital, Umea, Sweden
| | - Anup Katheria
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Lawrence Dong
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | - Susan W. Aucott
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Madoka Hayashi
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Anne Marie Heuchan
- Department of Pediatrics, University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
| | | | - Matthew Derrick
- Department of Pediatrics, Northshore University Health System, Evanston, IL
| | - Erika Fernandez
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital, San Diego
| | - Meera Sankar
- Department of Pediatrics, Good Samaritan Hospital, San Jose, CA
| | - Tina Leone
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jorge Perez
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
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El-Dib M, Soul JS. Monitoring and management of brain hemodynamics and oxygenation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:295-314. [PMID: 31324316 DOI: 10.1016/b978-0-444-64029-1.00014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States.
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25
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Hundscheid T, Onland W, van Overmeire B, Dijk P, van Kaam AHLC, Dijkman KP, Kooi EMW, Villamor E, Kroon AA, Visser R, Vijlbrief DC, de Tollenaer SM, Cools F, van Laere D, Johansson AB, Hocq C, Zecic A, Adang E, Donders R, de Vries W, van Heijst AFJ, de Boode WP. Early treatment versus expectative management of patent ductus arteriosus in preterm infants: a multicentre, randomised, non-inferiority trial in Europe (BeNeDuctus trial). BMC Pediatr 2018; 18:262. [PMID: 30077184 PMCID: PMC6090763 DOI: 10.1186/s12887-018-1215-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 07/09/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Much controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants, especially in those born at a gestational age (GA) less than 28 weeks. No causal relationship has been proven between a (haemodynamically significant) PDA and neonatal complications related to pulmonary hyperperfusion and/or systemic hypoperfusion. Although studies show conflicting results, a common understanding is that medical or surgical treatment of a PDA does not seem to reduce the risk of major neonatal morbidities and mortality. As the PDA might have closed spontaneously, treated children are potentially exposed to iatrogenic adverse effects. A conservative approach is gaining interest worldwide, although convincing evidence to support its use is lacking. METHODS This multicentre, randomised, non-inferiority trial is conducted in neonatal intensive care units. The study population consists of preterm infants (GA < 28 weeks) with an echocardiographic-confirmed PDA with a transductal diameter > 1.5 mm. Early treatment (between 24 and 72 h postnatal age) with the cyclooxygenase inhibitor (COXi) ibuprofen (IBU) is compared with an expectative management (no intervention intended to close a PDA). The primary outcome is the composite of mortality, and/or necrotising enterocolitis (NEC) Bell stage ≥ IIa, and/or bronchopulmonary dysplasia (BPD) defined as the need for supplemental oxygen, all at a postmenstrual age (PMA) of 36 weeks. Secondary outcome parameters are short term sequelae of cardiovascular failure, comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. Consequences regarding health economics are evaluated by cost effectiveness analysis and budget impact analysis. DISCUSSION As a conservative approach is gaining interest, we investigate whether in preterm infants, born at a GA less than 28 weeks, with a PDA an expectative management is non-inferior to early treatment with IBU regarding to the composite outcome of mortality and/or NEC and/or BPD at a PMA of 36 weeks. TRIAL REGISTRATION This trial is registered with the Dutch Trial Register NTR5479 (registered on 19 October 2015), the registry sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28 .
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MESH Headings
- Humans
- Infant, Newborn
- Cost-Benefit Analysis
- Cyclooxygenase Inhibitors/therapeutic use
- Ductus Arteriosus, Patent/complications
- Ductus Arteriosus, Patent/drug therapy
- Ductus Arteriosus, Patent/mortality
- Ductus Arteriosus, Patent/surgery
- Enterocolitis, Necrotizing/etiology
- Ibuprofen/therapeutic use
- Infant, Extremely Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/mortality
- Ligation
- Research Design
- Time-to-Treatment
- Watchful Waiting/economics
- Multicenter Studies as Topic
- Equivalence Trials as Topic
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Affiliation(s)
- Tim Hundscheid
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Wes Onland
- Department of Neonatology, Academic Medical Centre Amsterdam, Emma Children’s hospital, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - Bart van Overmeire
- Department of Paediatrics, Division of Neonatology, Cliniques Universitaires de Bruxelles, Erasme Hospital, Route de Lennik 808, 1070 Brussels, Belgium
| | - Peter Dijk
- Department of Paediatrics, Division of Neonatology, University Medical Centre Groningen, Beatrix Children’s Hospital, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Anton H. L. C. van Kaam
- Department of Paediatrics, Division of Neonatology, VU University Medical Centre Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Koen P. Dijkman
- Department of Neonatology, Maxima Medical Centre Veldhoven, de Run 4600, Postbus 7777, 5500 MB Veldhoven, The Netherlands
| | - Elisabeth M. W. Kooi
- Department of Paediatrics, Division of Neonatology, University Medical Centre Groningen, Beatrix Children’s Hospital, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Eduardo Villamor
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - André A. Kroon
- Department of Paediatrics, Division of Neonatology, Erasmus Medical Centre Rotterdam, Sophia Children’s Hospital, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Remco Visser
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Willem Alexander Children’s Hospital, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daniel C. Vijlbrief
- Department of Paediatrics, Division of Neonatology, University Medical Centre Utrecht, Utrecht University, Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Susanne M. de Tollenaer
- Department of Paediatrics, Division of Neonatology, Isala Women’s and Children’s Hospital Zwolle, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Filip Cools
- Department of Neonatology, UZ Brussel – Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - David van Laere
- Department of Paediatrics, Division of Neonatology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Anne-Britt Johansson
- Department of Paediatrics, Division of Neonatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Jean Joseph Crocqlaan 15, 1020 Brussels, Belgium
| | - Catheline Hocq
- Department of Paediatrics, Division of Neonatology, Cliniques Universitaires St Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Alexandra Zecic
- Department of Paediatrics, Division of Neonatology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Eddy Adang
- Department of Health Evidence, Radboud university medical centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Rogier Donders
- Department of Health Evidence, Radboud university medical centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Willem de Vries
- Department of Paediatrics, Division of Neonatology, University Medical Centre Utrecht, Utrecht University, Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Arno F. J. van Heijst
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Willem P. de Boode
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Weisz DE, Giesinger RE. Surgical management of a patent ductus arteriosus: Is this still an option? Semin Fetal Neonatal Med 2018; 23:255-266. [PMID: 29636280 DOI: 10.1016/j.siny.2018.03.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The evolution of neonatal intensive care over the past decade has seen the role of surgical patent ductus arteriosus (PDA) ligation in preterm infants both decrease in scope and become laden with uncertainty. Associations of ligation with adverse neonatal and neurodevelopmental outcomes have rendered the ligation decision more challenging for clinicians and have been associated with a decline in surgical treatment, but these findings may be due to bias from confounding by indication in observational studies rather than a causal detrimental effect of ligation. Accordingly, ligation may still be indicated for infants with large ductal shunts and moderate-severe respiratory insufficiency in whom the prospect of timely spontaneous closure appears low. Ultimately a randomized trial of surgical ligation versus conservative management is necessary to assess the efficacy of this invasive intervention in a population of extremely preterm infants with large ductal shunts. Simultaneously, the transcatheter approach to ductal closure in the very immature infant represents an exciting therapeutic alternative but which is still in its infancy. Insights into the pathophysiology of postoperative cardiorespiratory deterioration, including the importance of left ventricular afterload, may help clinicians avoid instability and mitigate a potentially injurious aspect of surgical treatment. This review examines the evidence regarding the benefits and risks of PDA surgery in preterm neonates and provides a pathophysiology-based management paradigm to guide perioperative care in high-risk infants.
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Affiliation(s)
- Dany E Weisz
- Department of Paediatrics, University of Toronto, Toronto, Canada; Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Regan E Giesinger
- Department of Paediatrics, University of Toronto, Toronto, Canada; Division of Neonatology, Department of Paediatrics, Hospital for Sick Children, Toronto, Canada
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27
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Abstract
Preterm infants are at increased risk for patent ductus arteriosus (PDA). Prolonged exposure to PDA may be deleterious and has been associated with neonatal morbidity and mortality. Although the molecular mechanisms underlying regulation of postnatal ductus arteriosus closure are not fully understood, clinical experience and research trials have informed recent changes in PDA management strategies and refocused treatment strategies on smaller subsets of infants who require intervention. This review examines current diagnostic and management approaches to PDA in preterm neonates.
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Affiliation(s)
- Maria Gillam-Krakauer
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
| | - Jeff Reese
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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28
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Cuzzolin L, Bardanzellu F, Fanos V. The dark side of ibuprofen in the treatment of patent ductus arteriosus: could paracetamol be the solution? Expert Opin Drug Metab Toxicol 2018; 14:855-868. [PMID: 29938546 DOI: 10.1080/17425255.2018.1492550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) persistence is associated, in prematures, to several complications. The optimal PDA management is still under debate, especially regarding the best therapeutic approach and the time to treat. The available drugs are not exempt from contraindications and side effects; ibuprofen itself, although representing the first-choice therapy, can show nephrotoxicity and other complications. Paracetamol seems a valid alternative to classic nonsteroidal anti-inflammatory Drugs, with a lower toxicity. Areas covered: Through an analysis of the published literature on ibuprofen and paracetamol effects in preterm neonates, this review compares the available treatments for PDA, analyzing the mechanisms underlining ibuprofen-associated nephrotoxicity and the eventual paracetamol-induced hepatic damage, also providing an update of what has been yet demonstrated and a clear description of the still open issues. Expert Opinion: Paracetamol is an acceptable alternative in case of contraindication to ibuprofen; its toxicity, in this setting, is very low. Lower doses may be effective, with even fewer risks. In the future, paracetamol could represent an efficacious first-line therapy, although its safety, optimal dosage, and global impact have to be fully clarified through long-term trials, also in the perspective of an individualized and person-based therapy taking into account the extraordinary individual variability.
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Affiliation(s)
- Laura Cuzzolin
- a Department of Diagnostics & Public Health-Section of Pharmacology , University of Verona , Verona , Italy
| | - Flamina Bardanzellu
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
| | - Vassilios Fanos
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
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29
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Abstract
A persistent left-to-right shunt through a patent ductus arteriosus (PDA) increases the rate of hydrostatic fluid filtration into the lung's interstitium, impairs pulmonary mechanics, and prolongs the need for mechanical ventilation. In preclinical trials, pharmacologic PDA closure leads to improved alveolarization and minimizes the impaired postnatal alveolar development that is the pathologic hallmark of bronchopulmonary dysplasia (BPD). Although routine prophylactic treatment of a PDA on the day of birth does not appear to offer any more protection against BPD than delaying treatment for 2-3 days, recent evidence from quality improvement trials suggests that early pharmacologic treatment decreases the incidence of BPD compared with a treatment approach that exposes infants to a moderate-to-large PDA shunt for the first 7-10 days after birth. After the first week, routine pharmacologic treatment (compared with continued PDA exposure) no longer appears to alter the course of BPD development. Evidence from epidemiologic, preclinical, and randomized controlled trials demonstrate that early ductus ligation is an independent risk factor for the development of BPD.
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Affiliation(s)
- Ronald I Clyman
- Cardiovascular Research Institute, Departments of Pediatrics and the Cardiovascular Research Institute, University of California, San Francisco, UCSF Box 1346, HSW 1408, 513 Parnassus Ave, San Francisco, CA 94143-1346.
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30
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Reese J, Scott TA, Patrick SW. Changing patterns of patent ductus arteriosus surgical ligation in the United States. Semin Perinatol 2018; 42:253-261. [PMID: 29954594 PMCID: PMC6512985 DOI: 10.1053/j.semperi.2018.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Optimal management of patent ductus arteriosus (PDA) is unclear. One treatment, surgical ligation, is associated with adverse outcomes. We reviewed data from the Kids' Inpatient Database (2000-2012) to determine if PDA ligation rates: (1) changed over time, (2) varied geographically, or (3) influenced surgical complication rates. In 2012, 47,900 infants <1500g birth weight were born in the United States, including 2,800 undergoing PDA ligation (5.9%). Ligation was more likely in infants <1000g (85.9% vs. 46.2%), and associated with necrotizing enterocolitis (59.2% vs. 37.5%), BPD (54.6% vs. 15.2%), severe intraventricular hemorrhage (16.4% vs. 5.3%), and hospital transfer (37.6% vs. 16.4%). Ligation rates peaked in 2006 at 87.4 per 1000 hospital births, dropping to 58.8 in 2012, and were consistently higher in Western states. Infants undergoing ligation were more likely to experience comorbidities. Rates of ligation-associated vocal cord paralysis increased over time (1.2-3.9%); however, mortality decreased (12.4-6.5%). Thus, PDA ligation has become less frequent, although infants being ligated are smaller and more medically complex. Despite increase in some complications, mortality rates improved perhaps reflecting advances in care.
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Affiliation(s)
- Jeff Reese
- Mildred T. Stahlman Division of Neonatology, Vanderbilt University Medical Center, 11111 Doctor’s Office Tower, 2200 Children’s Way, Nashville 37232–9544, TN
| | - Theresa A. Scott
- Mildred T. Stahlman Division of Neonatology, Vanderbilt University Medical Center, 11111 Doctor’s Office Tower, 2200 Children’s Way, Nashville 37232–9544, TN
| | - Stephen W. Patrick
- Mildred T. Stahlman Division of Neonatology, Vanderbilt University Medical Center, 11111 Doctor’s Office Tower, 2200 Children’s Way, Nashville 37232–9544, TN,Center for Health Services Research, Vanderbilt Center for Child Health Policy, Nashville, TN,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN,Corresponding author. (S.W. Patrick)
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Elsayed YN, Fraser D. Patent Ductus Arteriosus in Preterm Infants, Part 1: Understanding the Pathophysiologic Link Between the Patent Ductus Arteriosus and Clinical Complications. Neonatal Netw 2018; 36:265-272. [PMID: 28847349 DOI: 10.1891/0730-0832.36.5.265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The clinical guidelines for treating patent ductus arteriosus (PDA) have significantly evolved over the last decades from treating any ductal shunt to more conservative management where only the hemodynamically significant patent ductus arteriosus (HSPDA) is treated. This shift has resulted largely from a lack of evidence from randomized controlled trials supporting a relationship between treating a PDA and improving long-term neonatal outcomes. However, there are many unresolved issues. There is no consensus on the precise definition of HSPDA requiring treatment or a clear understanding of when to treat HSPDA. Moreover, the current evidence shows worsening of the long-term neurodevelopmental outcome for infants undergoing surgical PDA ligation.<br/> The presence of physiologic variability among preterm infants, and the presence of different compensatory mechanisms may make it difficult to establish a link between pathophysiology and long-term outcomes. That is, the physiologic variability cannot be simply assessed by randomly assigning infants into two arms of a study. Relying on research from animal and human studies, this article explains the link between the pathophysiology of a PDA and neonatal outcomes.
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Weisz DE, Mirea L, Resende MHF, Ly L, Church PT, Kelly E, Kim SJ, Jain A, McNamara PJ, Shah PS. Outcomes of Surgical Ligation after Unsuccessful Pharmacotherapy for Patent Ductus Arteriosus in Neonates Born Extremely Preterm. J Pediatr 2018; 195:292-296.e3. [PMID: 29306492 DOI: 10.1016/j.jpeds.2017.11.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/29/2017] [Accepted: 11/15/2017] [Indexed: 01/09/2023]
Abstract
A retrospective cohort study of neonates born extremely preterm with persistent patent ductus arteriosus after unsuccessful pharmacologic closure compared outcomes between 166 surgically ligated and 142 nonligated neonates. After adjustment for confounders, ligation was not associated with the composite outcome of death or neurodevelopmental impairment, neurodevelopmental impairment alone, chronic lung disease, or retinopathy of prematurity among survivors.
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Affiliation(s)
- Dany E Weisz
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
| | | | | | - Linh Ly
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Paige T Church
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Edmond Kelly
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - S Joseph Kim
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Patrick J McNamara
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Mt. Sinai Hospital, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Physiology and Experimental Medicine, SickKids Research Institute, Toronto, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Surgical Ligation Versus Percutaneous Closure of Patent Ductus Arteriosus in Very Low-Weight Preterm Infants: Which are the Real Benefits of the Percutaneous Approach? Pediatr Cardiol 2018; 39:398-410. [PMID: 29119215 DOI: 10.1007/s00246-017-1768-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/28/2017] [Indexed: 10/18/2022]
Abstract
Percutaneous treatment of patent ductus arteriosus (PDA) in extreme premature infants is technically difficult, and therefore, often not consider as an alternative to surgery. The main objective of our work was to compare respiratory status prior and post ductal closure and morbi-mortality, in our series of preterm infants with percutaneous PDA closure versus surgical ligation in the same time-period. Retrospective review of all premature infants submitted to percutaneous and surgical PDA closure from January 2011 to December 2016. All the antenatal, perinatal, and postnatal characteristics were collected. The main outcome was the assessment of the pulmonary status before and after ductal closure using a pulmonary score. Secondary outcomes included moderate-severe disability in neurodevelopment, death before discharge, moderate-severe chronic lung disease, and morbidity at discharge. 25 patients with a mean weight of 1330 g (± 280) underwent percutaneous closure of PDA with ADO-II-AS, and a total of 53 underwent surgical ligation. 28/53 with similar gestational age, birth weight, and procedure weight to those in the percutaneous group, were selected to perform the comparative study. Ductal closure (percutaneous and surgical) resulted in improved respiratory status. However, percutaneous group achieved a fastest respiratory improvement, than surgical group. The surgical closure group associated higher morbidity among survivors (HIV, number of sepsis, need, and duration of inotropics post-interventionism). The incidence of recurrent laryngeal nerve palsy among the surgical group was 17%. Percutaneous closure of PDA in carefully selected low-weight preterm infants is a safe and reliable alternative to surgical ligation.
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Treatment and Nontreatment of the Patent Ductus Arteriosus: Identifying Their Roles in Neonatal Morbidity. J Pediatr 2017; 189:13-17. [PMID: 28709633 PMCID: PMC5639904 DOI: 10.1016/j.jpeds.2017.06.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 06/22/2017] [Indexed: 11/23/2022]
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Bixler GM, Powers GC, Clark RH, Walker MW, Tolia VN. Changes in the Diagnosis and Management of Patent Ductus Arteriosus from 2006 to 2015 in United States Neonatal Intensive Care Units. J Pediatr 2017; 189:105-112. [PMID: 28600155 DOI: 10.1016/j.jpeds.2017.05.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/04/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify changes in the diagnosis, pharmacotherapy, and surgical ligation of patent ductus arteriosus (PDAs) in infants born premature and report on temporal changes in mortality and morbidity from a large volume of neonatal intensive care units (NICUs) in the US. STUDY DESIGN We queried the Pediatrix Clinical Data Warehouse for all inborn infants without major anomalies born between 23 and 30 weeks' gestation from 2006 to 2015 for a diagnosis of PDA, use of indomethacin or ibuprofen, history of ductal ligation, mortality, and major morbidities. RESULTS There were 829 091 infants entered in the Clinical Data Warehouse; 61 520 infants from 280 NICUs met our inclusion criteria. The diagnosis of PDA declined from 51% to 38% (P < .001), use of indomethacin or ibuprofen decreased from 32% to 18%, and PDA ligation decreased from 8.4% to 2.9% (both P < .001). During the study period, mortality decreased with no increase in any measured morbidity. Of the 163 sites with data for both periods, 128 (79%) showed a decrease in the diagnosis of PDA, and 132 (81%) showed a decrease in the use indomethacin and/or ibuprofen when 2011-2015 was compared with 2006-2010. Of 103 sites with at least 1 PDA ligation, 85 (83%) showed a decrease in PDA ligation in a similar comparison. CONCLUSIONS In this large population of infants <30 weeks' gestation from 280 NICUs across the US, there were significant decreases in the diagnosis and treatment of the PDA. Although there was no evidence of increased morbidities, it remains uncertain how these changes may directly affect infant outcomes.
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Affiliation(s)
- G Michael Bixler
- Division of Neonatology, Wright State University Boonshoft School of Medicine, Pediatrix Medical Group, Dayton, OH
| | - George C Powers
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio and Pediatrix Medical Group, San Antonio, TX
| | - Reese H Clark
- The Pediatrix Center for Research, Education, and Quality, MEDNAX, Inc, Sunrise, FL
| | - M Whit Walker
- Division of Neonatology, Greenville Health System, University of South Carolina School of Medicine - Greenville, Greenville, SC
| | - Veeral N Tolia
- Division of Neonatology, Department of Pediatrics, Baylor University Medical Center and Pediatrix Medical Group, Dallas, TX.
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Prophylactic Indomethacin Compared with Delayed Conservative Management of the Patent Ductus Arteriosus in Extremely Preterm Infants: Effects on Neonatal Outcomes. J Pediatr 2017; 187:119-126.e1. [PMID: 28396025 PMCID: PMC5533630 DOI: 10.1016/j.jpeds.2017.03.021] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/10/2017] [Accepted: 03/07/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine whether prophylactic indomethacin (PINDO) has more or less morbidity than delayed conservative management of the moderate-to-large patent ductus arteriosus (PDA). STUDY DESIGN We performed a prospective double cohort controlled study of infants delivered at ≤276/7 weeks gestation (n = 397). From January 2005 through April 2011, all infants were treated with PINDO (n = 247). From May 2011 through August 2016, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch, n = 150). Echocardiograms were performed on day 7 and at planned intervals until the PDA was small or closed. A single neonatologist prospectively collected all data. RESULTS The incidence of moderate-to-large PDA on day 7 and duration of exposure to moderate-to-large PDA were significantly less in the PINDO epoch (incidence = 10%, median = 2 days) than the conservative epoch (incidence = 67%, median = 14 days). Ligation rates were low in both epochs (PINDO = 14%, conservative = 5%). In multivariate analyses, PINDO infants had a significantly lower incidence of bronchopulmonary dysplasia (BPD) (risk ratio = 0.68, CI: 0.46-0.89) and BPD or death (risk ratio= 0.78, CI: 0.62-0.95) than conservative infants. There were no differences between the epochs in death, intraventricular hemorrhage grades 3 and 4, necrotizing enterocolitis, or retinopathy of prematurity receiving treatment. The effects of PINDO on BPD and BPD or death were no longer significant when analyses were adjusted for presence of a moderate-to-large PDA on day 7. The significant effects of PINDO were independent of whether or not a ligation was performed. CONCLUSIONS PINDO decreases BPD and BPD or death compared with delayed conservative PDA management. These effects are mediated by closure of the PDA.
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Paracetamol in Patent Ductus Arteriosus Treatment: Efficacious and Safe? BIOMED RESEARCH INTERNATIONAL 2017; 2017:1438038. [PMID: 28828381 PMCID: PMC5554551 DOI: 10.1155/2017/1438038] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/22/2017] [Accepted: 06/11/2017] [Indexed: 12/19/2022]
Abstract
In preterm infants, failure or delay in spontaneous closure of Ductus Arteriosus (DA), resulting in the condition of Patent Ductus Arteriosus (PDA), represents a significant issue. A prolonged situation of PDA can be associated with several short- and long-term complications. Despite years of researches and clinical experience on PDA management, unresolved questions about the treatment and heterogeneity of clinical practices in different centers still remain, in particular regarding timing and modality of intervention. Nowadays, the most reasonable strategy seems to be reserving the treatment only to hemodynamically significant PDA. The first-line therapy is medical, and ibuprofen, related to several side effects especially in terms of nephrotoxicity, is the drug of choice. Administration of oral or intravenous paracetamol (acetaminophen) recently gained attention, appearing effective as traditional nonsteroidal anti-inflammatory drugs (NSAIDs) in PDA closure, with lower toxicity. The results of the studies analyzed in this review mostly support paracetamol efficacy in ductal closure, with inconstant low and transient elevation of liver enzymes as reported side effect. However, more studies are needed to confirm if this therapy shows a real safety profile and to evaluate its long-term outcomes, before considering paracetamol as first-choice drug in PDA treatment.
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38
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Mohamed MA, El-Dib M, Alqahtani S, Alyami K, Ibrahim AN, Aly H. Patent ductus arteriosus in premature infants: to treat or not to treat? J Perinatol 2017; 37:652-657. [PMID: 28206995 DOI: 10.1038/jp.2017.4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/08/2016] [Accepted: 12/28/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Closing patent ductus arteriosus (PDA) is a widely accepted approach in the management of very low birth weight (VLBW) infants. Our objective is to test the hypothesis that conservative management (no treatment) of PDA will not affect survival without chronic lung diseases (CLD). STUDY DESIGN This retrospective study utilizes a prospectively collected database to compare two cohorts of VLBW infants. Infants in the first group (2001 to 2009) had their PDA treated with pharmacological and if necessary with surgical ligation. PDA in the second group (2010 to 2014) was not treated with medical or surgical intervention. The primary outcome was survival without oxygen requirement at 36 weeks. Pulmonary and non-pulmonary morbidities were also compared. Logistic regression analyses were performed to control for confounders. RESULTS This study included 643 VLBW infants, of them 415 infants in the Treat group and 228 in the No-Treat group. The rate of survival without CLD did not differ between Treat and No-Treat groups (78.4% vs 83.9%, respectively; adjusted odds ratio (aOR)=1.72, confidence interval (CI): 0.92 to 3.23, P=0.09). Mortality declined in No-Treat group (15.2% vs 10.5%, aOR=0.51, CI: 0.25 to 0.99, P=0.049), but the two groups did not differ in the incidence of CLD among survivors (5.8% vs 5.0%,=P0.47). Pulmonary complications and non-pulmonary morbidities did not differ between groups. CONCLUSIONS Conservative management (no treatment) of PDA may not compromise survival without CLD and is not associated with increased morbidities in VLBW infants. Prospective physiological studies are needed to determine the sector of VLBW infants, if any, who could benefit from PDA treatment.
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Affiliation(s)
- M A Mohamed
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - M El-Dib
- Department of Newborn Services, Brigham and Women's Hospital, Boston, MA, USA
| | - S Alqahtani
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - K Alyami
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - A N Ibrahim
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - H Aly
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
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Weisz DE, Mirea L, Rosenberg E, Jang M, Ly L, Church PT, Kelly E, Kim SJ, Jain A, McNamara PJ, Shah PS. Association of Patent Ductus Arteriosus Ligation With Death or Neurodevelopmental Impairment Among Extremely Preterm Infants. JAMA Pediatr 2017; 171:443-449. [PMID: 28264088 PMCID: PMC5470355 DOI: 10.1001/jamapediatrics.2016.5143] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Observational studies have associated patent ductus arteriosus (PDA) ligation among preterm infants with adverse neonatal outcomes and neurodevelopmental impairment in early childhood, with a resultant secular trend away from surgical treatment. However, to our knowledge, studies have inadequately addressed sources of residual bias, including survival bias and major neonatal morbidities arising before exposure to ligation. OBJECTIVE Evaluate the association between PDA ligation vs medical management and neonatal and neurodevelopmental outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of preterm infants younger than 28 weeks gestational age born between January 1, 2006, and December 31, 2012, with clinical and echocardiography diagnoses of hemodynamically significant PDA was conducted at 3 tertiary neonatal intensive care units and affiliated follow-up programs. EXPOSURE Surgical ligation vs medical management. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or neurodevelopmental impairment (NDI) at 18 to 24 months corrected age. Secondary outcomes included death before discharge, NDI, moderate-severe chronic lung disease, and severe retinopathy of prematurity. Multivariable logistic regression analysis was used to adjust for perinatal and postnatal confounders. RESULTS Of 754 infants with hemodynamically significant PDA (mean [standard deviation] gestational age 25.7 [1.2] weeks and birth weight 813 [183] grams), 184 (24%) underwent ligation. Infants who underwent ligation had a higher frequency of morbidities before PDA closure, including sepsis, necrotizing enterocolitis, and a dependence on mechanical ventilation. After adjusting for perinatal characteristics and preligation morbidities, there was no difference in the odds of death or NDI (adjusted odds ratio (aOR), 0.83; 95% CI, 0.52-1.32), NDI (aOR, 1.27; 95% CI, 0.78-2.06), chronic lung disease (aOR, 1.36; 95% CI, 0.78-2.39) or severe retinopathy of prematurity (aOR, 1.61; 95% CI, 0.85-3.06). Ligation was associated with lower odds of mortality (aOR, 0.09; 95% CI, 0.04-0.21). CONCLUSIONS AND RELEVANCE Patent ductus arteriosus ligation among preterm neonates younger than 28 weeks gestational age was not associated with the composite outcome of death or NDI, and there were no differences in chronic lung disease, retinopathy of prematurity, or NDI among survivors. Mortality was lower among infants who underwent ligation, though residual survival bias could not be excluded. Previously reported associations of ligation with increased morbidity may be because of bias from confounding by indication.
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Affiliation(s)
- Dany E. Weisz
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Lucia Mirea
- Phoenix Children's Hospital, Phoenix, Arizona
| | - Erin Rosenberg
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Maximus Jang
- Department of Pediatrics, Mt. Sinai Hospital, Toronto, Canada
| | - Linh Ly
- Department of Pediatrics, University of Toronto, Toronto, Canada,Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Paige T. Church
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Edmond Kelly
- Department of Pediatrics, University of Toronto, Toronto, Canada,Department of Pediatrics, Mt. Sinai Hospital, Toronto, Canada
| | - S. Joseph Kim
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Canada,Department of Pediatrics, Mt. Sinai Hospital, Toronto, Canada
| | - Patrick J. McNamara
- Department of Pediatrics, University of Toronto, Toronto, Canada,Department of Pediatrics, Hospital for Sick Children, Toronto, Canada,Department of Physiology, University of Toronto and Physiology and Experimental Medicine, SickKids Research Institute, Toronto, Canada
| | - Prakesh S. Shah
- Department of Pediatrics, University of Toronto, Toronto, Canada,Department of Pediatrics, Mt. Sinai Hospital, Toronto, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Ito S, Matsuda T, Usuda H, Watanabe S, Kitanishi R, Hanita T, Watanabe T, Adachi O. Surgical Ligation for Patent Ductus Arteriosus in Extremely Premature Infants: Strategy to Reduce their Risk of Neurodevelopmental Impairment. TOHOKU J EXP MED 2017; 240:7-13. [PMID: 27558322 DOI: 10.1620/tjem.240.7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical ligation for patent ductus arteriosus (PDA) in extremely low birth weight infants (ELBWIs) has been shown a possible association with neurodevelopmental impairment (NDI) because of its invasiveness. However, we have undergone surgical ligation for ELBWIs immediately after cyclooxygenase inhibitor failed to close a hemodynamically significant PDA (hsPDA) to maintain proper systemic circulation. We aimed to determine the effect of surgical ligation for hsPDA on NDI in ELBWIs. In enrolled 71 ELBWIs, the clinical parameters, including the developmental quotient (DQ), were collected and compared among three groups that were divided by closure mode: spontaneous closure (n = 11), cyclooxygenase inhibitor therapy (n = 37) and surgical ligation (n = 23). No significant differences in DQ at the age of 36 months among the three groups were found: Median (interquartile range): 92.0 (31.0), 89.0 (22.0) and 92.0 (24.5), respectively. In a comparison between groups of DQ < 70 (n = 15) and DQ ≥ 70 (n = 56), a significant difference was found in the parameters related to prematurity (p < 0.05 for each): gestational age [23.9 (1.70) vs. 25.4 (2.50) weeks], birth weight [595 (183) vs. 714 (192) g], Apgar score < 5 (1 min) (67% vs. 36%), and laser photocoagulation for retinopathy of prematurity (73% vs. 43%), but there was no significant association with hsPDA. Therefore, we propose that surgical ligation for hsPDA in ELBWIs should be immediately carried out for preventing future neurodevelopmental deterioration if the cyclooxygenase inhibitor failed to close hsPDA.
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Affiliation(s)
- Satoko Ito
- Center for Perinatal-Neonatal Medicine, Tohoku University Hospital
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Transcatheter Closure of Patent Ductus Arteriosus in Extremely Premature Newborns. JACC Cardiovasc Interv 2016; 9:2429-2437. [DOI: 10.1016/j.jcin.2016.09.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/12/2016] [Accepted: 09/08/2016] [Indexed: 11/19/2022]
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El-Khuffash A, Weisz DE, McNamara PJ. Reflections of the changes in patent ductus arteriosus management during the last 10 years. Arch Dis Child Fetal Neonatal Ed 2016; 101:F474-8. [PMID: 27118761 DOI: 10.1136/archdischild-2014-306214] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 11/04/2022]
Abstract
Despite a large body of scientific evidence on the management of premature infants with a patent ductus arteriosus controversy remains and neonatologists remain challenged for knowing which patient to treat, what is the most optimal timing of treatment and which treatments have a positive impact on both short-term and long-term outcomes. In this review article we discuss the increased body of evidence over the past 10 years, much of which questions the role of treatment and suggests the need to reconsider how haemodynamic significance is adjudicated. In addition, we discuss novel approaches to assessment and diagnosis, and highlight areas for future investigation.
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dany E Weisz
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada Physiology and Experimental Medicine Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Predictors of respiratory instability in neonates undergoing patient ductus arteriosus ligation after the introduction of targeted milrinone treatment. J Thorac Cardiovasc Surg 2016; 152:498-504. [DOI: 10.1016/j.jtcvs.2016.03.085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 02/24/2016] [Accepted: 03/19/2016] [Indexed: 02/07/2023]
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Acetaminophen to avoid surgical ligation in extremely low gestational age neonates with persistent hemodynamically significant patent ductus arteriosus. J Perinatol 2016; 36:649-53. [PMID: 27054842 DOI: 10.1038/jp.2016.60] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/11/2016] [Accepted: 03/03/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the effectiveness of rescue oral acetaminophen in improving echocardiography (echo) indices of patent ductus arteriosus (PDA) shunt volume and avoiding surgical ligation in extremely low gestational age (GA) neonates (ELGANs, <28 weeks) with persistent PDA. STUDY DESIGN Retrospective cohort study of ELGANs with moderate or severe PDA at risk for ligation after a practice change introducing oral acetaminophen (60 mg kg(-1) day(-1) for 3 to 7 days) to facilitate ductal constriction after indomethacin failure. RESULTS Twenty-six infants (median GA 24.4 weeks at birth) with persistent PDA under consideration for surgical ligation were treated with oral acetaminophen at a mean of 27 days of life. Echo indices of shunt volume improved in 12 (46%) infants (3 closed and 9 reduced to mild shunt), all of whom avoided ligation. There was no echo improvement in 14 (54%) infants, of which 8/14 underwent ligation, and ligation was deferred in 6/14 infants, mostly owing to improvement in respiratory stability. Fewer responders than non-responders underwent ligation (0% vs 57%, P<0.01), though there were no differences in other neonatal outcomes. CONCLUSIONS In ELGANs with persistent significant PDA, rescue therapy with oral acetaminophen was associated with improvement in echo indices of shunt volume and avoidance of ligation in nearly half of infants.
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The impact of a dedicated patent ductus arteriosus ligation team on neonatal health-care outcomes. J Perinatol 2016; 36:463-8. [PMID: 26765550 DOI: 10.1038/jp.2015.213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/11/2015] [Accepted: 11/24/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The decision to perform patent ductus arteriosus (PDA) ligation is controversial. Patient selection is oftentimes poorly standardized, leading to delays in referral and inappropriate intervention. A system for PDA ligation categorization and triaging process was introduced in 2006 at a quaternary hospital in Canada to streamline referrals and enhance perioperative care. We aimed to evaluate the impact of this dedicated PDA ligation triaging system comparing pre- and postimplementation of this system. STUDY DESIGN We performed a retrospective chart review. Demographic and cardiorespiratory data of neonates ⩽30 weeks gestation age at birth, who were referred for and/or had a PDA ligation performed during two distinct epochs (EPOCH 1 (2003 to 2005) and EPOCH 2 (2010 to 2012)), were analyzed. All surgeries were performed at The Hospital for Sick Children, the regional referral center for PDA ligation. The primary outcome was incidence of PDA ligation and procedural cancellations. Secondary outcomes included postoperative need for cardiovascular or respiratory support. Subgroup analysis was performed in neonates <1000 vs >1000 g at the time of surgery during both epochs. RESULT A total of 198 neonates underwent surgery with no difference in baseline demographics between epochs. The incidence of PDA ligation as a proportion of total live births under 30 weeks in Central East Region of Ontario was lower in the second epoch (EPOCH 1: 117/1092 (10.7%) vs EPOCH 2: 81/1520 (5.3%)). During the second epoch, 24% of referrals for surgery were canceled after review by our PDA ligation team. There were no overall differences in the proportion of neonates with oxygenation failure, ventilation failure or Post-Ligation Cardiac Syndrome (PLCS), after surgery, between epochs. The proportion of neonates who developed systemic hypotension was higher in patients <1000 g (n=34 (34%) vs n=17 (17.4%), P=0.01) at the time of surgery. In addition, we identified a reduction in the proportion of neonates <1000 g who developed PLCS in EPOCH 2. On the contrary, there was an increase in the proportion of neonates >1000 g who developed ventilation failure in EPOCH 2. CONCLUSION The presence of dedicated triaging and management system enhances efficiency of referral process through careful selection of patients for PDA ligation and optimizes perioperative management. We demonstrated a reduction in the incidence of PDA ligation without any negative impact on short-term neonatal morbidity. The use of targeted neonatal echocardiography in the assessment of PDA shunt volume and guiding postoperative decision making is likely to have contributed to these findings.
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Jerrell JM, Shuler CO, Tripathi A, Black GB, Park YMM. Long-Term Neurodevelopmental Outcomes in Children and Adolescents With Congenital Heart Disease. Prim Care Companion CNS Disord 2016; 17:15m01842. [PMID: 26835177 DOI: 10.4088/pcc.15m01842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/23/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Effective medical and surgical management of pediatric congenital heart disease (CHD) to reduce long-term adverse neurodevelopmental outcomes is an important clinical objective in primary and specialty health care. We identify clinical predictors associated with an increased risk of 6 long-term neurodevelopmental outcomes in children with CHD compared to the general pediatric Medicaid population. METHOD South Carolina's retrospective, 15-year Medicaid data set (January 1, 1996-December 31, 2010) for 19,947 patients aged ≤ 17 years diagnosed with ≥ 1 CHD lesions (on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes) were compared to 19,948 patients without CHD matched on age at entry into and duration in Medicaid using logistic and Cox proportional hazards regression. RESULTS The CHD cohort was significantly less likely to have incident neurologic or psychiatric disorders, mental retardation, developmental delays, or inattention/hyperactivity (adjusted odds ratios [ORs] = 0.34, 0.56, 0.03, 0.01, 0.004, respectively) but was more likely to have incident seizures (OR = 2.00) compared to controls. Exposure to both cardiac and noncardiac surgical intervention was associated with a significantly increased risk of developing neurologic or psychiatric disorders, mental retardation, developmental delays, or inattention/hyperactivity (cardiac ORs = 1.66, 2.00, 1.67, 1.43, 1.76, respectively) (noncardiac ORs = 2.25, 1.59, 1.48, 1.29, 1.36, 2.46, respectively). Any documented hypoxemia was associated with a significantly increased risk of developing 5 of the neurodevelopmental conditions (neurologic OR = 4.52, psychiatric OR = 1.60, mental retardation OR = 2.90, developmental delay OR = 2.12, seizures OR = 4.23). CONCLUSION Practitioners should maintain vigilant surveillance of all CHD patients, especially those exposed to surgical procedures or experiencing hypoxemia, to identify any neurodevelopmental issues early and address them promptly.
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Affiliation(s)
- Jeanette M Jerrell
- Departments of Neuropsychiatry and Behavioral Science and Pediatrics, University of South Carolina School of Medicine, Columbia
| | - C Osborne Shuler
- Departments of Neuropsychiatry and Behavioral Science and Pediatrics, University of South Carolina School of Medicine, Columbia
| | - Avnish Tripathi
- Department of Medicine, Division of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky
| | - George B Black
- Department of Internal Medicine, University of Virginia, Charlottesville
| | - Yong-Moon Mark Park
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia
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Liebowitz MC, Clyman RI. Predicting the Need for Home Oxygen Therapy in Preterm Infants Born Before 28 Weeks' Gestation. Am J Perinatol 2016; 33:34-9. [PMID: 26084746 PMCID: PMC5648327 DOI: 10.1055/s-0035-1555122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To discover a predictor, that could be used at least 3 to 4 weeks' before discharge, to identify infants who would need home oxygen therapy. We hypothesized that infants requiring a high level of respiratory support at 34 weeks' postmenstrual age (PMA) would require home oxygen. STUDY DESIGN Single center retrospective study of 143 infants less than 28 weeks' gestation. We determined when infants weaned from each level of respiratory support (mechanical ventilation, nasal continuous airway pressure [nCPAP] or biphasic positive pressure, nasal cannula flow ≥ 2 L/min, nasal cannula flow < 2 L/min or no respiratory support). Our primary outcome was need for home oxygen. RESULT Infants who required nCPAP at 34 weeks' PMA had a 100% positive predictive value for home oxygen therapy. CONCLUSION Higher levels of respiratory support at 34 weeks' PMA can predict the need for home oxygen and is useful in preparing patients and families for discharge.
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Affiliation(s)
| | - Ronald I. Clyman
- Department of Pediatrics, University of California, San Francisco, California,Cardiovascular Research Institute, University of California, San Francisco, California
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Bourgoin L, Cipierre C, Hauet Q, Basset H, Gournay V, Rozé JC, Flamant C, Gascoin G. Neurodevelopmental Outcome at 2 Years of Age according to Patent Ductus Arteriosus Management in Very Preterm Infants. Neonatology 2016; 109:139-46. [PMID: 26726863 DOI: 10.1159/000442278] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/09/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a condition frequently found in very preterm infants, and its treatment remains a subject of debate. Furthermore, there are only a few studies available that have examined the impact of these treatments on the neurological outcome of the patient. OBJECTIVE To evaluate the neurodevelopmental outcome of PDA treatment on preterm infants born between 24+0 and 28+6 weeks of gestation. METHODS We conducted an observational multicentric cohort study (LIFT Cohort). We compared three groups of patients according to their PDA treatment strategy: medical treatment with ibuprofen, surgical ligation, and no treatment. The neurodevelopmental outcome was assessed with a physical examination and cognitive function evaluation at 2 years of age. A propensity score was used to reduce bias in the analysis. RESULTS Between 2003 and 2011, 857 infants (91.3%) were evaluated at 2 years of corrected age and included in the analysis: 248 received ibuprofen treatment (29%), 104 had PDA surgical ligation (12%), and 505 did not receive any PDA treatment (59%). Surgical ligation of PDA was significantly associated with neurodevelopmental impairment at 2 years of age (adjusted odds ratio = 2.2; 95% confidence interval: 1.4-3.4). CONCLUSION We found an association between PDA surgical ligation and a nonoptimal neurodevelopmental outcome at 2 years of age for preterm infants born before 29 weeks of gestation. These results suggest that if surgical ligation is unavoidable, particular attention should be given to the patient's neurodevelopmental follow-up.
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Affiliation(s)
- Laura Bourgoin
- Department of Neonatal Medicine, University Hospital of Angers, Angers, France
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Abstract
Despite a large body of basic science and clinical research and clinical experience with thousands of infants over nearly 6 decades,(1) there is still uncertainty and controversy about the significance, evaluation, and management of patent ductus arteriosus in preterm infants, resulting in substantial heterogeneity in clinical practice. The purpose of this clinical report is to summarize the evidence available to guide evaluation and treatment of preterm infants with prolonged ductal patency in the first few weeks after birth.
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Janz-Robinson EM, Badawi N, Walker K, Bajuk B, Abdel-Latif ME, Bajuk B, Sedgley S, Carlisle H, Smith J, Craven P, Glover R, Cruden L, Argomand A, Rieger I, Malcolm G, Lutz T, Reid S, Stack J, Callander I, Medlin K, Marcin K, Shingde V, Lampropoulos B, Chin MF, Bonser K, Badawi N, Halliday R, Loughran-Fowlds A, Karskens C, Paradisis M, Kluckow M, Jacobs C, Numa A, Williams G, Young J, Luig M, Baird J, Lui K, Sutton L, Cameron D. Neurodevelopmental Outcomes of Premature Infants Treated for Patent Ductus Arteriosus: A Population-Based Cohort Study. J Pediatr 2015; 167:1025-32.e3. [PMID: 26227439 DOI: 10.1016/j.jpeds.2015.06.054] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 06/01/2015] [Accepted: 06/25/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare neurodevelopmental outcomes of extremely preterm infants diagnosed with patent ductus arteriosus (PDA) who were treated medically or surgically and those who were not diagnosed with PDA or who did not undergo treatment for PDA. STUDY DESIGN This retrospective population-based cohort study used data from a geographically defined area in New South Wales and the Australian Capital Territory served by a network of 10 neonatal intensive care units. Patients included all preterm infants born at <29 completed weeks of gestation between 1998 and 2004. Moderate/severe functional disability at 2-3 years corrected age was defined as developmental delay, cerebral palsy requiring aids, sensorineural or conductive deafness (requiring bilateral hearing aids or cochlear implant), or bilateral blindness (best visual acuity of <6/60). RESULTS Follow-up information at age 2-3 years was available for 1473 infants (74.8%). Compared with infants not diagnosed with a PDA or who did not receive PDA treatment for PDA, those with medically treated PDA (aOR, 1.622; 95% CI, 1.199-2.196) and those with surgically treated PDA (aOR, 2.001; 95% CI, 1.126-3.556) were at significantly greater risk for adverse neurodevelopmental outcomes at age 2-3 years. CONCLUSION Our results demonstrate that treatment for PDA may be associated with a greater risk of adverse neurodevelopmental outcome at age 2-3 years. This was particularly so among infants born at <25 weeks gestation. These results may support permissive tolerance of PDAs; however, reasons for this association remain to be elucidated through carefully designed prospective trials.
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Affiliation(s)
| | - Nadia Badawi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, Australia; Cerebral Palsy Alliance Research Foundation, Notre Dame University, Sydney, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, Australia; Cerebral Palsy Alliance Research Foundation, Notre Dame University, Sydney, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Barbara Bajuk
- Neonatal Intensive Care Units Data Collection, NSW Pregnancy and Newborn Services Network, Sydney Children's Hospitals Network, Sydney, Australia
| | - Mohamed E Abdel-Latif
- Department of Neonatology, Centenary Hospital for Women and Children, Garran, Australian Capital Territory, Australia; Medical School, College of Medicine, Biology & Environment, Australian National University, Acton, Canberra, Australia.
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