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Bischoff AR, Backes CH, Rivera B, Jasani B, Patel F, Cheung E, Sathanandam S, Philip R, McNamara PJ. Cardiorespiratory Instability after Percutaneous Patent Ductus Arteriosus Closure: A Multicenter Cohort Study. J Pediatr 2024; 271:114052. [PMID: 38615941 DOI: 10.1016/j.jpeds.2024.114052] [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: 02/22/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE To evaluate postprocedural clinical characteristics of preterm infants undergoing transcatheter patent ductus arteriosus (PDA) closure, including oxygenation/ventilation failure and cardiovascular compromise. STUDY DESIGN Multicenter retrospective cohort study of preterm infants who were ≤2 kg at the time of percutaneous PDA closure between August 2018 and July 2021. Indices of cardiorespiratory stability were collected pre-closure, immediately post-closure, and subsequently averaged every 4 hours for the first 24 hours post-procedure. The primary outcome was incidence of post-transcatheter cardiorespiratory syndrome: composite of hemodynamic instability (defined by systemic hypotension, systemic hypertension, or use of new inotropes/vasopressors in the first 24 hours after catheterization) and at least one of the following: (i) ventilation failure or (ii) oxygenation failure. RESULTS A total of 197 patients were included with a median [IQR] age and weight at catheterization of 34 [25, 43] days and 1090 [900, 1367] grams, respectively. The primary composite outcome of post-transcatheter cardiorespiratory syndrome was reported in 46 (23.3%). CONCLUSION Post-transcatheter cardiorespiratory syndrome is characterized primarily by systemic hypertension and oxygenation failure, with a very low incidence of hypotension and need for inotropes.
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Affiliation(s)
- Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Brian Rivera
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Bonny Jasani
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Foram Patel
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Erica Cheung
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ranjit Philip
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA; Department of Internal Medicine, University of Iowa, Iowa City, IA.
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Fernandez MC, Kase JS, Giamelli J, Reichlin A. Morbidity and neurodevelopmental outcomes at 2 years in preterm infants undergoing percutaneous transcatheter closure vs. surgical ligation of the PDA. J Perinatol 2024:10.1038/s41372-024-02019-w. [PMID: 38831120 DOI: 10.1038/s41372-024-02019-w] [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: 01/10/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Review a cohort of preterm infants ≤29 weeks of gestation at birth and compare morbidities and neurodevelopmental outcomes based on PDA status and type of PDA closure. STUDY DESIGN Single center observational retrospective-prospective case control study of premature infants who had no hsPDA, underwent surgical ligation or percutaneous transcatheter closure of the PDA. Neurodevelopmental testing was done using the Bayley Scales of Infant Development 3rd ed. RESULTS The percutaneous transcatheter closure group had an older post menstrual age and greater weight at the time of procedure, and started enteral feeds and achieved room air status at an earlier post procedure day. Infants in the surgical ligation group were more likely to experience vocal cord paralysis. There was no difference in neurodevelopmental outcomes between groups. CONCLUSION Waiting for infants to achieve the appropriate size for percutaneous transcatheter closure of the PDA may lead to reduced short-term complications without increasing the risk of neurodevelopmental impairment.
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Affiliation(s)
- Maria Cristina Fernandez
- Sunrise Children's Hospital, Las Vegas, NV, USA.
- The Regional Neonatal ICU Maria Fareri Children's Hospital at Westchester Medical Center - New York Medical College Valhalla, Valhalla, NY, USA.
| | - Jordan S Kase
- The Regional Neonatal ICU Maria Fareri Children's Hospital at Westchester Medical Center - New York Medical College Valhalla, Valhalla, NY, USA
| | - Joseph Giamelli
- Pediatric Cardiology Intervention, Maria Fareri Children's Hospital at Westchester Medical Center-New York Medical College Valhalla, Valhalla, NY, USA
| | - Amy Reichlin
- The Regional Neonatal ICU Maria Fareri Children's Hospital at Westchester Medical Center - New York Medical College Valhalla, Valhalla, NY, USA
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Lee WY, Yum SK, Seo YM, Kim S, Shin JA, Lee C. Patent ductus arteriosus management in very-low-birth-weight prematurity: a place for an early operation? Eur J Cardiothorac Surg 2024; 65:ezae175. [PMID: 38724226 DOI: 10.1093/ejcts/ezae175] [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: 12/21/2023] [Revised: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 05/19/2024] Open
Abstract
OBJECTIVES The goal was to evaluate neonatal outcomes based on treatment strategies and time points for haemodynamically significant patent ductus arteriosus (hsPDA) in very-low-birth-weight preterm infants, with a particular focus on surgical closure. METHODS This retrospective study included very-low-birth-weight infants born between 2014 and 2021 who received active treatment for hsPDA. Neonatal outcomes were compared between (i) primary surgical closure versus primary ibuprofen; (ii) early (<14th post-natal day) versus late primary surgical closure (≥14th post-natal day); and (iii) primary versus secondary surgical closure after ibuprofen failure. Further analysis using 1:1 propensity score matching was performed. Logistic regression was conducted to analyse the risk factors for post-ligation cardiac syndrome (PLCS) and/or acute kidney injury (AKI). RESULTS A total of 145 infants with hsPDA underwent active treatment for closure. The in-hospital death rate and the incidence of severe bronchopulmonary dysplasia (BPD) were similar between the primary surgical closure group and the primary ibuprofen group in a 1:1 matched analysis. Severe BPD was significantly higher in the late surgical closure group than in the early primary surgical closure group with 1:1 propensity score matching (72.7% vs 40.9%, P=0.033). The secondary surgical closure group showed the mildest clinical condition; however, the probability of PLCS/AKI was highest (38.6%) compared to the early (15.2%) or the late primary surgical group (28.1%, P<0.001), especially in extremely premature infants (gestational age < 28 weeks). CONCLUSIONS Surgical patent ductus arteriosus closure is not inferior to pharmacologic treatment. Considering the harmful effect of a prolonged patent ductus arteriosus shunt exposure, a timely decision and timely efforts should be made to minimize the risk of severe BPD and PLCS/AKI after surgical closure.
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Affiliation(s)
- Won Young Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sook Kyung Yum
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yu-Mi Seo
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sol Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Ae Shin
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Toyoshima K, Aoki H, Noguchi T, Saito N, Shimizu T, Kemmotsu T, Shimokaze T, Saito T, Shibasaki J, Kawataki M, Asou T, Tachibana T, Masutani S. Biventricular function in preterm infants with patent ductus arteriosus ligation: A three-dimensional echocardiographic study. Pediatr Res 2024:10.1038/s41390-024-03180-w. [PMID: 38615076 DOI: 10.1038/s41390-024-03180-w] [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: 09/05/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The detailed hemodynamics after patent ductus arteriosus (PDA) ligation in preterm infants remain unknown. We aimed to clarify the effect of surgical ligation on left ventricular (LV) and right ventricular (RV) volume and function. METHODS Echocardiography was performed in 41 preterm infants (median gestational age: 25 weeks) before and after PDA ligation. Global longitudinal strain was determined using three-dimensional speckle-tracking echocardiography. These values were compared with those in 36 preterm infants without PDA (non-PDA). RESULTS Preoperatively, the PDA group had greater end-diastolic volume (EDV) and cardiac output (CO) in both ventricles, a higher LV ejection fraction (LVEF) (53% vs 44%) and LV global longitudinal strain, and a lower RVEF (47% vs 52%) than the non-PDA group. At 4-8 h postoperatively, the two groups had a similar LVEDV and RVEDV. However, the PDA group had a lower EF and CO in both ventricles than the non-PDA group. At 24-48 h postoperatively, the RVEF was increased, but the LVEF remained decreased, and LVCO was increased. CONCLUSIONS PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery. Three-dimensional echocardiography may be beneficial to understand the status of both ventricles. IMPACT Preterm infants are at high risk of hemodynamic compromise following a sudden change in loading conditions after PDA ligation. Three-dimensional echocardiography enables quantitative and serial evaluation of ventricular function and volume in preterm infants with PDA. PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery.
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Affiliation(s)
- Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Hirosato Aoki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Noguchi
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tatsuto Shimizu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Kemmotsu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoyuki Shimokaze
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoko Saito
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Toshihide Asou
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
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Bischoff AR, Kennedy KF, Backes CH, Sathanandam S, McNamara PJ. Percutaneous Closure of the Patent Ductus Arteriosus in Infants ≤2 kg: IMPACT Registry Insights. Pediatrics 2023; 152:e2023061460. [PMID: 37529882 DOI: 10.1542/peds.2023-061460] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES Percutaneous patent ductus arteriosus (PDA) closure is becoming the standard of care for definitive closure in progressively smaller and younger neonates. The objective of this study was to assess safety and feasibility of percutaneous PDA closure in patients ≤2 kg. METHODS This was a cohort study using the IMPACT Registry (Improving Pediatric and Adult Congenital Treatments) from the American College of Cardiology Foundation's National Cardiovascular Data Registry. Patients who were ≤2 kg at the time of percutaneous PDA closure were included. The primary outcome was the composite of technical failure and/or major adverse event. RESULTS A total of 1587 attempted PDA closures were included, with a 3% incidence of technical failure and 5.5% incidence of the composite outcome. Major adverse events were observed in 3.8% of the patients; the most common events were device embolization requiring retrieval and unplanned cardiac or vascular surgery in 1.3% and 1.3% of cases, respectively. The incidence of the composite outcome was associated with the need for arterial access (P < .001) as well as annual hospital volume of percutaneous PDA closures in infants ≤2 kg (P = .001). The incidence of the composite outcome has decreased overtime, whereas median weight at the time of procedure has also diminished. CONCLUSIONS Percutaneous PDA closure appears to be safe and feasible procedures in infants ≤2 kg. The incidence of major adverse events has continued to decline over the years and seems to have a strong correlation with individual center case volumes and expertise.
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Affiliation(s)
| | | | - Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Patrick J McNamara
- Department of Pediatrics, Division of Neonatology
- Department of Internal Medicine University of Iowa, Iowa City, Iowa
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6
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Delayed Surgical Closure of the Patent Ductus Arteriosus: Does the Brain Pay the Price? J Pediatr 2023; 254:25-32. [PMID: 36241053 DOI: 10.1016/j.jpeds.2022.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the relation between duration of hemodynamically significant patent ductus arteriosus (PDA), cerebral oxygenation, magnetic resonance imaging-determined brain growth, and 2-year neurodevelopmental outcome in a cohort of infants born preterm whose duct was closed surgically. STUDY DESIGN Infants born preterm at <30 weeks of gestational age who underwent surgical ductal closure between 2008 and 2018 (n = 106) were included in this observational study. Near infrared spectroscopy-monitored cerebral oxygen saturation during and up to 24 hours after ductal closure and a Bayley III developmental test at the corrected age of 2 years is the institutional standard of care for this patient group. Infants also had magnetic resonance imaging at term-equivalent age. RESULTS In total, 90 infants fulfilled the inclusion criteria (median [range]: 25.9 weeks [24.0-28.9]; 856 g [540-1350]. Days of a PDA ranged from 1 to 41. Multivariable linear regression analysis showed that duration of a PDA negatively influenced cerebellar growth and motor and cognitive outcome at 2 years of corrected age. CONCLUSIONS Prolonged duration of a PDA in this surgical cohort is associated with reduced cerebellar growth and suboptimal neurodevelopmental outcome.
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Bischoff AR, Stanford AH, Aldoss O, Rios DR, McLennan DI, Mohammad Nijres B, Giesinger RE, McNamara PJ. Left ventricular function before and after percutaneous patent ductus arteriosus closure in preterm infants. Pediatr Res 2022:10.1038/s41390-022-02372-6. [PMID: 36380071 DOI: 10.1038/s41390-022-02372-6] [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: 02/23/2022] [Revised: 10/07/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Definitive closure of the patent ductus arteriosus (PDA) is associated with significant changes in the loading conditions of the left ventricle (LV), which may lead to cardiovascular and respiratory instability. The objective of the study was to evaluate targeted neonatal echocardiography (TnECHO) characteristics and the clinical course of preterm infants ≤2 kg undergoing percutaneous PDA closure. METHODS Retrospective cohort study of prospectively acquired pre- and post-closure TnECHOs to assess hemodynamic changes. Cardiorespiratory parameters in the first 24 h following PDA closure were also evaluated. RESULTS Fifty patients were included with a mean age of 30.6 ± 9.6 days and weight of 1188 ± 280 g. LV global longitudinal strain decreased from -20.6 ± 2.6 to -14.9 ± 2.9% (p < 0.001) after 1 h. There was a decrease in LV volume loading, left ventricular output, LV systolic and diastolic parameters. Cardiorespiratory instability occurred in 24 (48%) [oxygenation failure in 44%] but systolic hypotension and/or need for cardiovascular medications was only seen in 6 (12%). Patients with instability had worse baseline respiratory severity score and lower post-closure early diastolic strain rates. CONCLUSIONS Percutaneous PDA closure leads to a reduction in echocardiography markers of LV systolic/diastolic function. Post-closure cardiorespiratory instability is characterized primarily by oxygenation failure and may relate to impaired diastolic performance. IMPACT Percutaneous patent ductus arteriosus closure leads to a reduction in echocardiography markers of left ventricular volume loading, cardiac output, and left ventricular systolic/diastolic function. Post-procedural cardiorespiratory instability is characterized primarily by oxygenation failure. Post-procedural cardiorespiratory instability may relate to impaired diastolic performance.
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Affiliation(s)
| | - Amy H Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Osamah Aldoss
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Daniel I McLennan
- Section of Pediatric Cardiology, The Herma Heart Institute, Milwaukee, WI, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bassel Mohammad Nijres
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA. .,Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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Backes CH, Hill KD, Shelton EL, Slaughter JL, Lewis TR, Weisz DE, Mah ML, Bhombal S, Smith CV, McNamara PJ, Benitz WE, Garg V. Patent Ductus Arteriosus: A Contemporary Perspective for the Pediatric and Adult Cardiac Care Provider. J Am Heart Assoc 2022; 11:e025784. [PMID: 36056734 PMCID: PMC9496432 DOI: 10.1161/jaha.122.025784] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The burden of patent ductus arteriosus (PDA) continues to be significant. In view of marked differences in preterm infants versus more mature, term counterparts (viewed on a continuum with adolescent and adult patients), mechanisms regulating ductal patency, genetic contributions, clinical consequences, and diagnostic and treatment thresholds are discussed separately, when appropriate. Among both preterm infants and older children and adults, a range of hemodynamic profiles highlighting the markedly variable consequences of the PDA are provided. In most contemporary settings, transcatheter closure is preferable over surgical ligation, but data on longer-term outcomes, particularly among preterm infants, are lacking. The present review provides recommendations to identify gaps in PDA diagnosis, management, and treatment on which subsequent research can be developed. Ultimately, the combination of refined diagnostic thresholds and expanded treatment options provides the best opportunities to address the burden of PDA. Although fundamental gaps remain unanswered, the present review provides pediatric and adult cardiac care providers with a contemporary framework in PDA care to support the practice of evidence-based medicine.
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Affiliation(s)
- Carl H Backes
- Center for Perinatal Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Division of Neonatology Nationwide Children's Hospital Columbus OH
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Kevin D Hill
- Duke University Pediatric and Congenital Heart Disease Center Durham NC
- Duke Clinical Research Institute Durham NC
| | - Elaine L Shelton
- Department of Pediatrics Vanderbilt University Medical Center Nashville TN
- Department of Pharmacology Vanderbilt University Medical Center Nashville TN
| | - Jonathan L Slaughter
- Center for Perinatal Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Division of Neonatology Nationwide Children's Hospital Columbus OH
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- Division of Epidemiology, College of Public Health The Ohio State University Columbus OH
| | - Tamorah R Lewis
- Division of Neonatology Children's Mercy-Kansas City Kansas City MO
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation Children's Mercy-Kansas City Kansas City MO
- Department of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City MO
| | - Dany E Weisz
- Department of Paediatrics University of Toronto Ontario Canada
- Department of Newborn and Developmental Paediatrics Sunnybrook Health Science Center Toronto Ontario Canada
| | - May Ling Mah
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University School of Medicine, Lucille Packard Children's Hospital Stanford CA
| | - Charles V Smith
- Center for Integrated Brain Research University of Washington School of Medicine Seattle WA
| | - Patrick J McNamara
- Department of Pediatrics University of Iowa Iowa City IA
- Department of Internal Medicine University of Iowa Iowa City IA
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University School of Medicine, Lucille Packard Children's Hospital Stanford CA
| | - Vidu Garg
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
- Center for Cardiovascular Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Department of Molecular Genetics The Ohio State University Columbus OH
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Manica JLL, Neves JR, Arrieta R, Abujamra P, Rossi RI, Giuliano LC, Coimbra G, Teixeirense PT, Rossi JHA, Costa RND, Cristóvão SAB, Pedra C. Fechamento Percutâneo do Canal Arterial em Pacientes Prematuros Abaixo de 2 Kg: Experiência Inicial Brasileira. Arq Bras Cardiol 2022; 119:460-467. [PMID: 36074378 PMCID: PMC9438535 DOI: 10.36660/abc.20210818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/26/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento A incidência de ductus arteriosus patente (PCA) pode chegar a 50% em pacientes prematuros. Quando hemodinamicamente significativo, pode ser responsável por tempo de ventilação mecânica prolongado, além de importante fator de risco para o aparecimento de enterocolite necrotizante, hemorragia intraventricular e displasia broncopulmonar nessa população. Objetivo O objetivo deste estudo é descrever a experiência inicial do fechamento percutâneo de canal arterial em prematuros pesando menos de 2 kg. Métodos Trata-se de estudo prospectivo que compreendeu 14 pacientes consecutivos submetidos a fechamento percutâneo de canal arterial de março de 2020 a fevereiro de 2021 em 6 instituições no Brasil. Resultados A idade gestacional média ao nascimento foi de 28,45 ±3,14 semanas, a idade média no momento do procedimento foi de 38,85 ±17,35 dias e o peso médio de 1,41±0,41 kg. Dentre os prematuros, 79% necessitavam de ventilação mecânica e 79% tinham feito uso de, em média, 1,5 ciclos de anti-inflamatórios não esteroides. A maioria dos pacientes teve melhora dos parâmetros ventilatórios e o tempo médio de extubação foi de 12,6 ±7,24 dias. A taxa de sucesso foi de 100%. Não houve mortalidade relacionada ao procedimento. Conclusão Este estudo concluiu que o fechamento percutâneo do canal arterial em prematuros é uma realidade no Brasil, com resultados satisfatórios e baixa taxa de complicações.
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Gatelli IF, Vitelli O, De Rienzo F, Fossati M, Proto A, Annoni GA, Martinelli S. Electrical cardiometry in monitoring percutaneous closure of ductus arteriosus in preterm infants: a case study on five patients. Eur J Pediatr 2022; 181:2319-2328. [PMID: 35243543 DOI: 10.1007/s00431-022-04426-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 11/28/2022]
Abstract
Patent ductus arteriosus closure by catheter-based interventions has become the preferred therapeutic choice. However, hemodynamic perturbances associated to this procedure have not yet been investigated. This study sought to examine the on-site hemodynamic impact caused by the procedure in preterm neonates. In this study, hemodynamic monitoring was obtained in a non-invasive way using electrical cardiometry in five preterm infants who underwent percutaneous patent ductus arteriosus closing at ASST Grande Ospedale Metropolitano Niguarda of Milan. All five infants underwent successful transcatheter closures. All patients experienced immediate hemodynamic changes upon ductal closing. Significative modifications occurred mainly in heart contractility, cardiac output, and stroke volume. In three cases, there was also a significative increase of systemic vascular resistance which persisted for 4 h after closing. While in two cases they spontaneously reduced with an amelioration of cardiac output and contractility, in the other case they were persistently high, associated with an hypertensive crisis and a progressive reduction of cardiac functions. For these reasons, milrinone was started and hemodynamic parameters returned normal in about 3 h, so therapy was discontinued. Conclusions: Our single-center, prospective, consecutive, case series demonstrated hemodynamic aberrations due to sudden closure of a patent ductus arteriosus. Moreover, post procedural hemodynamic monitoring is important to precociously detect possible cardiac impairment and start an adequate therapy. What is Known: • It has previously suggested a temporarily impairment in cardiac output following patent ductus arteriosus closing. • Little is known about the other hemodynamic parameters during the procedure and how they change in the next hours according to the new hemodynamic status. What is New: • The persistence of increased systemic vascular resistance after percutaneous closure of ductus arteriosus could suggest the occurrence of hemodynamic complications. • Electrical cardiometry was useful to early detect postoperative hemodynamic changes.
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Affiliation(s)
- Italo Francesco Gatelli
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Ottavio Vitelli
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Francesca De Rienzo
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Marco Fossati
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Alice Proto
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy
| | | | - Stefano Martinelli
- Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell Ospedale Maggiore, 3, 20162, Milan, Italy.
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11
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Phenotyping respiratory decompensation following definitive closure of the patent ductus arteriosus in preterm infants. J Perinatol 2022; 42:649-654. [PMID: 34650199 DOI: 10.1038/s41372-021-01226-z] [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: 05/16/2021] [Revised: 07/27/2021] [Accepted: 08/20/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify risk factors associated with high-frequency ventilation (HFV) following definitive closure of the patent ductus arteriosus (PDA). METHODS We performed a retrospective study of premature infants (<37 weeks) who were mechanically ventilated before and after surgical or transcatheter PDA closure. Primary outcome was HFV requirement within 24 h of procedure. Logistic regression was used to estimate clinical associations with post procedure HFV requirement. RESULTS We identified 110 infants who were mechanically ventilated before PDA closure, of which 48 (44%) escalated to HFV within 24 h after closure. In the multivariable model, surgical ligation (OR 21.5, 95% CI 1.6-284), elevated Respiratory Severity Score (RSS) 1 h post-procedure (OR 1.78, 95% CI 1.07-2.99) and 12 h post-procedure (OR 2.12, 95% CI 1.37-3.26) were independent predictors of HFV. CONCLUSION Surgical ligation and elevated RSS values over the first 12 h after PDA closure are risk factors for HFV.
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Barcroft M, McKee C, Berman DP, Taylor RA, Rivera BK, Slaughter JL, El-Khuffash A, Backes CH, Backes CH. Percutaneous Closure of Patent Ductus Arteriosus. Clin Perinatol 2022; 49:149-166. [PMID: 35209997 PMCID: PMC8887783 DOI: 10.1016/j.clp.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Percutaneous-based patent ductus arteriosus closure is technically feasible among infants less than 1.5 kg. However, marked heterogeneity in the type and nature of adverse events obscures current safety profile assessments. Although data on the risks of postdevice closure syndrome remain promising, a lack of comparative trials of surgical ductal ligation and inconsistent surveillance across published studies obscure confidence in present estimates of safety and efficacy. To minimize risk and yield the greatest benefits, clinical studies of patent ductus arteriosus treatment should consider incorporating more robust assessments to ensure that infants at greatest risk for adverse ductal consequences are included.
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Affiliation(s)
- Megan Barcroft
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christopher McKee
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH,Department of Anesthesiology, Nationwide Children’s Hospital, Columbus, OH,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
| | - Darren P. Berman
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
| | - Rachel A. Taylor
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Jonathan L. Slaughter
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH,Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital; Dublin, Ireland,Department of Paediatrics; The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Carl H. Backes
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH,The Heart Center, Nationwide Children’s Hospital, Columbus, OH,Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
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Liu YM, Zheng ML, Sun X, Chen XB, Sun YX, Feng ZC, He SR. The clinical value of ultrasonic cardiac output monitor in very-low birth-weight and extremely-low-birth-weight infants undergoing PDA ligation. Early Hum Dev 2022; 165:105522. [PMID: 34959193 DOI: 10.1016/j.earlhumdev.2021.105522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/15/2021] [Accepted: 12/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiorespiratory instability occurs very often in very-low-birth-weight (VLBW) and extremely-low-birth-weight (ELBW) infants undergoing patent ductus arteriosus (PDA) ligation during the early postoperative period. This study aimed to investigate ultrasonic cardiac output monitor (USCOM) as a bedside tool by evaluating the hemodynamic changes in preterm infants following PDA ligation and assessing factors that may influence these changes. METHODS This was a single-center prospective observational study at a third-level neonatal intensive care unit. A total of 33 infants, including 21 VLBW and 12 ELBW infants, were involved. Hemodynamic measurements were performed in these infants using a USCOM preoperatively as well as 0-1 h, 8-10 h, and 24 h postoperatively. RESULTS The PDA ligation was associated with reductions of the left ventricular cardiac output (LVCO) (P < 0.001), cardiac index (P < 0.001), flow time corrected (FTC) (P < 0.001), Smith-Madigan inotropy index (SMII) (P < 0.001), oxygen delivery (DO2) (P < 0.001), and oxygen delivery index (DO2I) (P < 0.001) and an increase of the systemic vascular resistance index (SVRI) (P < 0.001) at 0-1 h, 8-10 h, and 24 h post-ligation compared with the respective preoperative values. Compared with the respective values at 0-1 h post-ligation, there was no significant difference in the CI, SMII, or FTC at 8-10 h and 24 h post-ligation. However, the SVRI decreased at 8-10 h and 24 h post-ligation. Moreover, the DO2I increased at 8-10 h and 24 h post-ligation, and the LVCO and DO2 increased at 24 h post-ligation. CONCLUSION Our study confirmed that the hemodynamic changes measured by the USCOM were similar to those measured by echocardiography in previous reports. Thus, USCOM is a useful and convenient bedside tool for assessing hemodynamic changes to guide the use of fluids, inotropic agents, and vasopressors and help modify the post-ligation course, and they may be a surrogate for repeated echocardiography during the early post-ligation period in preterm infants or a preliminary screening method.
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Affiliation(s)
- Yu-Mei Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China; Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Man-Li Zheng
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xin Sun
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiao-Bo Chen
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yun-Xia Sun
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zhi-Chun Feng
- Department of Neonatology, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing 100853, China
| | - Shao-Ru He
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China; Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China.
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Hemodynamic consequences of respiratory interventions in preterm infants. J Perinatol 2022; 42:1153-1160. [PMID: 35690691 PMCID: PMC9436777 DOI: 10.1038/s41372-022-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
Advances in perinatal management have led to improvements in survival rates for premature infants. It is known that the transitional period soon after birth, and the subsequent weeks, remain periods of rapid circulatory changes. Preterm infants, especially those born at the limits of viability, are susceptible to hemodynamic effects of routine respiratory care practices. In particular, the immature myocardium and cardiovascular system is developmentally vulnerable. Standard of care (but essential) respiratory interventions, administered as part of neonatal care, may negatively impact heart function and/or pulmonary or systemic hemodynamics. The available evidence regarding the hemodynamic impact of these respiratory practices is not well elucidated. Enhanced diagnostic precision and therapeutic judiciousness are warranted. In this narrative, we outline (1) the vulnerability of preterm infants to hemodynamic disturbances (2) the hemodynamic effects of common respiratory practices; including positive pressure ventilation and surfactant therapy, and (3) identify tools to assess cardiopulmonary interactions and guide management.
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Korkmaz L, Ozdemir A, Pamukçu Ö, Güneş T, Ozturk MA. Which Inotropic Drug, Dobutamine or Milrinone, Is Clinically More Effective in the Treatment of Postligation Cardiac Syndrome in Preterm Infants? Am J Perinatol 2022; 39:204-215. [PMID: 32781477 DOI: 10.1055/s-0040-1715118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to detect which of the two main medicines suggested in the treatment of postligation cardiac syndrome (PLCS)-dobutamine or mirinone-possesses a more therapeutic effect. While doing this, clinicians are provided with a broader perspective on the treatment and follow-up of cases. The desire was to increase the treatability and monitor ability of the cases in question and hence their survivability. STUDY DESIGN A retrospective review of a cohort of infants with PLCS was conducted between March 2012 and December 2018. In the treatment of infants with PLCS, dobutamine (dobutamine study group-DSG) or milrinone (milrinone study group-MSG) was used. The respiration, cardiac, echocardiography, and perfusion parameters of the cases were assessed both before and after ligation. Based on the data obtained, both the effects of the medicines on PLCS and the difference between their therapeutic effects were studied. The accuracy of prognostication was assessed with receiver operating characteristic analyses. RESULTS PLCS was detected in 29 (34.1%) of 85 patent ductus arteriosus ligation cases in total. Of all the PLCS cases, 13 (44.8%) were treated with dobutamine and 16 (55.2%) with milrinone. It was observed that the effects of the medicines on the respiratory system and cardiovascular system manifested in the third and 6th hour, respectively. It was detected that both medicines had more effect on the systolic blood pressure (SBP) (area under the curve [AUC]: 0.997/0.996, p = 0.001/0.002) than on the diastolic blood pressure (AUC: 0.911/0.843, p = 0.032/0.046). CONCLUSION Dobutamine and milrinone, two primary medicines that can be used in the treatment of cases with PLCS, possess similar therapeutic effects on this pathology. In addition, their postoperative therapeutic effects on the SBP are more in the foreground.
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Affiliation(s)
- Levent Korkmaz
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Ahmet Ozdemir
- Neonatology Unit, Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Özge Pamukçu
- Division of Pediatric Cardiology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Tamer Güneş
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Mehmet Adnan Ozturk
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
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Bischoff AR, Stanford AH, McNamara PJ. Short-term ventriculo-arterial coupling and myocardial work efficiency in preterm infants undergoing percutaneous patent ductus arteriosus closure. Physiol Rep 2021; 9:e15108. [PMID: 34806325 PMCID: PMC8606853 DOI: 10.14814/phy2.15108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 01/21/2023] Open
Abstract
Definitive closure of a patent ductus arteriosus (PDA) causes significant changes in loading conditions of the left ventricle (LV) which can lead to cardiorespiratory instability including hypotension, low cardiac output, oxygenation, and ventilation impairment. Physiological insights of the adaptation of the LV can be gained by looking at ventriculo-arterial coupling (VAC) and myocardial work-energetics. We conducted a retrospective cohort study of preterm infants with echocardiographic assessment of VAC parameters, including end-systolic and arterial elastance (EES , EA ), and myocardial work indices derived from longitudinal strain analysis before and 1-h after percutaneous PDA closure. A total of 35 patients were included with mean [±SD] age at intervention of 30.8 ± 9.9 days and median [IQR] weight of 1130 [995, 1318] grams. There was a reduction in preload and stroke volume, an increase in EA (38.6 ± 11.4 vs. 60 ± 15.1 mmHg/ml/kg, p < 0.001) and in EES (72 [61.5, 109.8] vs. 91.6 [72.2, 125.2] mmHg/ml/kg, p = 0.003) post-closure. Myocardial work indices reduced after PDA closure, including global work efficiency (93.9 ± 2.3 vs. 91.1 ± 3.6%, p < 0.001). A total of 17 (48.6%) patients developed post-closure instability which was associated with younger age, lower preload, and higher EA and EES . Percutaneous PDA closure is associated with major short-term changes in VAC and myocardium energetics, which may provide novel insights on the physiology of PDA closure and on the differential vulnerability to changes in loading conditions.
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Affiliation(s)
- Adrianne R. Bischoff
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Amy H. Stanford
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Patrick J. McNamara
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
- Department of Internal MedicineUniversity of IowaIowa CityIowaUSA
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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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Sharma AK, Agarwal A, Sinha SK, Razi MM, Pandey U, Shukla P, Thakur R, Verma CM, Bansal RK, Krishna V. An echocardiographic evaluation to determine the immediate and short-term changes in biventricular systolic and diastolic functions after PDA device closure-an observational analytical prospective study (echo- PDA study). Indian Heart J 2021; 73:617-621. [PMID: 34627579 PMCID: PMC8551535 DOI: 10.1016/j.ihj.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 06/03/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives –This prospective study with a sizable cohort was undertaken to assess changes in left and right ventricle systolic and diastolic functions after percutaneous patent ductus arteriosus device closure with appropriate follow up evaluation. Methods – It is an observational analytical prospective study. Ninety-eight patients were recruited out of which sixty-eight patients underwent percutaneous PDA device closure and were taken for final analysis. The primary objective was to study the left and right ventricular systolic and diastolic functions pre- and post-procedure at 48 h with follow up analysis at six months. Results – The mean age of the patients was 7.88 ± 5.05 years with the female to male ratio was 3.85:1. Thirty-three (48.52%) of the patients had immediate post PDA device closure LV systolic dysfunction. It was more common in those having pre-procedure mean low LVEF and those having a significant reduction in mitral A velocity. It became normal at six months follow up. The study reported immediate decrease in mea/n LVEF from 63.55 ± 8.11% to 48.19 ± 7.9%. The changes in LVEDD, LVEF, LVFS and LVEDV were statistically significant (p < 0.0001). In diastolic functions, there were significant reductions in peak early and late diastolic velocities. There was no statistically significant difference in right chamber functional assessment. Conclusion Asymptomatic LV systolic and diastolic dysfunction in immediate post PDA closure period is a common complication and reported in around 48.5% cases. It was more common in those having pre-procedure mean low LVEF and those having a significant reduction in mitral A velocity.
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Affiliation(s)
- Awadhesh Kumar Sharma
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India.
| | - Abhishek Agarwal
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Santosh Kumar Sinha
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - M M Razi
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Umeshwar Pandey
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Praveen Shukla
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Ramesh Thakur
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - C M Verma
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - R K Bansal
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Vinay Krishna
- Department of Cardiothoracic Surgury, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
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Rysavy MA, Mehler K, Oberthür A, Ågren J, Kusuda S, McNamara PJ, Giesinger RE, Kribs A, Normann E, Carlson SJ, Klein JM, Backes CH, Bell EF. An Immature Science: Intensive Care for Infants Born at ≤23 Weeks of Gestation. J Pediatr 2021; 233:16-25.e1. [PMID: 33691163 PMCID: PMC8154715 DOI: 10.1016/j.jpeds.2021.03.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Matthew A Rysavy
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA.
| | - Katrin Mehler
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - André Oberthür
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Satoshi Kusuda
- Department of Pediatrics, Neonatal Research Network of Japan, Kyorin University, Tokyo, Japan
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Regan E Giesinger
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Angela Kribs
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susan J Carlson
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Jonathan M Klein
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Carl H Backes
- Departments of Pediatrics and Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Edward F Bell
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
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Foster M, Mallett LH, Govande V, Vora N, Castro A, Raju M, Cantey JB. Short-Term Complications Associated with Surgical Ligation of Patent Ductus Arteriosus in ELBW Infants: A 25-Year Cohort Study. Am J Perinatol 2021; 38:477-481. [PMID: 31683323 DOI: 10.1055/s-0039-1698459] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This article aims to determine the incidence of short-term complications of surgical patent ductus arteriosus (PDA) ligations, the factors associated with those complications, and whether complications are associated with poor long-term outcomes. STUDY DESIGN Retrospective cohort study of all extremely low birth weight (ELBW, < 1,000 g) infants who underwent surgical PDA ligation at a single-center neonatal intensive care unit from 1989 to 2015. Demographic, clinical, and laboratory data were reviewed. The primary outcome was development of a short-term (< 2 weeks from ligation) surgical complication. Secondary outcomes include bronchopulmonary dysplasia (BPD), length of stay, and mortality. RESULTS A total of 180 ELBW infants were included; median gestational age and birth weight was 24 weeks and 683 g, respectively, and 44% of infants had at least one short-term complication. Need for vasopressors (33%) was the most common medical complication and vocal cord paralysis (9%) was the most common surgical complication. Younger corrected gestational age at time of repair was associated with increased risk for complications. Mortality, length of stay, and BPD rates were similar between infants with and without complications. CONCLUSION Serious complications were seen in a minority of infants. Additional research is needed to determine if short-term complications are associated with long-term adverse outcomes.
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Affiliation(s)
- Megan Foster
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Lea H Mallett
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Vinayak Govande
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Niraj Vora
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Abel Castro
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Muppala Raju
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Joseph B Cantey
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
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Parkerson S, Philip R, Talati A, Sathanandam S. Management of Patent Ductus Arteriosus in Premature Infants in 2020. Front Pediatr 2021; 8:590578. [PMID: 33643964 PMCID: PMC7904697 DOI: 10.3389/fped.2020.590578] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022] Open
Abstract
The patent ductus arteriosus (PDA) is the most commonly found cardiac condition in neonates. While there have been several studies and thousands of publications on the topic, the decision to treat the PDA is still strongly debated among cardiologists, surgeons, and neonatologists. This is in part due to the shortage of long-term benefits with the interventions studied. Practice variations still exist within sub-specialties and centers. This article briefly summarizes the history, embryology and histology of the PDA. It also succinctly discusses the hemodynamic significance of a PDA which builds the framework to review all the available literature on PDA closure in premature infants, though not a paradigm shift just yet; it introduces transcatheter PDA closure (TCPC) as a possible armament to the clinician for this age-old problem.
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Affiliation(s)
- Sarah Parkerson
- Department of Pediatrics, University of Tennessee, Memphis, TN, United States
| | - Ranjit Philip
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
| | - Ajay Talati
- Division of Neonatology, University of Tennessee, Memphis, TN, United States
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
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22
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Lenoir M, Wanert C, Bonnet D, Méot M, Tosello B, Fouilloux V, Ovaert C, Malekzadeh-Milani S. Anterior Minithoracotomy vs. Transcatheter Closure of Patent Ductus Arteriosus in Very Preterm Infants. Front Pediatr 2021; 9:700284. [PMID: 34869092 PMCID: PMC8640484 DOI: 10.3389/fped.2021.700284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patent ductus arteriosus (PDA) is common in preterm infants and contributes to morbidity and mortality. Several studies have shown the feasibility and safety of percutaneous PDA closure. Minimally invasive surgical ligation by anterior thoracotomy is an alternative, bedside technique for PDA closure in very low birth weight preterm infants. Our study aimed to compare short- and medium-term morbidity and mortality between anterior minithoracotomy and transcatheter PDA closure. Methods: From 2010 to 2020, 92 preterm infants <1,600 g underwent PDA closure in two centers: 44 surgical anterior minithoracotomies (center 1) and 48 transcatheter closures (center 2). Using a 1:1 propensity score match analysis, 22 patients in each group were included. The primary outcome was time to extubation after intervention. Results: Preoperative characteristics were similar in both groups after propensity matching (mean weight at procedure, 1,171 ± 183 g; p = 0.8). Mean time to extubation was similar: 10 ± 15 days in the surgical group vs. 9 ± 13 days in the transcatheter group (p = 0.9). Mean age at hospital discharge was 114 ± 29 days vs. 105 ± 19 days (p = 0.2). Two deaths occurred in the surgical group and one in the transcatheter group (p = 0.61). Five complications (pneumothorax n = 2, chylothorax n = 2, phrenic nerve injury n = 1) occurred in three patients after surgery. Three complications (chylothorax n = 1, endocarditis n = 1, renal vein thrombosis n = 1) occurred in two patients after percutaneous closure (p = 0.63). Conclusion: Equivalent efficiency and safety of surgical mini-invasive vs. transcatheter PDA closure in preterm infants <1,600 g are in favor of applying these alternative techniques according to centers' facilities and competences.
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Affiliation(s)
- Marien Lenoir
- Department of Pediatric Cardiac Surgery, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Chloé Wanert
- Department of Pediatric Cardiology, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Paris, France.,University of Paris, Paris, France
| | - Mathilde Méot
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Paris, France
| | - Barthélémy Tosello
- Department of Neonatology, Hôpital Nord, AP-HM, Marseille, France.,Aix-Marseille University, MMG, INSERM, Marseille, France
| | - Virginie Fouilloux
- Department of Pediatric Cardiac Surgery, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Caroline Ovaert
- Department of Pediatric Cardiology, Hôpital Timone Enfant, AP-HM, Marseille, France.,Aix-Marseille University, MMG, INSERM, Marseille, France
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Sehgal A, Steenhorst JJ, Mclennan DI, Merkus D, Ivy D, McNamara PJ. The Left Heart, Systemic Circulation, and Bronchopulmonary Dysplasia: Relevance to Pathophysiology and Therapeutics. J Pediatr 2020; 225:13-22.e2. [PMID: 32553872 DOI: 10.1016/j.jpeds.2020.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arvind Sehgal
- Monash Children's Hospital, Monash University, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Jarno J Steenhorst
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Daniel I Mclennan
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Institut für Chirurgische Forschung, Klinikum Universität München, Ludwig Maximillian Universität München, München, Germany
| | - Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
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24
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Bischoff AR, Giesinger RE, Bell EF, McNamara PJ. Precision medicine in neonatal hemodynamics: need for prioritization of mechanism of illness and defining population of interest. J Perinatol 2020; 40:1446-1449. [PMID: 32719495 DOI: 10.1038/s41372-020-0741-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Adrianne Rahde Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Edward F Bell
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
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25
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Influence of patent ductus arteriosus on left ventricular myocardial deformation in preterm neonates in the early neonatal period. Early Hum Dev 2020; 147:105093. [PMID: 32526629 DOI: 10.1016/j.earlhumdev.2020.105093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/20/2022]
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26
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Improved ventilation in premature babies after transcatheter versus surgical closure of patent ductus arteriosus. Int J Cardiol 2020; 311:22-27. [PMID: 32253052 DOI: 10.1016/j.ijcard.2020.03.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/08/2020] [Accepted: 03/16/2020] [Indexed: 11/22/2022]
Abstract
AIMS Patent ductus arteriosus (PDA) is common in preterm infants and can contribute to morbidity and mortality. We aimed to compare results and outcome of transcatheter closure using the Amplatzer Piccolo Occluder versus surgical closure in 2 matched groups of preterm infants weighing <3000 g. METHODS AND RESULTS A total of 147 babies from three tertiary centres were retrospectively analysed. Sixty-four babies undergoing catheter closure were compared with 83 matched surgical cases. Patent ductus arteriosus closure was successful in all cases. During neonatal unit course, mortality was 6.3% (n = 4) after catheterization and 12% (n = 10) after surgery (p = 0.24). Median duration of mechanical ventilation was shorter after catheterisation than after surgery (3 vs 5 days, p = 0.035). Before 4 weeks of age the difference between transcatheter and surgical closure for mechanical ventilation was even more pronounced (3 vs 9 days, p = 0.022). Additionally, when catheterisation was performed before 4 weeks, babies were discharged home earlier as compared to those who underwent closure later in life (39+1 vs. 42+1 weeks, p = 0.021). Such difference was not found in the surgical group. CONCLUSIONS Transcatheter closure of patent ductus arteriosus is safe, effective and is associated with shorter mechanical ventilation than after surgery. Hospital stay might be shorter when performed earlier in life.
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27
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Serrano RM, Madison M, Lorant D, Hoyer M, Alexy R. Comparison of 'post-patent ductus arteriosus ligation syndrome' in premature infants after surgical ligation vs. percutaneous closure. J Perinatol 2020; 40:324-329. [PMID: 31578421 DOI: 10.1038/s41372-019-0513-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the incidence of post-PDA ligation syndrome after surgical vs. percutaneous closure of PDAs in very low birth weight (VLBW) infants. STUDY DESIGN Cohort study comparing 59 infants who underwent surgical ligation with 25 infants who underwent percutaneous closure. Comparisons between groups were made using two-sample t-tests and a Fisher's exact test. Comparisons of pre vs. post variables within each group were made using paired t-tests. RESULTS Patients who underwent surgical ligation had a higher need for initiation of post-procedure hemodynamic support (12/59 vs. 0/24, p = 0.016), a higher post-procedure peak FiO2 (0.64 vs. 0.43, p = 0.004), and a larger absolute change in peak FiO2 (0.23 vs. 0.09, p = 0.008). CONCLUSION VLBW infants who had percutaneous closure of their PDA did not experience post ligation syndrome and had less escalation of respiratory support compared with infants who underwent surgical ligation.
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Affiliation(s)
- Ryan M Serrano
- Riley Hospital for Children, Department of Pediatric Cardiology, Indianapolis, IN, USA
| | - Mackenzie Madison
- Riley Hospital for Children, Department of Pediatric Cardiology, Indianapolis, IN, USA
| | - Diane Lorant
- Riley Hospital for Children, Department of Neonatology, Indianapolis, IN, USA
| | - Mark Hoyer
- Riley Hospital for Children, Department of Pediatric Cardiology, Indianapolis, IN, USA
| | - Ryan Alexy
- Riley Hospital for Children, Department of Pediatric Cardiology, Indianapolis, IN, USA. .,Riley Hospital for Children, Department of Neonatology, Indianapolis, IN, USA.
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28
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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: 17] [Impact Index Per Article: 4.3] [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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29
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What echocardiographic indices are predictive of patent ductus arteriosus surgical closure in early preterm infants? A prospective multicenter cohort study. J Cardiol 2019; 74:512-518. [DOI: 10.1016/j.jjcc.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/03/2019] [Accepted: 05/07/2019] [Indexed: 11/21/2022]
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30
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Kim HS, Schechter MA, Manning PB, Eghtesady P, Balzer DT, Shahanavaz S, Rockefeller TA, Abarbanell AM. Surgical Versus Percutaneous Closure of PDA in Preterm Infants: Procedural Charges and Outcomes. J Surg Res 2019; 243:41-46. [DOI: 10.1016/j.jss.2019.04.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/14/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
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31
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Castagno M, Menegon V, Monzani A, Zanetta S, Secco GG, Rosso R, Binotti M, Maiuri L, Di Mario C, Gazzolo D, Ferrero F, Genoni G. Small-for-gestational-age birth is linked to cardiovascular dysfunction in early childhood. Am Heart J 2019; 217:84-93. [PMID: 31520898 DOI: 10.1016/j.ahj.2019.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 08/01/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to assess clinical and echographic markers of cardiovascular dysfunction in infants born small for gestational age (SGA) compared to a control group of subjects born adequate for gestational age (AGA). METHODS This was a single-center cross-sectional case-control study. We recruited 20 SGA and 20 gestational age-matched AGA subjects at 24 months of age. The study population underwent anthropometric and Doppler 2-dimensional echocardiographic assessments, and carotid artery intima-media thickness (cIMT) and endothelium-dependent vasodilation evaluation (FMD). The pressure-volume curve during diastole was calculated using the algorithm for the elastance calculation on 1 single beat. RESULTS SGA children showed lower stroke volume, lower left ventricle (LV) dimensions and volume, and greater LV thickness. Diastolic function was impaired in SGA with lower capacitance and higher elastance. Birth weight standard deviation score was positively associated with capacitance and negatively associated with E/E' ratio and elastance, and in SGA infants, the end-diastolic pressure-related volume curve was shifted to the left compared to AGA. cIMT and systemic vascular resistance were significantly higher, while FMD was lower, in SGA compared to AGA; birth weight standard deviation score was directly correlated with FMD and inversely correlated with cIMT. Finally, a longer breastfeeding duration was associated to a lower cIMT even after correction for confounding factors. CONCLUSIONS This study shows that infants born SGA present an early and subtle cardiovascular dysfunction compared to AGA controls. These alterations are strongly related to weight at birth. Finally, breastfeeding exerts an important protective and beneficial cardiovascular effect.
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Affiliation(s)
- Matteo Castagno
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Veronica Menegon
- Vascular Surgery, Maggiore della Carità University Hospital, Novara, Italy
| | - Alice Monzani
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Sara Zanetta
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Gioel Gabrio Secco
- Interventional Cardiology, Santi Antonio, Biagio e Cesare Arrigo Hospital, Alessandria, Italy.
| | - Roberta Rosso
- Coronary Care Unit and Catheterization laboratory, Maggiore della Carità University Hospital, Novara, Italy
| | - Marco Binotti
- Neonatal and Pediatric Intensive Care Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Luigi Maiuri
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology Unit, Careggi University Hospital, Florence, Italy
| | - Diego Gazzolo
- Department of Maternal, Fetal and Neonatal Medicine, Cesare Arrigo Children's Hospital, Alessandria, Italy
| | - Federica Ferrero
- Neonatal and Pediatric Intensive Care Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Giulia Genoni
- Neonatal and Pediatric Intensive Care Unit, Maggiore della Carità University Hospital, Novara, Italy
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Follow-up after Percutaneous Patent Ductus Arteriosus Occlusion in Lower Weight Infants. J Pediatr 2019; 212:144-150.e3. [PMID: 31262530 PMCID: PMC6707834 DOI: 10.1016/j.jpeds.2019.05.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To describe longer term outcomes for infants <6 kg undergoing percutaneous occlusion of the patent ductus arteriosus (PDA). STUDY DESIGN This was a retrospective cohort study of infants <6 kg who underwent isolated percutaneous closure of the PDA at a single, tertiary center (2003-2017). Cardiopulmonary outcomes and device-related complications (eg, left pulmonary artery obstruction) were examined for differences across weight thresholds (very low weight, <3 kg; low weight, 3-<6 kg). We assessed composite measures of respiratory status during and beyond the initial hospitalization using linear mixed effects models. RESULTS In this cohort of lower weight infants, 92 of 106 percutaneous occlusion procedures were successful. Median age and weight at procedure were 3.0 months (range, 0.5-11.1 months) and 3.7 kg (range, 1.4-5.9 kg), respectively. Among infants with pulmonary artery obstruction on initial postprocedural echocardiograms (n = 20 [22%]), obstruction persisted through hospital discharge in 3 infants. No measured variables were associated with device-related complications. Rates of oxygenation failure (28% vs 8%; P < .01) and decreased left ventricular systolic function (29% vs 5%; P < .01) were higher among very low weight than low weight infants. Pulmonary scores decreased (indicating improved respiratory status) following percutaneous PDA closure. CONCLUSIONS Percutaneous PDA occlusion among lower weight infants is associated with potential longer term improvements in respiratory health. Risks of device-related complications and adverse cardiopulmonary outcomes, particularly among very low weight infants, underscore the need for continued device modification. Before widespread use, clinical trials comparing percutaneous occlusion vs alternative treatments are needed.
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Population Pharmacokinetics and Dosing of Milrinone After Patent Ductus Arteriosus Ligation in Preterm Infants. Pediatr Crit Care Med 2019; 20:621-629. [PMID: 30664589 DOI: 10.1097/pcc.0000000000001879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The postoperative course of patent ductus arteriosus ligation is often complicated by postligation cardiac syndrome, occurring in 10-45% of operated infants. Milrinone might prevent profound hemodynamic instability and improve the recovery of cardiac function in this setting. The present study aimed to describe the population pharmacokinetics of milrinone in premature neonates at risk of postligation cardiac syndrome and give dosing recommendations. DESIGN A prospective single group open-label pharmacokinetics study. SETTINGS Two tertiary care neonatal ICUs: Tallinn Children's Hospital and Tartu University Hospital, Estonia. PATIENTS Ten neonates with postmenstrual age of 24.6-30.1 weeks and postnatal age of 5-27 days undergoing patent ductus arteriosus ligation and at risk of postligation cardiac syndrome, based on echocardiographic assessment of left ventricular output of less than 200 mL/kg/min 1 hour after the surgery. INTERVENTIONS Milrinone at a dose of 0.73 μg/kg/min for 3 hours followed by 0.16 μg/kg/min for 21 hours. Four blood samples from each patient for milrinone plasma concentration measurements were collected. MEASUREMENTS AND MAIN RESULTS Concentration-time data of milrinone were analyzed with nonlinear mixed-effects modeling software (NONMEM Version 7.3 [ICON Development Solutions, Ellicott City, MD]). Probability of target attainment simulations gave a dosing schedule that maximally attains concentration targets of 150-250 μg/L. Milrinone pharmacokinetics was described by a one-compartmental linear model with allometric scaling to bodyweight and an age maturation function of glomerular filtration rate. Parameter estimates for a patient with the median weight were 0.350 (L/hr) for clearance and 0.329 (L) for volume of distribution. The best probability of target attainment was achieved with a loading dose of 0.50 μg/kg/min for 3 hours followed by 0.15 μg/kg/min (postmenstrual age < 27 wk) or 0.20 μg/kg/min (postmenstrual age ≥ 27 wk). CONCLUSIONS Population pharmacokinetic modeling and simulations suggest a slow loading dose followed by maintenance infusion to reach therapeutic milrinone plasma concentrations within the timeframe of the postligation cardiac syndrome.
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Bravo MC, Ybarra M, Madero R, Pellicer A. Childhood Neurodevelopmental Outcome in Low Birth Weight Infants With Post-ligation Cardiac Syndrome After Ductus Arteriosus Closure. Front Physiol 2019; 10:718. [PMID: 31244680 PMCID: PMC6579928 DOI: 10.3389/fphys.2019.00718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 05/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background Post-ligation cardiac syndrome (PLCS) is a common complication of patent ductus arteriosus (PDA) surgical closure in low birth weight infants. It has been associated with mortality, but there is a lack of information about the neurodevelopmental outcome of the survivors. We aimed to explore the prevalence of PLCS and to assess whether this clinical condition is a risk factor for adverse outcome, (moderate or severe neurodevelopmental disabilities). Methods We retrospectively reviewed the medical charts of all the infants < 30 weeks of gestation who underwent ductus arteriosus ligation at our unit between 2005 and 2009. Results During the study period, 39 preterm infants [mean gestational age 26.4 (2) weeks] underwent surgical closure of the PDA at a mean postnatal age of 25.3 (2.3) days. Twenty six percent of the study population developed PLCS. Five infants died and the follow-up was accomplished in 24 infants (70% of the survivors) at a mean age of 5.3 (1.5) years (range 2–9 years). Neurodevelopmental impairment was observed in 6 in the PLCS group (75%) and in 6 infants in the no PLCS group (37%), p = 0.08]. Multiple regression analyses showed that the best fitting model for predicting adverse outcome included PLCS and low birth weight, p = 0.018. Conclusion Preterm infants undergoing surgical closure of PDA who fulfill the criteria of PLCS according to this study seem to have a tendency toward higher risk of long-term neurodevelopmental impairment. Prospective clinical trials reporting long-term follow-up data should be designed to confirm the hypotheses generated in this pilot study.
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Affiliation(s)
| | - Marta Ybarra
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Rosario Madero
- Division of Statistics, La Paz University Hospital, Madrid, Spain
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
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35
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Impacto sobre la función ventricular izquierda del cierre quirúrgico de ductus arterioso persistente en recién nacidos de menos de 1.500 g. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2018.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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36
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Giesinger RE, Bischoff AR, McNamara PJ. Anticipatory perioperative management for patent ductus arteriosus surgery: Understanding postligation cardiac syndrome. CONGENIT HEART DIS 2019; 14:311-316. [DOI: 10.1111/chd.12738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/10/2018] [Accepted: 11/25/2018] [Indexed: 12/11/2022]
Affiliation(s)
| | | | - Patrick J. McNamara
- Department of Pediatrics University of Iowa Iowa City Iowa
- Department of Internal Medicine University of Iowa Iowa City Iowa
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Philip R, Towbin JA, Sathanandam S, Goldberg J, Yohannan T, Swaminathan N, Johnson JN. Effect of patent ductus arteriosus on the heart in preterm infants. CONGENIT HEART DIS 2019; 14:33-36. [DOI: 10.1111/chd.12701] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/16/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Ranjit Philip
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Jeffrey A. Towbin
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Shyam Sathanandam
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Jason Goldberg
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Thomas Yohannan
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Nithya Swaminathan
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
| | - Jason Nathaniel Johnson
- Division of Pediatric Cardiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
- Division of Pediatric Radiology; University of Tennessee Health Science Center, Le Bonheur Children’s Hospital; Memphis Tennessee
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38
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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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Hypotension within 1 week of life associated with poor short- and long-term outcomes in very low birth weight infants. Cardiol Young 2018; 28:1037-1041. [PMID: 29962357 DOI: 10.1017/s1047951118000732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We examined whether hypotension in very low birth weight infants aged⩽1 week was associated with hospital morbidities and overall mortality. Further, we studied whether hypotension was associated with poor neurodevelopmental outcomes in these patients at the corrected age of 18 months. A total of 166 very low birth weight infants were studied during this period. Hospital outcomes and neurodevelopmental outcomes at the corrected age of 18 months were evaluated. Among the 166 very low birth weight infants, 95 patients (57.2%) experienced hypotension at⩽1 week and were associated with an increased incidence of morbidities and mortality. At the corrected age of 18 months, hypotension of the⩽1 week group had significantly lower scores in all three - cognitive, language, and motor - composites of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) screening tests. In addition, a multivariable logistic regression analysis showed that longer mechanical ventilation and periventricular leukomalacia were additionally associated with worse cognitive and language neurodevelopmental outcomes. Hypotension in very low birth weight infants within 1 week of life was associated with increased morbidities and overall mortality. It was also associated with an increased risk of cognitive and language outcomes.
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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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Ulrich TJB, Hansen TP, Reid KJ, Bingler MA, Olsen SL. Post-ligation cardiac syndrome is associated with increased morbidity in preterm infants. J Perinatol 2018; 38:537-542. [PMID: 29453434 DOI: 10.1038/s41372-018-0056-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/14/2017] [Accepted: 01/12/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The influence of post-ligation cardiac syndrome (PLCS), a complication of patent ductus arteriosus (PDA) ligations, on neonatal outcomes is unknown. The purpose of this study was to determine the risks of PLCS on severe pulmonary morbidity and severe retinopathy of prematurity (ROP). STUDY DESIGN Retrospective cohort study of infants who underwent a PDA ligation between 2006 and 2015. Data were collected on patients with and without PLCS. The primary outcome was the difference in severe bronchopulmonary dysplasia (BPD) between groups. Secondary outcomes included discharge with home oxygen and severe ROP. RESULT A total of 100 infants that underwent PDA ligation during the study period were included in the study; 31 (31%) neonates developed PLCS. In adjusted analysis, PLCS was associated with increased risk for severe BPD (RR 1.67, 95% CI: 1.15-2.42) and home oxygen therapy (RR: 1.47, 95% CI: 1.09-1.99) only. No association with severe ROP was seen (RR: 1.48; 95% CI: 0.87-2.52). CONCLUSION PLCS is associated with severe neonatal pulmonary morbidity, but not with severe ROP. Further investigation is warranted to validate these results.
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Affiliation(s)
- Timothy J B Ulrich
- Department of pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.
| | - Taylor P Hansen
- Department of pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Kimberly J Reid
- Department of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Steven L Olsen
- Department of pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
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Rios DR, Bhattacharya S, Levy PT, McNamara PJ. Circulatory Insufficiency and Hypotension Related to the Ductus Arteriosus in Neonates. Front Pediatr 2018; 6:62. [PMID: 29600242 PMCID: PMC5863525 DOI: 10.3389/fped.2018.00062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 12/12/2022] Open
Abstract
The biological role of the ductus arteriosus (DA) in neonates varies from an innocent bystander role during normal postnatal transition, to a supportive role when there is compromise to either systemic or pulmonary blood flow, to a pathological state in the presence of hemodynamically significant systemic to pulmonary shunts, as occurs in low birth weight infants. Among a wide array of clinical manifestations arising due to the ductal entity, systemic circulatory insufficiency and hypotension are of significant concern as they are particularly challenging to manage. An understanding of the physiologic interplay between the DA and the circulatory system is the key to developing appropriate targeted therapeutic strategies. In this review, we discuss the relationship of systemic hypotension to the DA, emphasizing the importance of critical thinking and a precise individual approach to intensive care support. We particularly focus on the variable states of hypotension arising directly due to a hemodynamically significant DA or seen in the period following successful surgical ligation. In addition, we explore the mechanistic contributions of the ductus to circulatory insufficiency that may manifest during the transitional period, states of maladapted transition (such as acute pulmonary hypertension of the newborn), and congenital heart disease (both ductal dependent and non-ductal dependent lesions). Understanding the dynamic modulator role of the ductus according to the ambient physiology enables a more precise approach to management. We review the pathophysiology, clinical manifestations, diagnosis, monitoring, and therapeutic intervention for the spectrum of DA-related circulatory compromise.
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Affiliation(s)
- Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Philip T. Levy
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Saint Louis, MI, United States
| | - Patrick J. McNamara
- Division of Neonatology, Department of Paediatrics and Physiology, University of Toronto, Toronto, ON, 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: 55] [Impact Index Per Article: 9.2] [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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Rodríguez Sánchez de la Blanca A, Sánchez Luna M, González Pacheco N, Arriaga Redondo M, Navarro Patiño N. Electrical velocimetry for non-invasive monitoring of the closure of the ductus arteriosus in preterm infants. Eur J Pediatr 2018; 177:229-235. [PMID: 29222766 DOI: 10.1007/s00431-017-3063-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED Closure of a patent ductus arteriosus (PDA) in preterm infants modifies cardiac output and induces adaptive changes in the hemodynamic situation. The present study aims to analyze those changes, through a non-invasive cardiac output monitor based on blood electrical velocimetry, in preterm babies. A prospective observational study of preterm infants with a gestational age of less than 28 weeks, and a hemodynamic significant PDA, requires intravenous ibuprofen or surgical closure. All patients were monitored with electrical velocimetry before treatment and through the following 72 h. Two groups were defined, ibuprofen and surgical closure. Variations of cardiac output were analyzed from the basal situation and at 1, 8, 24, 48, and 72 h on each group. During a 12-month period, 18 patients were studied. The median gestational age in the ibuprofen group (12/18) was 26+5 weeks (25+5-27+3) with a median birth weight of 875 (670-1010) g. The cardiac output index (CI) value was 0.29 l/kg/min (0.24-0.34). Among the patients with confirmed ductus closure (50%), a significant CI decrease was shown (0.24 vs 0.29 l/kg/min; P 0.03) after 72 h (three ibuprofen doses). A statistically significant decrease in systolic volume (SVI) was found: 1.62 vs 1.88 ml/kg, P 0.03 with a decrease in contractility (ICON), 85 vs 140, P 0.02. The gestational age in the surgical group (6/18) was 25+2 weeks (24-26+3) with a median weight of 745 (660-820) g. All patients in this group showed a decrease in the immediate postoperative CI (1 h after surgery) 0.24 vs 0.30 l/kg/min, P 0.05, and a significant decrease in contractility (ICON 77 vs 147, P 0.03). In addition, a no statistically significant decrease in SVI (1.54 vs 1.83 ml/kg, P 0.06), as well as an increase in systemic vascular resistance (10,615 vs 8797 dyn/cm2, P 0.08), were detected. This deterioration was transient without significant differences in the remaining periods of time evaluated. CONCLUSION The surgical closure of the PDA in preterm infants causes a transient deterioration of cardiac function linked to a documented decrease in the left ventricular output. The hemodynamic changes detected after pharmacological PDA closure are similar but those patients present a better clinical tolerance to changes in the cardiac output. What is Known: • Surgical ductus closure generates acute hemodynamic changes in cardiac output and left ventricular function. What is New: • The hemodynamic changes detected after pharmacological ductus closure are similar to those found in the surgical closure. Electrical velocimetry can detect those changes.
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Affiliation(s)
| | - M Sánchez Luna
- Neonatology Division, HGU Gregorio Marañón, C/ O'Donnell 48, 28009, Madrid, Spain
| | - N González Pacheco
- Neonatology Division, HGU Gregorio Marañón, C/ O'Donnell 48, 28009, Madrid, Spain
| | - M Arriaga Redondo
- Neonatology Division, HGU Gregorio Marañón, C/ O'Donnell 48, 28009, Madrid, Spain
| | - N Navarro Patiño
- Neonatology Division, HGU Gregorio Marañón, C/ O'Donnell 48, 28009, Madrid, Spain
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Kang SJ, Cho YS, Hwang SJ, Kim HJ. Outcomes of Left Ventricular Function According to Treatment Response for a Patent Ductus Arteriosus in Preterm Infants. J Cardiovasc Ultrasound 2018; 25:131-137. [PMID: 29333220 PMCID: PMC5762696 DOI: 10.4250/jcu.2017.25.4.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/16/2017] [Accepted: 12/16/2017] [Indexed: 11/22/2022] Open
Abstract
Background To evaluate the outcomes of left ventricular (LV) function according to treatment response for a hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants. Methods Echocardiograms of 21 preterm infants born at gestational age < 31 weeks obtained at term-equivalent age were retrospectively studied. Among preterm infants with a hsPDA, 9 underwent ligation after failure of pharmacological closure (ligation group) and 6 experienced successful pharmacological closure (medication group). Six preterm infants without hsPDA (no-hsPDA group) were studied as controls. LV peak longitudinal systolic strain (ε) of each infant was retrospectively obtained from echocardiograms using velocity vector imaging, along with neonatal outcomes. Results Pharmacological closures were attempted at postnatal day 2-3. In the ligation group, the median postnatal age at ligation was 20 days. In the ligation group, LV peak longitudinal systolic ε was significantly decreased at term-equivalent age compared to the other groups. Between the medication and no-hsPDA groups, LV peak longitudinal systolic ε did not differ significantly. Among the neonatal outcomes, infants who experienced necrotizing enterocolitis (NEC) showed significantly decreased LV peak longitudinal systolic ε compared to the infants who did not experience NEC . Conclusion We speculate that in preterm infants with an hsPDA, in cases of medical treatment failure, early PDA ligation at less than 20 days of postnatal age would be beneficial for preserving LV systolic function.
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Affiliation(s)
- Soo Jung Kang
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Young Sun Cho
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Seo Jung Hwang
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyo Jin Kim
- Department of Diagnostic Laboratory Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Carrillo SA. "What we know is little, and what we are ignorant of is immense". J Thorac Cardiovasc Surg 2017; 154:2052-2053. [PMID: 28964490 DOI: 10.1016/j.jtcvs.2017.08.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Sergio A Carrillo
- Children's Heart Center Nevada and the Department of Surgery, University of Nevada, Las Vegas (UNLV), Las Vegas, Nev.
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Michel Macías C, Carrera Muiños S, Fernández Carrocera L, Guido Ramíres O, Machuca Vaca A, Cordero González G. Evolución de los recién nacidos prematuros con cierre quirúrgico del conducto arterioso. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2017. [DOI: 10.1016/j.rprh.2018.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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48
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Noori S, Kumar SR. Pre-dicting post-ligation syndrome. J Thorac Cardiovasc Surg 2017; 154:2060-2061. [PMID: 28967417 DOI: 10.1016/j.jtcvs.2017.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Shahab Noori
- Fetal and Neonatal Institute, Children's Hospital of Los Angeles, Los Angeles, Calif; Division of Neonatology, Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - S Ram Kumar
- Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif.
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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: 33] [Impact Index Per Article: 4.7] [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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Gray MA, Graham EM, Atz AM, Bradley SM, Kavarana MN, Chowdhury SM. Preoperative echocardiographic measures of left ventricular mechanics are associated with postoperative vasoactive support in preterm infants undergoing patent ductus arteriosus ligation. J Thorac Cardiovasc Surg 2017; 154:2054-2059.e1. [PMID: 28743382 DOI: 10.1016/j.jtcvs.2017.06.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 06/13/2017] [Accepted: 06/27/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Preoperative risk factors associated with poor outcomes after patent ductus arteriosus ligation in preterm infants have not been well defined. The aim of this study was to determine the association between preoperative echocardiographic measures of left ventricular mechanics and postoperative clinical outcomes after patent ductus arteriosus ligation. METHODS Preterm infants less than 90 days of age with no other significant congenital anomalies who underwent patent ductus arteriosus ligation between 2007 and 2015 were considered for retrospective analysis. The primary outcome was peak postoperative vasoactive inotropic score. Conventional echocardiographic measures of ventricular size, function, and patent ductus arteriosus size were performed. Echocardiographic single-beat, pressure-volume loop analysis estimates of contractility (end-systolic elastance) and afterload (arterial elastance) were calculated. Ventriculoarterial coupling was assessed using the arterial elastance/end-systolic elastance ratio. Multivariable linear regression was performed using clinical and echocardiographic data. RESULTS Echocardiograms from 101 patients (42.5% male) were analyzed. We found a statistically significant association between vasoactive inotropic score and both end-systolic elastance and arterial elastance. No patient with arterial elastance/end-systolic elastance greater than 0.78 (n = 32) had a vasoactive inotropic score 20 or greater. Analysis of our secondary outcomes found associations between preoperative end-systolic elastance and postoperative urine output less than 1 mL/kg/h at 24 hours, creatinine change greater than 0.5 mg/dL, and time to first extubation. CONCLUSIONS End-systolic elastance and arterial elastance were the only predictors of postoperative vasoactive inotropic score after patent ductus arteriosus ligation in preterm infants. Those neonates with increased contractility and low afterload were at highest risk for elevated inotropic support. These findings suggest a role for echocardiographic end-systolic elastance and arterial elastance in the preoperative assessment of preterm infants undergoing patent ductus arteriosus ligation.
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Affiliation(s)
- Margaret A Gray
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Eric M Graham
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Andrew M Atz
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Scott M Bradley
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Minoo N Kavarana
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Shahryar M Chowdhury
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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