Ligation of patent ductus arteriosus in very low birth weight premature infants

Lung ultrasound score predicts patent ductus arteriosus ligation among neonates ≤25 weeks

BACKGROUND

This prospective study aimed to investigate whether lung ultrasound score (LUSs) can predict the patent ductus arteriosus (PDA) ligation.

METHODS

Preterm infants ≤25 weeks of gestational age (GA) were enrolled. A lung ultrasound was performed on the 14th day of life. Each lung zone was given a score between 0 and 4. A receiver-operating characteristic (ROC) curve was constructed to evaluate the ability of the LUSs for predicting ligation.

RESULTS

A total of 81 infants were eligible with a median GA and birth weight (BW) of 25 weeks (24.1-25.2) and 710 g (645-770), respectively. The median time from birth to ligation was 35 days (32-51). Those who underwent ligation had a longer time of mechanical ventilation (34 [26-39] vs. 19 [12-30], p < 0.001), shorter time of noninvasive respiratory support (39 [32-51] vs. 50 [41.5-57], p < 0.01), higher incidence of the bronchopulmonary dysplasia (BPD) (p < 0.01), and severe BPD (p < 0.001). The LUSs had an area under the ROC of 0.96 (95% confidence interval: 0.93-0.99) for the prediction of ligation. A LUSs cutoff of 36 has a sensitivity and specificity of 96% and 86% and positive and negative predictive values of 82% and 98%, respectively.

CONCLUSIONS

LUSs at an early stage of life can predict PDA ligation in extremely preterm infants. It would be helpful to reduce morbidity by reducing the duration and magnitude of respiratory support.

The Predictive Value of Lung Ultrasound Score on Hemodynamically Significant Patent Ductus Arteriosus among Neonates ≤25 Weeks

Lung ultrasound (LU) is increasingly used to diagnose and monitor neonatal pulmonary disorders; however, its role in hemodynamically significant patent ductus arteriosus (hsPDA) has not been elucidated. This prospective study investigated the predictive value of the LU score (LUS) for hsPDA in preterm infants with gestational age (GA) ≤ 25 weeks. Preterm infants with GA ≤ 25 weeks were enrolled in this study. LU was conducted on the fourth day of life (DOL). Six lung regions in every lung were scanned, with each region rated as 0-4 points. The performance of the LUS in predicting hsPDA among infants aged ≤25 weeks was analyzed by plotting the receiver operating characteristic (ROC) curve. A total of 81 infants were included in this study. GA, birth weight (BW), gender, Apgar score, delivery mode, antenatal steroids, meconium-stained amniotic fluid, premature rapture of membrane, and early-onset sepsis were not significantly different, but infants in the hsPDA group had increased LUS (38.2 ± 2.8 vs. 30.3 ± 4.3, p < 0.001) compared with non-hsPDA group. The area under the ROC curve (AUC) value of the LUS on the fourth DOL was 0.94 (95% CI: 0.93-0.99) in predicting hsPDA. The LUS threshold at 33 achieved 89% sensitivity and 83% specificity, with the positive and negative predictive values (PPV and NPV) being 87 and 86%, respectively. The LUS can predict hsPDA in extremely preterm infants at an early stage.

Clinical outcomes of different patent ductus arteriosus treatment in preterm infants born between 28 and 32 weeks in Taiwan

BACKGROUND

The patent ductus arteriosus (PDA) treatment in very preterm infants is controversial. This study focused on preterm infants born at 28-32 weeks of gestation and analyzed the association between various PDA treatments and clinical outcomes.

METHODS

We conducted a retrospective cohort study of infants born at 28-32 weeks of gestation between 2016 and 2019 at 22 hospitals in the Taiwan Premature Infant Follow-up Network. We categorized the infants into four groups according to treatment strategies: medication, primary surgery, medication plus surgery, or conservative treatment.

RESULTS

A total of 1244 infants presented with PDA, and 761 (61.1%) were treated. Medication was the predominant treatment (50.0%), followed by conservative treatment (38.9%), medication plus surgery (7.6%), and primary surgery (3.5%). The risk of mortality was not reduced in the active treatment group compared to the conservative treatment group. There was a higher prevalence of severe intraventricular hemorrhage, necrotizing enterocolitis (NEC), and any degree of bronchopulmonary dysplasia (BPD) in both the primary surgery and medication plus surgery groups than in the conservative treatment group. After adjustment, both the primary surgery and medication plus surgery groups still had higher odds ratios for the occurrence of NEC and any degree of BPD.

CONCLUSIONS

Compared with active PDA treatment, conservative treatment for PDA did not increase the risk of mortality and morbidity in very preterm infants born at 28-32 weeks of gestation. The risks and benefits of surgery (PDA ligation) in these infants must be considered cautiously.

Outcomes of patent ductus arteriosus ligation in very low birth weight premature infants: A retrospective cohort analysis

INTRODUCTION

Patent ductus arteriosus (PDA) can be a significant hemodynamic problem in preterm infants leading to increased morbidity and mortality. PDA ligation is therefore considered an urgent procedure in infants who have failed medical therapy. However, there is controversy regarding optimal timing and decision to operate. This study aimed to evaluate the outcomes and efficacy of PDA ligation in very low birth weight premature infants.

METHODS

We performed a retrospective review of our institution's database and included very low birth weight premature infants (<1500 g) who underwent PDA ligation from 2008 to 2019 among 6 centers within the Southern California Kaiser Permanente network system. Indications for PDA ligation were variable but included congestive heart failure, respiratory failure, necrotizing enterocolitis, renal failure, and contraindications to medical therapy. PDA ligations were performed via thoracotomy incisions with ligations using a clip or tie. The primary outcome measure was mortality, and secondary outcomes included various postoperative morbidities.

RESULTS

A total of 449 patients met criteria and were included in the study. The mean birth weight was 735 g (125 g-1460 g), and mean gestational age was 25 weeks (21-36 weeks). The mean operating room time was 28 min (9-84 min). 97% of PDAs were clipped, and 3% were tied. Comorbidities at the time of operation included bronchopulmonary dysplasia (59%), retinopathy of prematurity (39%), intraventricular hemorrhage (28%), and necrotizing enterocolitis (10%). There were 2 (0.4%) operative deaths, 15 (3%) deaths within 30 days, and 20 (4%) deaths within 1 year. Other postoperative outcomes included recurrent laryngeal nerve injury (1%), chylothorax (1%), pneumothorax (0.4%), and 3 (0.6%) reoperations.

DISCUSSION

Very low birthweight premature infants with hemodynamically and clinically significant PDA are complicated patients. The risks of surgical ligation must be weighed against the potential clinical benefits. The mortality rate in our patient group within our hospital system is lower than those reported in the literature. Surgical ligation appears to be a safe and acceptable option for treatment of this complex problem, especially when medical therapy fails. Further studies are needed to elucidate specific independent risk factors that are associated with morbidity and mortality to further improve outcomes.

LEVEL OF EVIDENCE RATING

Level II TYPE OF STUDY: Prognosis study.

The clinical value of ultrasonic cardiac output monitor in very-low birth-weight and extremely-low-birth-weight infants undergoing PDA ligation

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.

Covariation of changing patent ductus arteriosus management and preterm infant outcomes in Pediatrix neonatal intensive care units

OBJECTIVE

To test the hypothesis that NICU-specific preterm infant outcomes co-vary with changes in local patent ductus arteriosus (PDA) management.

STUDY DESIGN

This retrospective multicenter study examined NICU-specific aggregated data for infants born 400-1499 g (VLBW) in the Pediatrix Clinical Data Warehouse. For each NICU and each year 2006-2016 we calculated proportion of infants receiving cyclooxygenase inhibitor (COXI) and/or PDA ligation and determined NICU-specific changes in these therapies between consecutive years. We examined relationships between NICU-specific changes in COXI/ligation and concurrent changes in local adjusted in-hospital outcomes.

RESULTS

In 5678 observations of change at 259 NICUs summarizing 78,105 infants, between-year decreases in NICU-specific proportion treated with COXI/ligation were associated with concurrent increases in local mortality and decreases in BPD among infants 400-749 g, and with decreased pulmonary hemorrhage in larger infants.

CONCLUSIONS

NICU-specific adjusted mortality, BPD, and pulmonary hemorrhage rates co-vary with changes in local COXI/ligation rates in some VLBW infant subgroups.

Patent ductus arteriosus treatment trends and associated morbidities in neonates

To evaluate national epidemiologic data on infants treated for patent ductus arteriosus (PDA) in Korea and analyze outcomes associated with different PDA treatments. We retrospectively evaluated data on 12,336 patients diagnosed with PDA (International Classification of Diseases-10 code: Q250) between 2015 and 2018 from the Health Insurance Review and Assessment database. Among them, 1623 patients underwent surgical ligation (code: O1671). We used birth certificate data from Statistics Korea to estimate the prevalence, diagnosis, and treatment of PDA. The prevalence of infants with PDA was 81 infants per 10,000 live births and 45.2% in very low birth weight (VLBW) infants, which increased from 2015 to 2018. PDA ligation was performed in 2571 infants and 22% VLBW infants. Medical treatment was administered to 4202 infants, which decreased significantly, especially in VLBW infants (62% to 53%). The proportion of treatment was as follows: conservative treatment (53.1%), intravenous ibuprofen (24.4%), surgery (20.4%), and oral ibuprofen (10.7%); that among 4854 VLBW infants was as follows: intravenous ibuprofen (46.3%), conservative treatment (33.2%), surgery (22.2%), and oral ibuprofen (14.2%). Surgical treatment had a significantly higher risk (odds ratio 1.36) of mortality than conservative treatment. Surgical and/or medical treatments were associated with a higher risk of morbidity. Recently, increased use of conservative management of PDA has contributed to improved neonatal outcomes in VLBW infants. Select patients may still benefit from surgical ligation following careful consideration.