The use of non-steroidal anti-inflammatory drugs for patent ductus arteriosus closure in preterm infants

Acetaminophen for Patent Ductus Arteriosus and Risk of Mortality and Pulmonary Morbidity

OBJECTIVE

Emerging data indicate that acetaminophen may adversely affect lung health. We examined whether acetaminophen compared with cyclooxygenase (COX) inhibitor alone for patent ductus arteriosus (PDA) is associated with mortality or respiratory morbidity in extremely preterm infants.

METHODS

This is a retrospective cohort study using data from the National Institute of Child Health and Human Development Neonatal Research Network. Infants were born at 22 to 28 weeks' gestation or weighing 401 to 1000 g between 2016 and 2020 and received acetaminophen, ibuprofen, and/or indomethacin for PDA closure. The primary outcome was death or grade 2 to 3 bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age. Secondary outcomes included predischarge mortality and respiratory morbidities. Risk ratios were adjusted for baseline and early postnatal factors. Additional exploratory analyses were adjusted for later postnatal covariates.

RESULTS

Of 1921 infants, 627 (32.6%) received acetaminophen and 1294 (67.3%) received COX inhibitor only. Multidrug therapy (42.9% vs 4.7%) and surgical or catheter PDA closure (26.5% vs 19.9%) were more common among acetaminophen-exposed infants. Death or grade 2 to 3 BPD at 36 weeks' postmenstrual age was similar between infants treated with acetaminophen versus COX inhibitor only (57.1% vs 58.3%; adjusted relative risk [aRR] 0.96, 95% confidence interval [CI] 0.87-1.06). Acetaminophen was associated with increased risk of predischarge mortality (13.3% vs 10.0%) when adjusting for perinatal and early postnatal factors (aRR 1.42, 95% CI 1.02-1.93), but not in exploratory analyses that included later postnatal factors (aRR 1.28, 95% CI 0.91-1.82).

CONCLUSIONS

Treatment with acetaminophen versus COX inhibitor alone for PDA was not associated with the composite outcome of death or BPD in extremely preterm infants. Our results support further evaluation of whether acetaminophen for PDA increases mortality.

PDA management strategies and pulmonary hypertension in extreme preterm infants with bronchopulmonary dysplasia

BACKGROUND

Premature infants are at risk for developing pulmonary hypertension (PH) in the context of bronchopulmonary dysplasia (BPD). Studies suggest a potential link between prolonged patent ductus arteriosus (PDA) exposure and BPD-PH, though management strategies remain controversial.

METHODS

Retrospective echocardiographic evaluation of newborns <29 weeks gestational age with BPD at two distinct centers. Primary objective was to evaluate the relationship between center-specific PDA management strategies (interventional or conservative) and the prevalence of BPD-PH. BPD was defined as oxygen or respiratory support at 36 weeks post-menstrual age (PMA). The presence of PH was defined as either an estimated sPAP of ≥40 mmHg or sEI ≥1.3. Center A has a conservative PDA policy. Center B has a targeted interventional policy.

RESULTS

PH rates were similar between sites (21% vs 17%), while rates of PDA treatment was different (7% vs 81). Adjusted models did not demonstrate an association for center or PDA treatment exposure for PH and EI, although infants from Center A had echocardiography evidence of higher systolic eccentricity index (EI; 1.12 ± 0.19 vs 1.06 ± 0.15, p = 0.04). Markers of RV function (TAPSE and RV-FAC) were similar between groups.

CONCLUSION

In preterm infants <29 weeks with BPD, conservative PDA treatment policy was not associated with higher rate of pulmonary hypertension diagnosis.

IMPACT

The association between PDA-management approaches and the occurrence of BPD-associated pulmonary vascular disease in premature infants has sparsely been described. We found that a conservative policy, regarding the PDA, was not associated with an increase in pulmonary hypertension diagnosis. We identified that, in patients with BPD, echocardiographic metrics of LV performance were lower.

Analysis of perinatal risk factors for massive pulmonary hemorrhage in very low birth weight infant: A nationwide large cohort database

OBJECTIVE

To determine perinatal risk factors for Massive pulmonary hemorrhage (MPH) and MPH-caused mortality to guide clinicians in implementing preventive measures at the beginning of life for improving the survival of very low birth weight infant (VLBWIs).

STUDY DESIGN

A total of 13,826 VLBWIs born between 2013 and 2020 in the Korean Neonatal Network database were included.

RESULTS

MPH occurred in 870 (6.3 %) VLBWIs. Among infants with MPH, 162 (18.6 %) VLBWIs died due to MPH. In the multivariate logistic regression analysis, independent risk factors for MPH were identified as small for gestational age, multiple gestation, high CRIB-II score, use of surfactant, and symptomatic patent ductus arteriosus (sPDA) in VLBIWs. Independent risk factors for MPH-caused mortality were identified as multiple gestation in VLBWIs. Receiving a complete course of antenatal corticosteroids (ACS) was found to be a significant independent protective factor for MPH-caused mortality in VLBWIs.

CONCLUSION

Proactive managements for reducing unnecessary use of pulmonary surfactant and for decreasing the risk of sPDA at the beginning of life could be recommended as preventive strategies to reduce the risk of MPH in extremely preterm infants. ACS therapy is highly recommended for women with a high likelihood of giving birth preterm to reduce the risk of mortality caused by MPH.

Trial of Selective Early Treatment of Patent Ductus Arteriosus with Ibuprofen

BACKGROUND

The cyclooxygenase inhibitor ibuprofen may be used to treat patent ductus arteriosus (PDA) in preterm infants. Whether selective early treatment of large PDAs with ibuprofen would improve short-term outcomes is not known.

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial evaluating early treatment (≤72 hours after birth) with ibuprofen for a large PDA (diameter of ≥1.5 mm with pulsatile flow) in extremely preterm infants (born between 23 weeks 0 days' and 28 weeks 6 days' gestation). The primary outcome was a composite of death or moderate or severe bronchopulmonary dysplasia evaluated at 36 weeks of postmenstrual age.

RESULTS

A total of 326 infants were assigned to receive ibuprofen and 327 to receive placebo; 324 and 322, respectively, had data available for outcome analyses. A primary-outcome event occurred in 220 of 318 infants (69.2%) in the ibuprofen group and 202 of 318 infants (63.5%) in the placebo group (adjusted risk ratio, 1.09; 95% confidence interval [CI], 0.98 to 1.20; P = 0.10). A total of 44 of 323 infants (13.6%) in the ibuprofen group and 33 of 321 infants (10.3%) in the placebo group died (adjusted risk ratio, 1.32; 95% CI, 0.92 to 1.90). Among the infants who survived to 36 weeks of postmenstrual age, moderate or severe bronchopulmonary dysplasia occurred in 176 of 274 (64.2%) in the ibuprofen group and 169 of 285 (59.3%) in the placebo group (adjusted risk ratio, 1.09; 95% CI, 0.96 to 1.23). Two unforeseeable serious adverse events occurred that were possibly related to ibuprofen.

CONCLUSIONS

The risk of death or moderate or severe bronchopulmonary dysplasia at 36 weeks of postmenstrual age was not significantly lower among infants who received early treatment with ibuprofen than among those who received placebo. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Baby-OSCAR ISRCTN Registry number, ISRCTN84264977.).

Fetal circular shunt in Ebstein's anomaly and non-steroidal anti-inflammatory treatment

A circular shunt is a poor prognostic factor associated with Ebstein's anomaly. Targeting the constriction of the ductus arteriosus (DA) in order to limit or resolve the circular shunt, has been shown to improve fetal outcomes. Prenatal non-steroidal anti-inflammatory drugs (NSAIDs) have been known to constrict the DA. Recently, prenatal NSAIDs have been used for that purpose in the treatment of circular shunt. Limited research shows that it may be an effective treatment leading to improved fetal outcomes. In this article, we did an extensive review of literature to describe this therapy's effectiveness and outcomes. 82% of fetuses were able to achieve ductal constriction with prenatal NSAID therapy. For fetuses who achieved ductal constriction, fetal demise was less likely (6%) when compared to those who were unable to achieve the same (50%). Of all the fetuses with hydrops, 50% had resoluation of hydrops with prenatal NSAID treatment.

Congenital Heart Disease: The State-of-the-Art on Its Pharmacological Therapeutics

Congenital heart disease is one of the most common causes of death derived from malformations. Historically, its treatment has depended on timely diagnosis and early pharmacological and surgical interventions. Survival rates for patients with this disease have increased, primarily due to advancements in therapeutic choices, but mortality remains high. Since this disease is a time-sensitive pathology, pharmacological interventions are needed to improve clinical outcomes. Therefore, we analyzed the applications, dosage, and side effects of drugs currently used for treating congenital heart disease. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and potassium-sparing diuretics have shown a mortality benefit in most patients. Other therapies, such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostaglandins, and soluble guanylyl cyclase stimulators, have benefited patients with pulmonary artery hypertension. Likewise, the adjunctive symptomatic treatment of these patients has further improved the outcomes, since antiarrhythmics, digoxin, and non-steroidal anti-inflammatory drugs have shown their benefits in these cases. Conclusively, these drugs also carry the risk of troublesome adverse effects, such as electrolyte imbalances and hemodynamic compromise. However, their benefits for survival, symptom improvement, and stabilization outweigh the possible complications from their use. Thus, cases must be assessed individually to accurately identify interventions that would be most beneficial for patients.

Natural evolution of the patent ductus arteriosus in the extremely premature newborn and respiratory outcomes

OBJECTIVE

Evaluate spontaneous closure of the patent ductus arteriosus (PDA) in extremely preterm infants and their respiratory outcomes, especially at <26 weeks gestational age (GA).

STUDY DESIGN

Retrospective study in <29 weeks, admitted within 24 h after birth (Feb 2015 and Dec 2019). Infants without any intervention to promote ductal closure, ≥1 echocardiography, and alive at discharge were included.

RESULTS

Two hundred and fourteen infants (average GA 26.3 ± 1.5 weeks) were included; 84 (39%) <26 weeks. PDA closed spontaneously in 194 (91%); 76/84 (90%) for infants <26 weeks. PDA closure was ascertained on an echocardiography performed at a median age of 36.4 [34.4-40.1] weeks. Rate of moderate-to-severe bronchopulmonary dysplasia decreased throughout the study period (OR for year of birth: 0.70 [95% CI: 0.57-0.87], p = 0.001).

CONCLUSION

Majority of extremely preterm infants, including <26 weeks, had spontaneous closure of the ductus before term corrected age. There was a concomitant improvement of respiratory outcomes.

Outcomes of Extremely Premature Infants Comparing Patent Ductus Arteriosus Management Approaches

OBJECTIVE

To evaluate the change in the proportion of deaths/bronchopulmonary dysplasia (BPD) among premature infants (born <26 and 26-29 weeks of gestational age) following a policy change to a strict nonintervention approach, compared with standard treatment.

STUDY DESIGN

We examined 1249 infants (341 born <26 weeks of gestational age) at 2 comparable sites. Site 1 (control) continued medical treatment/ligation, and site 2 (exposed) changed to a nonintervention policy in late 2013. Using the difference-in-differences approach, which accounts for time-invariant differences between sites and secular trends, we assessed changes in death or BPD separately among infants born 26-29 weeks and <26 weeks of gestational age in 2 epochs (epoch 1: 2011-2013; epoch 2: 2014-2017).

RESULTS

Baseline characteristics were similar across sites and epochs. Medical treatment/ligation use remained stable at site 1 but declined progressively to 0% at site 2, indicating adherence to policy. We saw no difference in death/BPD among infants born at 26-29 weeks of gestational age (12%, 95% CI -1% to 24%). However, incidence of death/BPD increased by 31% among infants born <26 weeks of gestational age (95% CI 10%-51%) in site 2, whereas there was no change in outcomes in site 1. The Score for Neonatal Acute Physiology-Version II, used as a control outcome, did not change in either site, suggesting that our findings were not due to changes in patients' severity.

CONCLUSIONS

Adherence to a strict conservative policy did not impact death or BPD among 26 weeks but was associated with a significant rise in infants born <26 weeks.

Comparison of standard versus high-dose ibuprofen for the treatment of hemodynamically significant patent ductus arteriosus in preterm infants

OBJECTIVE

To evaluate the effectiveness and safety of standard vs. high-dose ibuprofen for the treatment of hemodynamically significant patent ductus arteriosus(hs-PDA).

STUDY DESIGN

A retrospective study of preterm infants who received either standard (10-5-5 mg/kg/day) or high (postnatal age 1-3 days: 10-5-5 mg/kg/day; 3-5 days: 15-7.5-7.5 mg/kg/day; >5 days: 20-10-10 mg/kg/day) dose ibuprofen for hs-PDA was conducted.

RESULT

Sixty preterm infants with a mean birthweight of 898.2 (±262.6) g and mean gestational age of 26.3 (±0.6) weeks were included. High-dose ibuprofen was associated with a 21%(95% CI, -1.87 to 39.06%; p = 0.07) absolute reduction in PDA ligation compared to standard-dose ibuprofen. On adjusted analysis, receipt of standard-dose ibuprofen (OR 7.37, 95% CI, 1.2-45.27; p = 0.03) independently predicted increased PDA ligation risk. There were no differences in oliguria, NEC, or BPD between groups.

CONCLUSION

High-dose ibuprofen may significantly reduce PDA ligations. No difference in the safety profile with high-dose ibuprofen as compared to the standard-dose regimen was demonstrated.

Patent ductus arteriosus management and the drift towards therapeutic nihilism - What is the evidence?

The published literature on patent ductus arteriosus (PDA) management is challenging to interpret due to poorly designed trials with high rates of open label treatments, homogenisation of patients with varying physiological subtypes, poor treatment efficacy, and spontaneous closure in more mature infants. The perceived lack of clinical benefit has led to a drift away from medical and surgical treatment of all infants with a PDA. This therapeutic nihilism as a default response to PDA management fails to recognise the physiological relevance of a left-to-right shunt with early haemodynamic instability after birth and subsequent pulmonary volume overload with prolonged exposure. Clinicians need to know if therapeutic nihilism is safe. This review will provide an overview of the available data on the efficacy of known PDA treatments, conservative management and supportive care measures that are currently applied.

Management of Patent Ductus Arteriosus in Premature Infants in 2020

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.

New BPD-prevalence and risk factors for bronchopulmonary dysplasia/mortality in extremely low gestational age infants ≤28 weeks

OBJECTIVE

To evaluate prevalence and risk factors of moderate-severe Bronchopulmonary dysplasia (BPD)/Death in extremely low gestation age neonates (ELGANs).

STUDY DESIGN

Study of 266 ELGANs born at gestational age (GA) ≤ 28 weeks (w). Primary Outcome measure-composite outcome of moderate-severe BPD/Death using the National Institute of Child Health and Human Development NICHD's (2001) BPD definition.

RESULT

Cohort's mean GA and birth-weight (BW) were 25.3 ± 1.4w and 724 ± 14 g respectively with an overall mortality of 19% and moderate-severe BPD of 67%. Prevalence of moderate-severe BPD/death decreased significantly with increasing GA (86-93%) at 23-24 w; to <60% at 27-28w (OR 0.63; 95% CI; 0.52-0.77). On univariate analysis, other risk factors included BW(OR 1.005; 95% CI; 1.003-1.007), Sepsis (OR 2.9; 95% CI, 1.3-6.4), PDA needing treatment (OR 2.2; 95% CI, 1.3-3.9); air leaks (OR 2.7; 95% CI; 1.02-7.3) FiO₂ requirement >25%(OR 1.06; 95% CI; 1.01-1.11); and mechanical ventilation(MV) on Day7 (OR5.5; 95% CI; 2.8-10.8). Only need for Day7 MV was independently predictive of composite outcome (OR1.97; 95% CI; 1.3-3.1).

CONCLUSION

Risk factor identification will enable initiatives to implement lung protective strategies and develop prospective models for BPD prediction and prognostication.

A Randomized Placebo-Controlled Pilot Trial of Early Targeted Nonsteroidal Anti-Inflammatory Drugs in Preterm Infants with a Patent Ductus Arteriosus

OBJECTIVE

To establish the feasibility of a future large randomized trial to compare early treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) while awaiting spontaneous patent ductus arteriosus (PDA) closure.

STUDY DESIGN

Preterm infants at <29 weeks of gestation with a PDA diameter >1.5 mm and <72 hours after birth were randomized to NSAIDs vs placebo. No open-label NSAID treatment was allowed in either arm, but all infants with PDA volume load received supportive management, including optimization of airway pressure, careful fluid management, and diuretics as needed. The pilot outcomes were recruitment rate and incidence of open-label treatment. Secondary clinical outcomes included chronic lung disease or death, the planned primary outcome for a future large trial.

RESULTS

Overall, 54% of the approached parents consented to participate in the study. The median recruitment rate was 3 infants per month, and a total of 72 infants were randomized. One patient in each arm received open-label treatment. PDA closure rates were 74% for the NSAIDs arm vs 30% for the placebo arm, but this was not associated with significant changes in clinical outcomes.

CONCLUSIONS

This pilot trial showed that recruitment of more than one-half of eligible infants with a low incidence of open-label treatment is feasible. PDA closure rates and clinical outcomes were similar to those reported in previous PDA trials.

Hemodynamic and clinical consequences of early versus delayed closure of patent ductus arteriosus in extremely low birth weight infants

OBJECTIVES

To describe changes in hemodynamics, respiratory support, and growth associated with transcatheter PDA closure (TCPC) in ELBW infants, stratified by postnatal age at treatment.

STUDY DESIGN

This is an observational study of ELBW infants who underwent TCPC at ≤4 weeks (Group-1; n = 34), 4-8 weeks (Group-2; n = 33), and >8 weeks of age (Group-3; n = 33). Hemodynamic assessment was performed during TCPC. Multivariate Cox-proportionate-hazard modeling was used to identify factors associated with respiratory severity score (RSS) > 2 for >30 days following TCPC.

RESULTS

In comparison with Group-1, Group-3 infants had higher pulmonary vascular resistance (PVRi = 3.3 vs. 1.6 WU*m²; P = 0.01), less weight gain between 4 and 8 weeks of age (16 vs. 25 g/day) and took longer to achieve RSS < 2 (median 81 vs. 20 days; P = 0.001). RSS > 2 for >30 days was associated with TCPC > 8 weeks (OR = 3.2, 95% CI: 1.75-5.8; p = 0.03) and PVRi ≥ 3 (OR = 4.5, 95% CI: 2.7-8.9; p < 0.01).

CONCLUSION

ELBW infants may benefit from PDA closure within the first 4 weeks of life in order to prevent early onset pulmonary vascular disease, promote faster growth, and for quicker weaning of ventilator and oxygen support.

Does crossover treatment of control subjects invalidate results of randomized trials of patent ductus arteriosus treatment?

Optimal management of patent ductus arteriosus (PDA) in extremely preterm infants remains controversial. There is paucity of evidence on the benefits of PDA treatment in reducing mortality and morbidities in extremely preterm infants. Failure of randomized clinical trials to demonstrate beneficial effects of PDA treatment on outcomes has often been attributed to open treatment of control subjects. This perspective examines the PDA treatment trials to date, with specific focus on rates of and ages of subjects at open rescue treatment. Although these trials demonstrate that ductal closure is significantly increased with treatment, that does not translate to a significant decrease in major morbidities or mortality in premature infants, even when trials with high rates of rescue treatment of controls are excluded. Trials in which enrollment occurred after 7 days of age include insufficient numbers of subjects to evaluate this relationship.

Assessing Patent Ductus Arteriosus (PDA) Significance on Cardiac Output by Whole-Body Bio-impedance

We evaluated the effectiveness of a whole-body bioimpedance device (NICaS®, NI Medical, Petach Tikva, Israel) to predict the presence of a hemodynamically significant patent ductus arteriosus (PDA) in premature infants. A total of 36 infants less than 35 week's gestation age and birth weights of less than 1750 g were included in the study. Using the NICaS® device, we obtained whole-body bioimpedance measurements of stroke volume index (SI), cardiac output index (CI) and total peripheral resistance index. A total of 61 measurements were taken together with echocardiograph imaging. The study population was divided into three groups according to the echocardiograph results: group 1-small PDA, group 2-moderate PDA, and group 3-large PDA. Both SI and CI significantly increased from a median value of 22.6 ml/m² and 3.4 l/min/m² to 23.8 and 3.7, to 39.8 and 5.4 between groups 1, 2 and 3 respectively. The difference was statistically significant between groups 1 and 3 (P = 0.005 for SI and P = 0.002 for CI) and between groups 2 and 3 (P = 0.037 for SI and P = 0.05 for CI). We found statistically significant differences in SI and CI between infants with large PDAs and infants with no or small and medium PDAs. We suggest that these differences can be used in real time, in addition to echocardiography, in assessing the presence of significant PDAs.

Use of combination therapy with acetaminophen and ibuprofen for closure of the patent ductus arteriosus in preterm neonates

Objective

To compare effectiveness and safety of combination therapy (acetaminophen and ibuprofen) to monotherapy (ibuprofen, indomethacin, or acetaminophen alone) in treatment of the patent ductus arteriosus (PDA) in premature neonates.

Methods

This was a retrospective cohort study of neonates admitted to a tertiary-level neonatal intensive care unit. Included neonates were born at <32 weeks gestation and received pharmacotherapy for PDA closure. Based on the primary therapy received, our cohort was divided into the following four groups: indomethacin alone, ibuprofen alone, acetaminophen alone, and ibuprofen and acetaminophen (in combination). Baseline characteristics, effectiveness, safety, neonatal mortality, and morbidities rates between these groups were compared.

Results

One hundred and forty neonates were analyzed; 17 received combination therapy, and 123 neonates received monotherapy: 22 (17.9%) ibuprofen, 29 (23.6%) acetaminophen, and 72 (58.5%) indomethacin. The PDA closure rates were 41.7% for indomethacin, 41.2% for combination therapy, 37.9% for acetaminophen, and 31.8% for ibuprofen (P=0.100). Rates of adverse effects were comparable between the groups.

Conclusion

The rate of ductal closure was not different between combination therapy and monotherapy. The study did not demonstrate any increased adverse effects in the combination group. Future well-designed prospective clinical trials are needed to guide clinical practice.

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants

OBJECTIVE

Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation.

METHOD

Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared.

RESULTS

This study included 188 patients (27±2 weeks, 973±272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p<0.001) and surgical closure (34.5% P1 versus 16.1% P2, p<0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p=0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p=0.403), necrotizing enterocolitis (15.5% versus 6.9%, p=0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p=0.264), mortality (17.5% versus 15.2%, p=0.690) or survival-without-morbidity adjusted OR=1.10 (95% CI: 0.55-2.22); p=0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n=82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p=0.019) and more survival-without-morbidity (20% versus 45.6%, p=0.028) were found.

CONCLUSION

A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

Toward rational management of patent ductus arteriosus: ductal disease staging and first line paracetamol

Aims: To study paracetamol (PCM) use as first line therapy for significant patent ductus arteriosus (sPDA) closure, stratified by echocardiography.Methods: In this retrospective observational study, a prepublished score comprising PDA size and velocity, PDA:left pulmonary artery ratio, diastolic flow in main and LPA, LA:Ao ratio and left ventricular:aortic ratio were included for shunt severity. Successful closure was defined a priori as closure or ≥50% reduction in score. Comparisons were made between infants with sPDA who were treated and not treated.Results: During November 2017-2018, 227 infants from 23 to 31⁺⁶ weeks' gestational age (GA) were admitted; 50 (22%) infants were diagnosed with PDA, 32 treated with PCM, overall treatment rate of 32/227 (14%). Successful therapy was noted in 23/32 (72%) and was higher when treated at ≤7 days (80 versus 68%, p = .68), in infants >26 weeks GA (62.5 versus 100%, p = .07) and BW >1000 g (65.4 versus 100%, p = .14). Univariate analysis noted statistical significance only for GA. Eighteen infants were managed conservatively. Treated infants had a lower GA and BW, higher composite ECHO score (14.4 ± 0.5 versus 19 ± 0.4, p < .001).Conclusions: Composite scoring helped reduce exposure, and focus more on infants with lower GA and BW with greater shunt severity.

From Galen to Gross and beyond: a brief history of the enigmatic patent ductus arteriosus

Anatomists since antiquity and pathologists since at least the 17th century had identified the ductus arteriosus (DA) in cadavers and postmortem examinations, respectively. However, healthcare providers for more than a century have struggled to understand the significance of a patent ductus arteriosus (PDA) in patients, debated whether to treat it or not and if so, when and how. Accepted answers depended upon the authoritative position of the person(s) offering recommendations, the cumulative contemporary medical knowledge, and the changing patient population characteristics. The treatment choices were most often based on one's understanding of the balance between the risks and benefits of the chosen treatment. In the current era, with the increasing popularity of transcatheter occlusion of the PDA with relative ease even in extremely premature infants whose survival rates have improved dramatically, a basic question has reemerged-what are the benefits to treating the PDA in any preterm infant. In this brief review, I am providing a chronicle of the evolution of knowledge about the DA, the varying nature of the challenges a patent ductus posed for the caregivers, and the roots of the continued debate concerning the management of the enigmatic PDA.

Treatment of fetal circular shunt with non-steroidal anti-inflammatory drugs

A circular shunt (CS) is a life-threatening condition involving massive shunting of systemic arterial blood via the ductus arteriosus to the left ventricle without traversing the lungs. In the prenatal setting, it occurs mainly in fetuses with severe forms of Ebstein's anomaly (EA) owing to unrestricted ductal flow and significant pulmonary and tricuspid regurgitation. We aimed to improve the fetal hemodynamics and chances of survival of affected fetuses by inducing ductal constriction using transplacental non-steroidal anti-inflammatory drugs (NSAIDs). Following initiation of treatment between 26 and 34 weeks' gestation, three (75%) of four fetuses with EA/CS responded with sustained ductal constriction and improved hemodynamic function, which allowed continuation of pregnancy for 3-7 weeks and elective delivery. All successfully treated cases underwent neonatal surgery immediately after birth to eliminate the CS and survived. This included two neonates that underwent single-ventricle palliation surgery that required postoperative extracorporeal membrane oxygenation and hemofiltration for transient respiratory and renal failure. The one case that did not respond to treatment with NSAIDs was delivered prematurely for progressive fetal compromise and died shortly after birth. Transplacental treatment with NSAIDs represents a novel approach to controlling fetal CS, avoiding in-utero death and prolonging the pregnancy to a more advanced gestational age, thereby potentially increasing the chances of neonatal survival. This treatment should be considered and initiated at an early stage of systemic steal to prevent brain injury due to hypoperfusion. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Practice for preterm patent ductus arteriosus; focusing on the hemodynamic significance and the impact on the neonatal outcomes

Hemodynamically significant preterm patent ductus arteriosus (PDA) affects mortality; comorbidities such as necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia; and adverse long-term neurodevelopmental outcomes in preterm infants, particularly in very low birth weight infants. However, recent studies have indicated that there is no consensus on the causal relationship between PDA and neonatal outcomes, the benefit of PDA treatment, the factors guiding the need for treatment, and optimal treatment strategies. Such uncertainty has resulted in wide variations in practice for treating preterm PDA between units, regions, and nations. Nowadays, there has been a paradigm shift to more conservative treatment for preterm PDA, and suggestions regarding selective management of preterm PDA considering risk factors and hemodynamic significance are increasing. Neonatologist-performed echocardiography and advances in modalities to assess hemodynamic significance such as biologic markers and near-infrared spectroscopy also help improve the efficacy of selective treatment of preterm PDA.

Patent ductus arteriosus and small for gestational age infants: Treatment approaches and outcomes

BACKGROUND

The current treatment approach in patent ductus arteriosus suggests the identification of high-risk infants that may benefit the most from treatment. Small for gestational age infants are a high-risk population in which the treatment approach to the patent ductus arteriosus and outcomes have not been described.

AIM

To compare the patent ductus arteriosus treatment approach and outcomes in small for gestational age and appropriate for gestational age infants.

STUDY DESIGN

Retrospective analysis of infants born between January 1, 2011 and December 31, 2015 at <33 weeks' GA and admitted to neonatal intensive care units (NICU) part of the Canadian Neonatal Network.

RESULTS

595 of 2507 small for gestational age infants (23.7%) and 4714 of 20,002 appropriate for gestational age infants (23.6%) had a patent ductus arteriosus. The patent ductus arteriosus treatment approach (conservative, medical, surgical) was similar in both groups. Small for gestational age infants with and without a patent ductus arteriosus had increased risk of the composite outcome of death or bronchopulmonary dysplasia (aOR 3.40; 95% CI 2.73, 4.24; and aOR 2.72; 95% CI 2.24, 3.31) respectively.

CONCLUSIONS

Patent ductus arteriosus management did not differ between small for gestational age and appropriate for gestational age infants. Small for gestational age infants had increased risk of death or bronchopulmonary dysplasia regardless of their patent ductus arteriosus status.

Impaired antimicrobial response and mucosal protection induced by ibuprofen in the immature human intestine

BACKGROUND

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin (INDO) and ibuprofen (IBU) has been shown to be an effective therapy for the closure of patent ductus arteriosus (PDA). However, this treatment has been associated with an increased risk of developing enteropathies in neonates. Whether the use of IBU is safer than INDO for the immature intestine remains to be elucidated.

METHODS

The direct impact of IBU on the human immature intestinal transcriptome was investigated using serum-free organ culture. Differentially expressed genes were analyzed with Ingenuity Pathway Analysis software and compared with those previously reported with INDO. Validation of differentially expressed genes was confirmed by qPCR.

RESULTS

We identified several biological processes that were significantly modulated by IBU at similar levels to what had previously been observed with INDO, while the expression of genes involved in "antimicrobial response" and "mucus production" was significantly decreased exclusively by IBU in the immature intestine.

CONCLUSIONS

Our findings indicate that IBU has a harmful influence on the immature intestine. In addition to exerting many of the INDO observed deleterious effects, IBU alters pathways regulating microbial colonization and intestinal epithelial defense.

International perspective on management of a patent ductus arteriosus: Lessons learned

Whereas association between a patent ductus arteriosus (PDA) and neonatal morbidities has been well described, consensus has not been reached on whether the relationship is causal, on benefit of (or lack of) treatment, on factors guiding the 'need to treat', and on treatment strategies. Trials to date have primarily focused on the narrow outcome of successful ductal closure. Evidence from several retrospective studies has suggested that management may be modified with increased use of conservative treatment. A paradigm shift has resulted in decreased use of treatments to close the PDA in some centres. This approach cites the lack of demonstrable improvement in short- and long-term respiratory and neurodevelopmental outcomes as an argument. This article reviews current understanding of the wide variation in practice at either institutional, regional, national, or international level. It discusses the potential contributors to variability in diagnostic ascertainment and therapeutic intervention.

End-Organ Saturation Differences in Early Neonatal Transition for Left- versus Right-Sided Congenital Heart Disease

BACKGROUND

For neonates with congenital heart disease (CHD), left-sided (LL) and right-sided (RL) single ventricular physiologies (LL, hypoplastic left heart syndrome; RL, tricuspid atresia or pulmonary atresia with intact ventricular septum) may demonstrate distinct changes in tissue saturation in the first 72 h of life. Near-infrared spectroscopy (NIRS) can measure regional cerebral saturation (Csat) and renal saturation (Rsat) to clarify differences between LL and RL over time.

OBJECTIVES

Our primary objective was to measure changes in Csat and Rsat in the first 72 h of life using NIRS between CHD infants with LL compared to RL. The secondary objective was to correlate NIRS values to an echocardiographic marker of perfusion.

METHOD

Newborns with hypoplastic left heart syndrome, tricuspid atresia, and pulmonary atresia with intact ventricular septum from 2013 to 2016 underwent routine NIRS monitoring. Csat, Rsat, and systemic saturations (SpO2) in the first 72 h of life were retrospectively analyzed and the echocardiographic descending aorta velocity time integral (VTI) was measured. Mixed effects models compared differences over time between LL and RL.

RESULTS

The final cohort included 13 LL, 12 RL, and 4 controls. Csat decreased for RL compared to LL (p = 0.005), while Rsat decreased for both (p = 0.008). Over time, SpO2 increased for LL but decreased for RL (p = 0.046). Compared to the controls, infants with CHD had lower Csat, lower Rsat, and lower SpO2. The descending aorta VTI was correlated with Rsat (R2 = 0.24, p = 0.02).

CONCLUSION

NIRS Csat measures were better preserved in LL compared to RL. Rsat decreased in both groups through time. The correlation between the descending aorta VTI and Rsat suggests an association between NIRS measures of renal saturation and renal perfusion.