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Hoffmann JK, Khazal Z, Apers W, Sharma P, Weismann CG, Kaganov K, Wheeler CR, Farias M, Porras D, Levy P, Morton SU. Who Still Gets Ligated? Reasons for Persistence of Surgical Ligation of the Patent Ductus Arteriosus Following Availability of Transcatheter Device Occlusion for Premature Neonates. J Cardiovasc Dev Dis 2024; 11:132. [PMID: 38786954 PMCID: PMC11122133 DOI: 10.3390/jcdd11050132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/09/2024] [Accepted: 04/20/2024] [Indexed: 05/25/2024] Open
Abstract
(1) Background: To identify reasons for the persistence of surgical ligation of the patent ductus arteriosus (PDA) in premature infants after the 2019 Food and Drug Administration (FDA) approval of transcatheter device closure; (2) Methods: We performed a 10-year (2014-2023) single-institution retrospective study of premature infants (<37 weeks) and compared clinical characteristics and neonatal morbidities between neonates that underwent surgical ligation before (epoch 1) and after (epoch 2) FDA approval of transcatheter closure; (3) Results: We identified 120 premature infants that underwent surgical ligation (n = 94 before, n = 26 after FDA approval). Unfavorable PDA morphology, active infection, and recent abdominal pathology were the most common reasons for surgical ligation over device occlusion in epoch 2. There were no differences in demographics, age at closure, or outcomes between infants who received surgical ligation in the two epochs; (4) Conclusions: Despite increasing trends for transcatheter PDA closure in premature infants, surgical ligation persists due to unfavorable ductal morphology, active infection, or abdominal pathology.
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Affiliation(s)
- Julia K. Hoffmann
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
| | - Zahra Khazal
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
| | - Wievineke Apers
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
| | - Puneet Sharma
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
| | - Constance G. Weismann
- Department of Pediatric Cardiology, Skåne University Hospital, Department of Clinical Sciences, Lund University, 221 00 Lund, Sweden
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig Maximilian University, 80539 Munich, Germany
| | - Kira Kaganov
- Department of Neonatology, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Craig R. Wheeler
- Departments of Respiratory Care and Extracorporeal Membrane Oxygenation, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Michael Farias
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Diego Porras
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Philip Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
| | - Sarah U. Morton
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA (P.L.)
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Veldhuis MS, Dix LML, Breur JMPJ, de Vries WB, Koopman C, Eijsermans MJC, Swanenburg de Veye HFN, Molenschot MC, Lemmers PMA, van Bel F, Vijlbrief DC. Role of patent ductus arteriosus in preterms in long-term outcome. Early Hum Dev 2024; 190:105953. [PMID: 38330542 DOI: 10.1016/j.earlhumdev.2024.105953] [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: 11/08/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This study aimed to determine long-term neurodevelopmental outcome and cerebral oxygenation in extremely preterm infants, comparing those with a hemodynamic significant patent ductus arteriosus (hsPDA) to those without. STUDY DESIGN We included infants born before 28 weeks of gestation from 2008 to 2010 with routine echocardiography. Prior to echocardiography, regional cerebral oxygen saturation was measured. At 5 years of age, we evaluated neurodevelopmental outcomes using the Movement Assessment Battery for Children 2nd Dutch edition for motor skills and the Wechsler Preschool and Primary Scale of Intelligence 3rd Dutch edition for cognition. RESULTS A total of 66 infants (gestational age 26.6 ± 0.9 weeks, birth weight 912 ± 176 g) were included, 34 infants with a hsPDA (including treatment). The group infants with hsPDA showed lower pre-closure cerebral saturation levels (58.2 % ±7.8 % versus 62.8 % ±7.0 %; p = 0.01). At 5 years, impaired motor outcome occurred more often in infants with hsPDA (17 (53 %) vs. 7 (23 %); p = 0.01). In multivariate analysis existence of hsPDA remained unfavourably related to the motor subdomain "aiming and catching". There were no potential effects of hsPDA on cognitive performance at 5 years of age. CONCLUSION Treatment-receiving infants with hsPDA appear to exhibit motor deficits, specifically in "aiming and catching", by the age 5. Persistent ductal patency could be a contributing factor.
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Affiliation(s)
- Moniek S Veldhuis
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Laura M L Dix
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Johannes M P J Breur
- Department of Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willem B de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Corine Koopman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maria J C Eijsermans
- Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Mirella C Molenschot
- Department of Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Petra M A Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel C Vijlbrief
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.
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Kourelis G, Kanakis M, Loukas C, Kakava F, Kyriakoulis K, Bobos D, Apostolopoulou S, Rammos S, Giannopoulos N. Efficiency and Safety of Patent Ductus Arteriosus Surgical Ligation in Extremely Low Birth Weight Infants Without Chest Tube Placement. J Pediatr Intensive Care 2023; 12:264-270. [PMID: 37970142 PMCID: PMC10631836 DOI: 10.1055/s-0041-1731786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/28/2021] [Indexed: 10/20/2022] Open
Abstract
Patent ductus arteriosus (PDA) has been associated with increased morbidity and mortality in preterm infants. Surgical ligation (SL) is generally performed in symptomatic infants when medical management is contraindicated or has failed. We retrospectively reviewed our institution's experience in surgical management of PDA for extremely low birth weight (ELBW) infants without chest tube placement assessing its efficiency and safety. We evaluated 17 consecutive ELBW infants undergoing SL for symptomatic PDA (January 2012-January 2018) with subsequent follow-up for 6 months postdischarge. Patients consisted of 9 (53%) females and 8 (47%) males. Mean gestational age (GA) at birth was 27.9 ± 2.1 weeks. Median values for surgical age (SA) from birth to operation was 10 days (interquartile range [IQR]: 8-12); PDA diameter 3.4 mm (IQR: 3.2-3.5); surgical weight (SW) 750 g (IQR: 680-850); and days of mechanical ventilation (DMV) as estimated by Kaplan-Meier curve 22 days (95% confidence interval: 14.2-29.8). We observed a statistically significant negative association between DMV and GA at birth (rho = - 0.587, p = 0.017), SA (rho = - 0.629, p = 0.009) and SW (rho = - 0.737, p = 0.001). One patient experienced left laryngeal nerve palsy confirmed by laryngoscopy. Otherwise, there were no adverse events to include surgical-related mortality, recurrence of PDA, or need for chest tube placement during follow-up. SL of PDA in ELBW infants without chest tube placement is both efficient and safe. Universal consensus recommendations for the management of PDA in ELBW neonates are needed. Further study is required regarding the use of the less invasive option of percutaneous PDA closure in ELBW infants.
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Affiliation(s)
- Georgios Kourelis
- Pediatric Cardiac and Adult Congenital Heart Disease Intensive Care Unit, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Meletios Kanakis
- Paediatric Cardiac and Adult Congenital Heart Disease Surgical Department, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Constantinos Loukas
- Medical School, Medical Physics Lab, National and Kapodistrian University of Athens, Athens, Greece
| | - Felicia Kakava
- Pediatric Cardiac and Adult Congenital Heart Disease Intensive Care Unit, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Konstantinos Kyriakoulis
- Pediatric Cardiac and Adult Congenital Heart Disease Intensive Care Unit, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Dimitrios Bobos
- Paediatric Cardiac and Adult Congenital Heart Disease Surgical Department, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Sotiria Apostolopoulou
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Spyridon Rammos
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Nikolaos Giannopoulos
- Paediatric Cardiac and Adult Congenital Heart Disease Surgical Department, Onassis Cardiac Surgery Center, Kallithea, Greece
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Francescato G, Doni D, Annoni G, Capolupo I, Ciarmoli E, Corsini I, Gatelli IF, Salvadori S, Testa A, Butera G. Transcatheter closure in preterm infants with patent ductus arteriosus: feasibility, results, hemodynamic monitoring and future prospectives. Ital J Pediatr 2023; 49:147. [PMID: 37932790 PMCID: PMC10629028 DOI: 10.1186/s13052-023-01552-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023] Open
Abstract
Ductal patency of preterm infants is potentially associated with long term morbidities related to either pulmonary overflow or systemic steal. When an interventional closure is needed, it can be achieved with either surgical ligation or a catheter-based approach.Transcatheter PDA closure is among the safest of interventional cardiac procedures and it is the first choice for ductal closure in adults, children, and infants weighing more than 6 kg. In preterm and very low birth weight infants, it is increasingly becoming a valid and safe alternative to ligation, especially for the high success rate and the minor invasiveness and side effects. Nevertheless, being it performed at increasingly lower weights and gestational ages, hemodynamic complications are possible events to be foreseen.Procedural steps, timing, results, possible complications and available monitoring systems, as well as future outlooks are here discussed.
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Affiliation(s)
- Gaia Francescato
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Daniela Doni
- Neonatal Intensive Care Unit Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giuseppe Annoni
- Pediatric Cardiology, Regina Margherita Children's Hospital, Turin, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Elena Ciarmoli
- U.O. Di Neonatologia, Patologia Neonatale E Pediatria, ASST Della Brianza, P.O. Vimercate, Vimercate, Italy
| | - Iuri Corsini
- Division of Neonatalogy, Careggi University Hospital of Florence, Florence, Italy
| | - Italo Francesco Gatelli
- Division of Neonatology and Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Sabrina Salvadori
- Women and Child Health Department, Neonatal Intensive Care Unit, Azienda Ospedaliera -Università Di Padova, Padua, Italy
| | - Alberto Testa
- Sapienza School for Advanced Studies, Sapienza University of Rome, Rome, Italy
| | - Gianfranco Butera
- Cardiology, Cardiac Surgery and Heart Lung Transplantation; ERN GUARD HEART: Bambino Gesù Hospital and Research Institute, IRCCS, Rome, Italy
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Taslimi Taleghani N, Hamrahi B, Falahi M, Nazar E, Palizban F, Naseh A, Khoshnood Shariati M. Treatment of Patent Ductus Arteriosus in Premature Infants: Intravenous Paracetamol or Oral Ibuprofen? ARCHIVES OF IRANIAN MEDICINE 2023; 26:330-337. [PMID: 38310434 PMCID: PMC10685834 DOI: 10.34172/aim.2023.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/10/2022] [Indexed: 02/05/2024]
Abstract
BACKGROUND The similarity in the mechanism of action between paracetamol and ibuprofen can cause similar side effects. However, in preterm neonates with feeding intolerance, intravenous (IV) paracetamol has replaced oral ibuprofen. Therefore, a comparison of the effectiveness and side effects is essential. METHODS In this retrospective cohort study, the data of 118 preterm infants with a definite diagnosis of patent ductus arteriosus (PDA), including 59 patients who received oral ibuprofen and 59 patients who received IV paracetamol were analyzed. Laboratory evaluations of serum total and direct bilirubin, hemoglobin, and creatinine levels before and seven days after treatment were made. Using analysis of covariance (ANCOVA) and multiple multinomial logistic regression models, the effect of two treatment groups on the post-treatment variables as well as their efficacy comparison were evaluated. RESULTS In both pre- and post-treatment periods, there was no significant association between echocardiography variables with treatment groups. The results from the ANCOVA model showed that the paracetamol and ibuprofen were followed by a significant decrease in the mean total bilirubin and Hct variables after treatment by 1.38 and 1.65 units, respectively. In addition, results from the Mann-Whitney U test revealed that the median Hb and K differences after and before treatment had a significant difference between the two treatment groups. Furthermore, based on the multiple multinomial logistic model results, the odds of complete arterial duct closure with IV paracetamol was 1.27 times higher than with oral ibuprofen, while in the oral ibuprofen group, the odds of closing was 1.44 times higher than the IV paracetamol group, but there was no statistically significant difference between the two groups. CONCLUSION Intravenous paracetamol has equal efficacy compared to oral ibuprofen in the treatment of PDA. Also, it seems to be associated with a lower risk of hyperbilirubinemia following the treatment.
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Affiliation(s)
- Naeeme Taslimi Taleghani
- Neonatal Health Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Banafshe Hamrahi
- Neonatal Health Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Minoo Falahi
- Neonatal Health Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Eisa Nazar
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Farzane Palizban
- Neonatal Health Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Naseh
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Khoshnood Shariati
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Wei YJ, Ju YT, Hsieh ML, Kan CD, Lin YC, Wang JN. Surgical ligation, not transcatheter closure, associated with a higher severity of bronchopulmonary dysplasia in extremely preterm infant intervened for patent ductus arteriosus. Pediatr Pulmonol 2023; 58:1221-1228. [PMID: 36696083 DOI: 10.1002/ppul.26325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/03/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Patent ductus arteriosus (PDA) is a common complication among premature infants, which may be responsible for prematurity-related complications such as bronchopulmonary dysplasia (BPD). It is unclear whether different interventional methods contribute to the severity of BPD, given the original National Institute of Child Health and Human Development (NICHD) 2001 definition. To date, surgical ligation and the transcatheter approach have been equally successful in premature infants with hemodynamically significant PDA after medical treatment failure. Immediate improvement in the respiratory condition has been reported after transcatheter closure. However, the short-term pulmonary outcome has not been clarified yet. METHODS This retrospective study investigated infants born with a body weight <1000 g and who underwent either surgical ligation or transcatheter closure of PDA in a single tertiary institution. The infants were divided into groups according to the type of procedure (surgical ligation or transcatheter occlusion). The primary outcome was the severity of BPD at discharge or at a postmenstrual age of 36 weeks. The outcome was analyzed with logistic regression. RESULTS Forty-four patients met the inclusion criteria, of whom 14 underwent transcatheter occlusion and 30 underwent surgical ligation. The overall birth body weights and gestational age ranges were not different. The univariate model revealed an association between the procedure type and BPD severity. After adjusting for confounders, the multivariate model confirmed associations between BPD severity and procedure type and severe respiratory distress syndrome requiring surfactant. CONCLUSION Compared with the transcatheter approach, surgery for PDA in extremely preterm infants is associated with severe BPD at discharge. Further large-scale studies are needed to determine the exact mechanism.
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Affiliation(s)
- Yu-Jen Wei
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Tzu Ju
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Min-Ling Hsieh
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Dann Kan
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Jieh-Neng Wang
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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7
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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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Chock VY, Bhombal S, Variane GFT, Van Meurs KP, Benitz WE. Ductus arteriosus and the preterm brain. Arch Dis Child Fetal Neonatal Ed 2023; 108:96-101. [PMID: 35732482 DOI: 10.1136/archdischild-2022-324111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
As the approach to the patent ductus arteriosus (PDA) in the preterm infant remains controversial, the potential consequences of a significant ductal shunt on the brain should be evaluated. In this population at high risk of adverse outcomes, including intraventricular haemorrhage and white matter injury, as well as longer-term neurodevelopmental impairment, it is challenging to attribute sequelae to the PDA. Moreover, individual patient characteristics including gestational age and timing of PDA intervention factor into risks of brain injury. Haemodynamic assessment of the ductus combined with bedside neuromonitoring techniques improve our understanding of the role of the PDA in neurological injury. Effects of various PDA management strategies on the brain can similarly be investigated. This review incorporates current understanding of how the PDA impacts the developing brain of preterm infants and examines modalities to measure these effects.
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Affiliation(s)
- Valerie Y Chock
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shazia Bhombal
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gabriel F T Variane
- Pediatrics, Division of Neonatology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
| | - Krisa P Van Meurs
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - William E Benitz
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
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Sahai I, Ghosh B, Agrawal G, Christopher J, Rao T. A Rare Association of Patent Ductus Arteriosus (PDA) With Persistent Left Superior Vena Cava (PLSVC) and Unroofed Coronary Sinus (UCS) Terminating Into Left Atrium (LA): A Case Report of an Indian Infant. Cureus 2022; 14:e30124. [DOI: 10.7759/cureus.30124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
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Kılıç Y, Irdem AK, Doyurgan O, Özlem G, Balik H, Bıcak EA, Salik F, Aldudak B. Ligation of patent ductus arteriosus through left anterior mini-thoracotomy in preterm infants. Cardiol Young 2022; 33:1-6. [PMID: 35611831 DOI: 10.1017/s1047951122001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patent ductus arteriosus is an important cause of morbidity and mortality, especially in very low birth weight infants. The aim of the study is to report our single-centre short-term results of preterm patients who underwent ligation through left anterior mini-thoracotomy . METHODS Data of 27 preterm infants operated by the same surgeon who underwent Patent ductus arteriosus (PDA) closure with left anterior mini-thoracotomy technique between November 2020 and January 2022 at a single institution were reviewed. The patients were divided into two groups according to their weight at the time of surgery. Data on early postoperative outcomes and survival rates after discharge were collected. RESULTS Twenty-seven patients with a mean (±SD) gestational age of 25.8 (±2.0) weeks and a mean birth weight of 1027 (±423) g were operated using left anterior mini-thoracotomy technique. The lowest body weight was 480 g. Complications such as bleeding, abnormal healing of incision, or pneumothorax were not seen. There were 8 mortalities after the operation (29,6 %). The causes of the deaths were sepsis, necrotising enterocolitis, hydrops fetalis, hepatoblastoma, and intracranial bleeding. There was no statistically significant difference in the rates of complication between the groups. CONCLUSIONS Left anterior mini-thoracotomy technique can be performed as the first choice when transcatheter intervention cannot be applied in preterm infants. It provides easy access to the PDA, a good exposure, minimal contact with the lungs, good cosmetic results in early and mid-term and shortens the operation time, especially in very low birth weight preterm babies. However, early ligation may be helpful to minimise the complications related to PDA.
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Affiliation(s)
- Yiğit Kılıç
- Department of Pediatric Cardiac Surgery, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Ahmet Kuddusi Irdem
- Department of Pediatric Cardiac Surgery, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Onur Doyurgan
- Department of Pediatric Cardiac Surgery, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Gül Özlem
- Department of Pediatric Cardiology, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Hasan Balik
- Department of Pediatric Cardiology, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Esra Aktiz Bıcak
- Department of Anesthesiology and Reanimation, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Fikret Salik
- Department of Anesthesiology and Reanimation, Dicle University Medical Faculty, Diyarbakir, Turkey
| | - Bedri Aldudak
- Department of Pediatric Cardiology, Dr. Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
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[Timing of surgical ligation of patent ductus arteriosus in very low birth weight infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:500-506. [PMID: 35644189 PMCID: PMC9154378 DOI: 10.7499/j.issn.1008-8830.2112151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To study the effect of timing of surgical ligation of patent ductus arteriosus (PDA) on the prognosis of very low birth weight infants (VLBWI). METHODS The medical data of VLBWI who underwent transthoracic ligation for PDA from June 2018 to May 2021 were reviewed retrospectively. The infants were divided into early ligation group (≤21 days of age) and late ligation group (>21 days of age) based on the age of ligation. The two groups were compared in terms of perioperative clinical features, complications, and mortality. The risk factors for early surgical ligation were analyzed. RESULTS A total of 72 VLBWI were enrolled, with 19 infants (26%) in the early ligation group and 53 infants (74%) in the late ligation group. There were significant differences in birth weight, gestational age, weight at operation, days of age at operation, rates of preoperative invasive and noninvasive mechanical ventilation, incidence rate of pulmonary hemorrhage, incidence rate of hypotension, preoperative PDA internal diameter (mm/kg), intraoperative PDA external diameter (mm/kg), incidence rate of post-ligation cardiac syndrome, and duration of postoperative invasive mechanical ventilation between the two groups (P<0.05). A binary logistic regression analysis showed that pulmonary hemorrhage was an indication of early surgical ligation of PDA (P<0.05). There were no significant differences in the incidence rates of post-operative complications and the mortality rate between the early ligation and late ligation groups. CONCLUSIONS Early surgical ligation may be performed for VLBWI who are experiencing pulmonary hemorrhage and hemodynamically significant PDA confirmed by cardiac ultrasound after birth. However, post-ligation cardiac syndrome should attract enough attention. In addition, early surgical ligation of PDA does not increase the risk of surgery-related and long-term complications or death, indicating that it is a safe and feasible treatment option.
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Scerbo D, Cua CL, Rivera BK, Marzec LC, Smith CV, Slaughter JL, Berman DP, Backes CH. Percutaneous Closure of the Patent Ductus Arteriosus in Very-Low-Weight Infants. Neoreviews 2021; 21:e469-e478. [PMID: 32611564 DOI: 10.1542/neo.21-7-e469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In view of the known complications of drug therapy and open surgical ligation, and the potential for prolonged patent ductus arteriosus (PDA) exposure to be harmful, health care practitioners have sought new approaches to achieve definitive ductal closure. Interest in percutaneous (catheter-based) PDA closure has emerged within the neonatal community as a viable treatment option, because it has been fueled by recent procedural and device modifications, as well as mounting feasibility and safety data. Herein, we provide a contemporary review of percutaneous PDA closure among infants at the crux of the medical debate-very-low-weight infants (≤1,500 g), including: 1) characterization of traditional PDA treatments (drug therapy, open surgical ligation) and conservative (nonintervention) management options; 2) a general overview of the major procedural steps of percutaneous ductal closure, including efforts to reduce thrombotic complications and the emergence of a novel US Food and Drug Administration-approved device; 3) a systematic review and meta-analysis to better understand risk profiles of percutaneous PDA closure in this population; and 4) discussion of current gaps in our understanding of optimal PDA care, including the critical need for well-designed, randomized, controlled clinical trials.
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Affiliation(s)
- Danielle Scerbo
- The Ohio University Heritage College of Osteopathic Medicine, Athens, OH.,Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Clifford L Cua
- Department of Pediatrics, The Ohio State University College of Medicine, 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
| | - Laura C Marzec
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, WA
| | - Jonathan L Slaughter
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH
| | - Darren P Berman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at 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.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
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Meot M, Gaudin R, Szezepanski I, Bajolle F, Bonnet D, Malekzadeh-Milani S. Transcatheter patent arterial duct closure in premature infants: A new technique to ease access to the patent arterial duct, with particular benefit for the tricuspid valve. Arch Cardiovasc Dis 2021; 114:482-489. [PMID: 34312100 DOI: 10.1016/j.acvd.2021.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/08/2021] [Accepted: 06/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transcatheter patent arterial duct (PAD) closure in premature infants has been shown to be feasible. Since our early transcatheter PAD closure procedures in premature infants at Hôpital Necker Enfants Malades, we have changed our technique several times to advance the guidewire through the right heart to avoid tricuspid valve damage. AIM To describe the technique we have been using since May 2019, to report our results with a particular focus on tricuspid leaks and to analyse the potential mechanisms of tricuspid lesion development with previous methods. METHODS All premature infants weighing<2kg who underwent transcatheter PAD closure with this new technique were included. Demographic data, procedural data, outcome and procedural complications were reviewed, with particular attention to the occurrence of tricuspid regurgitation. RESULTS Between May 2019 and May 2020, 33 patients were included. Median gestational age was 25 weeks. Median birth weight and procedural weight were 690g (range 490-1065g; interquartile range [IQR] 620-785g) and 1160g (range 900-1900g; IQR 1030-1300g), respectively. Median age at procedure was 35 (IQR 30-46) days. PAD anatomy was evaluated on transthoracic echocardiography only. The median duct diameter was 3 (IQR 2.5-3.2) mm at the pulmonary end. Success rate was 100% (defined as successful closure without residual shunt). One patient had a renal vein thrombosis, which fully resolved with low-molecular-weight heparin anticoagulation. No tricuspid regurgitation or stenosis of the left pulmonary artery or the aorta was seen. One patient died of a superior caval vein obstruction with bilateral chylothorax related to a central catheter thrombosis 56 days after the procedure, unrelated to the catheter procedure. CONCLUSION In this prospective study, we describe a new technique to avoid tricuspid valve damage and facilitate delivery of the PAD device.
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Affiliation(s)
- Mathilde Meot
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France.
| | - Régis Gaudin
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France
| | - Isabelle Szezepanski
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France
| | - Fanny Bajolle
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France
| | - Damien Bonnet
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Sophie Malekzadeh-Milani
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, 75015 Paris, France
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14
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Chen YJ, Chu WY, Yu WH, Chen CJ, Chia ST, Wang JN, Lin YC, Wei YJ. Massive Gastric Hemorrhage after Indomethacin Therapy: A Rare Presentation and Critical Management in an Extremely Preterm Infant. CHILDREN-BASEL 2021; 8:children8070545. [PMID: 34202886 PMCID: PMC8304301 DOI: 10.3390/children8070545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/03/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022]
Abstract
Indomethacin has been widely used in preterm infants with hemodynamically significant patent ductus arteriosus (PDA). Gastrointestinal complications of indomethacin have been reported in 5% of treated neonates. However, massive gastric mucosa hemorrhage is a rarely reported complication. To the best of our knowledge, the infant in this report is the smallest reported in the literature to have undergone successful surgery for such a complication. A male preterm infant weighing 566 g was born at 252/7 weeks of gestational age without a complicated maternal history. Soon after birth, he received nasal noninvasive respiratory support and minimal feeding. PDA was observed since the first day of life (DOL), treatments were initiated on the second DOL for the hemodynamical significance, and PDA was closed after two courses of indomethacin therapy (0.2 mg/kg). At midnight on the seventh DOL, generalized pallor, bloody gastric drainage, and a distended stomach were observed. Massive gastric bleeding was suspected. He suffered from intermittent hypotension, which was corrected with blood products and fluid resuscitation under monitoring with a radial arterial line. Gastric lavage with cooling saline was performed twice but in vain. Prior to surgical consultation, intravascular volume transfusion was given twice. An exploratory laparotomy was arranged after obtaining the parents' consent. Blood oozing from the gastric mucosa was observed through gastrostomy and was successfully stopped via epinephrine-soaked gauze compression. After the operation, his clinical course remained uneventful, and he was discharged without neurological anomaly at two-year follow-up. Physicians need to be cautious of indomethacin's effect on platelet dysfunction in preterm infants with multiple predisposing factors. The tendency for mucosal bleeding should be continuously monitored after indomethacin therapy.
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Affiliation(s)
- Yen-Ju Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Wei-Ying Chu
- Department of Pediatrics, Tainan Hospital, Ministry of Health and Welfare, Tainan 700007, Taiwan;
| | - Wen-Hao Yu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Chau-Jing Chen
- Department of Surgery, Tainan Sinlau Hospital, Tainan 701002, Taiwan;
- Department of Surgery, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan;
| | - Shu-Ti Chia
- Department of Surgery, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan;
| | - Jieh-Neng Wang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Yung-Chieh Lin
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
- Correspondence: (Y.-C.L.); (Y.-J.W.); Tel.: +81-052-853-8244 (Y.-C.L.); +886-62-353-535 (ext. 4189) (Y.-J.W.)
| | - Yu-Jen Wei
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
- Correspondence: (Y.-C.L.); (Y.-J.W.); Tel.: +81-052-853-8244 (Y.-C.L.); +886-62-353-535 (ext. 4189) (Y.-J.W.)
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Patent ductus arteriosus treatment trends and associated morbidities in neonates. Sci Rep 2021; 11:10689. [PMID: 34021202 PMCID: PMC8139968 DOI: 10.1038/s41598-021-89868-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/28/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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16
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Santos J, Soares P, Ferreras C, Flor-de-Lima F, Guimarães H. Patent ductus arteriosus in preterm newborns: a tertiary hospital experience. Rev Port Cardiol 2021; 41:109-118. [PMID: 33934914 DOI: 10.1016/j.repc.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) in preterm newborns has been associated with increased mortality and co-morbidities. This study aimed to characterize the population of preterm infants diagnosed with PDA and to identify predictive factors of response to medical treatment of PDA. METHODS An eight-year retrospective observational study was conducted, which included all preterm newborns (PTNB) with a gestational age between 23 and 32 weeks diagnosed with PDA, admitted to the Neonatal Unit of the Centro Hospitalar Universitário de São João. Univariate comparative analysis was performed and models for predicting the effectiveness of PDA treatment with ibuprofen were explored by multivariate logistic regression analysis. RESULTS 115 cases were included in the study and 34 were excluded, with a final sample of 81 PTNB with PDA. The univariate analysis revealed significant differences in the closure efficacy by medical treatment with ibuprofen in several variables, and a multivariate logistic regression model was obtained (discriminative capacity 72.2%, sensitivity 98.1%, specificity 57.1%), considering the effect of gestational age, type of delivery, need for diuretics treatment and platelet transfusion. CONCLUSION This study enabled the characterization of the population of preterm infants diagnosed with PDA and the identification of a predictive model that can assist with predicting the effectiveness of the medical treatment and thus contribute to optimizing the medical approach to non-responders.
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Affiliation(s)
- Joana Santos
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Paulo Soares
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Neonatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Cristina Ferreras
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Pediatria, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Filipa Flor-de-Lima
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Neonatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Hercília Guimarães
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Cardiovascular R&D Center, Faculty of Medicine University of Porto, Portugal
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Godin R, Rodriguez JC, Kahn DJ. Oral Versus Intravenous Medications for Treatment of Patent Ductus Arteriosus in Preterm Neonates: A Cost-Saving Initiative. J Pediatr Pharmacol Ther 2021; 26:291-299. [PMID: 33833632 DOI: 10.5863/1551-6776-26.3.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/18/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The purpose of the study was to quantify cost savings after promoting oral pharmacotherapy for the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). METHODS This was a retrospective before-and-after time series quality improvement study. Oral ibuprofen and acetaminophen use criteria were developed and recommended, rather than the more costly intravenous equivalents. There were 24-month medication use reports generated for both the pre-criteria (Era-1) and the post-criteria (Era-2) implementation phases to identify neonates prescribed hsPDA medications in order to assess cost differences. RESULTS Era-1 had 190 treatment courses in 110 neonates for a total medication cost of $171,260.70. Era-2 had 210 courses in 109 patients for a total medication cost of $47,461.49, yielding savings of $123,799.21 ($61,899.61 annually) after criteria implementation. The reduction in intravenous ibuprofen use in Era-2 accounted for all the savings. CONCLUSION Preferentially prescribing lower-cost oral medications to treat hsPDA led to significant cost savings.
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18
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Martini S, Galletti S, Kelsall W, Angeli E, Agulli M, Gargiulo GD, Chen SE, Corvaglia L, Singh Y. Ductal ligation timing and neonatal outcomes: a 12-year bicentric comparison. Eur J Pediatr 2021; 180:2261-2270. [PMID: 33713339 PMCID: PMC7955694 DOI: 10.1007/s00431-021-04004-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 01/30/2023]
Abstract
Patent ductus arteriosus (PDA) is common among extremely preterm infants. In selected cases, surgical PDA ligation may be required. The timing for PDA ligation may depend upon a variety of factors, with potential clinical implications. We aimed to investigate the impact of different surgical PDA managements on ligation timing and neonatal outcomes. Inborn infants < 32 weeks of gestation and < 1500 g admitted at two tertiary Neonatal Intensive Care Units that underwent PDA ligation between 2007 and 2018 were enrolled in this retrospective cohort study and split into the following groups based on their surgical management: on-site bedside PDA ligation (ONS) vs. referral to an off-site pediatric cardiac surgery (OFS). Neonatal characteristics, surgical timing, and clinical outcomes of the enrolled infants were compared between the groups. Multivariate analysis was performed to evaluate the impact of PDA ligation timing on significantly different outcomes. Seventy-eight neonates (ONS, n = 39; OFS, n = 39) were included. Infants in the ONS group underwent PDA ligation significantly earlier than those in the OFS group (median age 12 vs. 36 days, p < 0.001) with no increase in postoperative mortality and complications. The multivariate analysis revealed a significant association between PDA ligation timing, late-onset sepsis prevalence (OR 1.045, 0.032), and oxygen need at discharge (OR 1.037, p = 0.025).Conclusions: Compared with off-site surgery, on-site bedside ligation allows an earlier surgical closure of PDA, with no apparent increase in mortality or complications. Earlier PDA ligation may contribute to reduced rates of late-onset sepsis and post-discharge home oxygen therapy, with possible cost-benefit implications. What is known: • Ineffective or contraindicated pharmacological closure of a hemodynamically significant PDA may require a surgical ligation. • Available literature comparing the effect of early vs. late PDA ligation on the main neonatal morbidities has yield contrasting results. What is new: • The availability of a cardiac surgery service performing bedside PDA ligation allows an earlier intervention compared to patient referral to an off-site center, with no difference in postoperative mortality and complications compared to off-site surgery. • Earlier PDA ligation was associated with a lower prevalence of late-onset sepsis and of oxygen need at discharge, with possible cost-benefit implications.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138, Bologna, Italy.
| | - Silvia Galletti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Wilf Kelsall
- Neonatal Intensive Care Unit, Department of Paediatrics, Addenbrooke’s Hospital, Cambridge, UK
| | - Emanuela Angeli
- Pediatric Cardiac Surgery Unit, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marta Agulli
- Anaesthesiology and Intensive Care Unit, Cardio-Thoracic-Vascular Department, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | - Si Emma Chen
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Yogen Singh
- Neonatal Intensive Care Unit, Department of Paediatrics, Addenbrooke’s Hospital, Cambridge, UK
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Akyuz M, Isik O, Mercan I, Cakmak M. Bedside surgical ligation of the patent ductus arteriosus in very-low-birth-weight premature infants: Limited upper ministernotomy as an alternative approach. J Card Surg 2020; 36:436-441. [PMID: 33283315 DOI: 10.1111/jocs.15171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is an important cause of morbidity and mortality, especially in very-low-birth-weight infants. The aim of the present study was to evaluate the outcomes of bedside surgical ligation of PDA via limited upper ministernotomy as an alternative approach to thoracotomy. MATERIALS AND METHODS A total of 23 low-birth-weight premature infants, who underwent bedside ligation of PDA in the neonatal intensive care unit between January 2017 and April 2020, were enrolled. The patients were divided into two groups: those with thoracotomy (n = 13) and those with limited upper ministernotomy (n = 10). These patients were evaluated retrospectively in terms of clinical and preoperative, intraoperative, postoperative parameters between the groups. RESULTS Mean birth weight was 1059 ± 275 g in the thoracotomy group and 1035 ± 285 g in the ministernotomy group. There was no statistically significant difference in the age at surgery, weight at surgery, preoperative mechanical ventilation (MV) support, inotropic score onset of surgery, and total procedure time between the groups. There was a statistically significant difference in the hospital length of stay, postoperative MV time, and complications in the intensive care unit in favor of the ministernotomy group (p = .04, p = .03, p = .034, respectively). The study showed no statistically significant difference in the mortality rate between the two groups (two patients in the thoracotomy group and one patient in the ministernotomy group). CONCLUSION The limited upper ministernotomy is an anatomically and technically feasible alternative to classical left posterolateral thoracotomy for bedside surgical PDA ligation.
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Affiliation(s)
- Muhammet Akyuz
- Department of Congenital Heart Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Onur Isik
- Department of Congenital Heart Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ilker Mercan
- Department of Congenital Heart Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Meltem Cakmak
- Department of Anesthesiology and Reanimation, Tepecik Training and Research Hospital, Izmir, Turkey
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Ruoss JL, Bazacliu C, Giesinger RE, McNamara PJ. Patent ductus arteriosus and cerebral, cardiac, and gut hemodynamics in premature neonates. Semin Fetal Neonatal Med 2020; 25:101120. [PMID: 32513596 DOI: 10.1016/j.siny.2020.101120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patent ductus arteriosus is associated with multiple comorbidities in premature infants, however a causal link or strategy to decrease these morbidities has not been found. The association between the patent ductus arteriosus and morbidities has biologic plausibility as, like any cardiac mixing lesion, a significant systemic to pulmonic shunt may lead to pulmonary over-circulation and systemic hypoperfusion. Understanding the underlying pathophysiology of associated morbidities in the setting of a patent ductus arteriosus may aid in risk stratifying infants and offer a patient targeted approach to infants with a pathological ductal shunt. While the deleterious impact of increased pulmonary blood flow maybe easier to identify, the impact on end-organ perfusion is more challenging. In this review, we will discuss the pathophysiology of a hemodynamically significant patent ductus arteriosus in premature infants, impact on end-organ perfusion and associated morbidities, and novel modalities to assess shunt volume and effect on end-organ perfusion.
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Affiliation(s)
- J L Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - C Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - R E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - P J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA; Department of Internal Medicine, University of Iowa, 8803 John Pappajohn Pavillion 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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21
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Kanabar K, Bootla D, Kaur N, Pruthvi CR, Krishnappa D, Santosh K, Guleria V, Rohit MK. Outcomes of transcatheter closure of patent ductus arteriosus with the off-label use of large occluders (≥16 mm). Indian Heart J 2020; 72:107-112. [PMID: 32534682 PMCID: PMC7296248 DOI: 10.1016/j.ihj.2020.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/23/2019] [Accepted: 03/28/2020] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Transcatheter closure is the first-choice strategy for the management of appropriate patients with patent ductus arteriosus (PDA). The management of large PDAs is challenging due to the limited available sizes of approved devices and the inherent risks of surgical ligation, especially in adults with calcified PDAs. This study aimed to assess the outcomes of the off-label use of large occluders at a tertiary center. METHODS This retrospective review included patients who underwent transcatheter PDA closure with large occluders (≥16 mm) over 16 years. The baseline patient data, procedural details, angiograms, and immediate outcomes were recorded and patients were followed up at 3, 6, 12 months after the intervention and annually thereafter. RESULTS Of the 685 patients who underwent transcatheter PDA closure, 36 patients (mean age 16.6 ± 12.5 years) needed occluders ≥ 16 mm in size. Cocoon duct occluder, Cera duct occluder, Amplatzer atrial septal occluder (ASO), and Cera muscular ventricular septal defect occluders were used for PDA closure. There was no device embolization, one patient in whom ASO was used had residual shunt with intravascular hemolysis requiring surgery, and one patient had mild left pulmonary artery narrowing after the intervention, which was managed conservatively. No patient had residual shunt and one patient had persistent pulmonary hypertension at an intermediate duration of follow-up. CONCLUSION Transcatheter PDA closure with the use of large devices, which are available in Asia and Europe, is an effective and safe method, especially in adolescents and adults. However, a close follow-up of these patients is mandatory.
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Affiliation(s)
- Kewal Kanabar
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Dinakar Bootla
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Navjyot Kaur
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - C R Pruthvi
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Darshan Krishnappa
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Krishna Santosh
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vivek Guleria
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Manoj Kumar Rohit
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Yan H, Ma F, Li Y, Zhou K, Hua Y, Wan C. The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19356. [PMID: 32118777 PMCID: PMC7478603 DOI: 10.1097/md.0000000000019356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a particularly common problem in preterm infants. Although surgical ligation is rarely performed in many contemporary neonatal intensive care units, it remains a necessary treatment option for preterm infants with a large hemodynamically significant PDA under strict clinical criteria, and it can reduce mortality in preterm infants. However, the optimal timing of surgical ligation is still controversial. We conducted this systematic review and meta-analysis to compare the mortality and morbidity of early and late surgical ligation of PDA in preterm or very-low-birth-weight (VLBW) infants. METHODS This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019133686). We searched the databases of PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform up to May 2019. RESULTS This review included 6 retrospective studies involving 397 premature or VLBW infants with PDA. Pooled analysis showed that compared with the late ligation group, the early ligation group had a lower fraction of inspired oxygen (FiO2) at 24 hours postoperatively (mean difference [MD] -6.34, 95% confidence interval [CI] -9.45 to -3.22), fewer intubation days (MD -19.69, 95% CI -29.31 to -10.07), earlier date of full oral feeding (MD -22.98, 95% CI -28.63 to -17.34) and heavier body weight at 36 weeks of conceptional age (MD 232.08, 95% CI 57.28 to 406.88). No significant difference in mortality or other complications was found between the early and late groups. CONCLUSION Our meta-analysis implies that compared with late surgical ligation, early ligation might have a better respiratory outcome and nutritional status for PDA in preterm or VLBW infants. There was no difference in mortality or postoperative complications between early and late ligation. A randomized prospective clinical trial with a possible large sample size is urgently needed to reinvestigate this conclusion. PROSPERO REGISTRATION NUMBER CRD42019133686.
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Affiliation(s)
- Hualin Yan
- Department of Medical Ultrasound, West China Hospital, Sichuan University
- West China School of Medicine, Sichuan University
| | - Fan Ma
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chaomin Wan
- West China School of Medicine, Sichuan University
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
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Abstract
Management of persistent patent ductus arteriosus (PDA) continues to be a challenging issue. The attitude toward PDA has shifted in the opposite direction during the last 20 years, from advocating an aggressive and early closure toward a call for watchful observation. While persistent PDA may cause challenges in the medical management of preterm neonates secondary to volume overload, pulmonary edema or hemorrhage, hypotension, and impaired tissue perfusion, its contribution toward long-term neonatal morbidities including bronchopulmonary dysplasia (BPD), ROP, NEC, and NDI has not been substantiated. By advocating conservative management, it is clear now that the majority of the PDA cases show spontaneous closure and do not require treatment. However, there has not been agreement regarding what constitutes a hemodynamically significant PDA and when, if any, it should be targeted for treatment. With increasing concern regarding possible associated complications with PDA ligation, a new trend for transcatheter approach to PDA closure is expanding. In this review, we summarize current understanding of the pathophysiology, diagnosis, and management of PDA in preterm infants, and we make some recommendations regarding evidence-based approach.
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Affiliation(s)
| | - Eyad Almidani
- Department of Pediatrics, King Faisal Specialist Hospital& Research Center, Riyadh, Saudi Arabia
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Backes CH, Giesinger RE, Rivera BK, Berman DP, Smith CV, Cua CL, Kelleher KJ, McNamara PJ, Slaughter JL. Percutaneous Closure of the Patent Ductus Arteriosus in Very Low Weight Infants: Considerations Following US Food and Drug Administration Approval of a Novel Device. J Pediatr 2019; 213:218-221. [PMID: 31255391 DOI: 10.1016/j.jpeds.2019.05.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Carl H Backes
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH; The Heart Center at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.
| | | | - Brian K Rivera
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
| | - Darren P Berman
- The Heart Center at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Clifford L Cua
- The Heart Center at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kelly J Kelleher
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Jonathan L Slaughter
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH; Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH
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25
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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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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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Arkhipov AN, Omelchenko AY, Zubritskiy AV, Khapaev TS, Soynov IA, Ivantsov SM, Pavlushin PM, Bogachev-Prokophiev AV, Karaskov AM. [Thoracoscopic clipping of patent ductus arteriosus: position of surgery in the era of transcatheter procedures]. Khirurgiia (Mosk) 2019:5-12. [PMID: 30855584 DOI: 10.17116/hirurgia20190215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To describe single-center evolution of the procedure and to evaluate the results of thoracoscopic clipping of patent ductus arteriosus (PDA) with diameter over 3,0 mm in term infants weighting over 4,0 kg. MATERIAL AND METHODS Thoracoscopic clipping of PDA has been performed in 140 patients for the period from March 2012 to March 2018 in Meshalkin National Medical Research Center. Mean age was 4.0 years (range 3 months - 13 years), mean body mass index - 15.4±2.2 kg/m2. INCLUSION CRITERIA PDA size 3.5-10 mm, Qp/Qs >1,3/1,0, weight 4.0-40 kg. Mean PDA size was 4.6±0.9 mm (range 3.5-8.0 mm), mean pulmonary artery pressure - 34.3±5.8 mm Hg, mean systemic/pulmonary flow Qp/Qs - 1.6±0.3. All patients underwent successful PDA closure through four-port technique under endotracheal general anesthesia and no need for pleural drainage. RESULTS Mean procedure time was 24.5±15.5 min. In 29 (20,7%) cases we used titanium clips, in 11 (79.3%) - polymer locking ligating clips. There was 1 conversion to mini-thoracotomy. There were no deaths, bleeding or any other life-threatening complications. 94 (67.1%) patients were weaned from ventilator within operating theatre, in other 46 (32.9%) patients mean ventilation time in ICU was 1.3±1.0 hours. In-hospital postoperative complications: pneumothorax - 2 (1.4%) cases, recurrent laryngeal nerve dysfunction - 1 (0.7%), false croup - 1 (0.7%). There were 2 residual leakages in 2 (1.4%) patients in 10 and 6 months after titanium clip deployment. Both of them underwent transcatheter closure using the coil. Considering these cases all following patients underwent PDA closure by polymer locking ligating clips with no cases of residual leakage. CONCLUSION Thoracoscopic PDA closure by polymer locking ligating clip is safe and effective technique for surgical management of PDA with diameter over 3.0 mm in term infants weighting over 4.0 kg.
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Affiliation(s)
- A N Arkhipov
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A Yu Omelchenko
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A V Zubritskiy
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - T S Khapaev
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - I A Soynov
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - S M Ivantsov
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - P M Pavlushin
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A V Bogachev-Prokophiev
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A M Karaskov
- Meshalkin National Medical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
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