Is surgical ligation of a patent ductus arteriosus the preferred initial approach for the neonate with extremely low birth weight?

Left vocal cord paralysis after patent ductus arteriosus ligation: A systematic review

CONTEXT

Extremely premature (EP) infants are at increased risk of left vocal cord paralysis (LVCP) following surgery for patent ductus arteriosus (PDA).

OBJECTIVE

A Systematical Review was conducted to investigate the incidence and outcomes of LVCP after PDA ligation in EP born infants.

DATA SOURCES

Searches were performed in Cochrane, Medline, Embase, Cinahl and PsycInfo.

STUDY SELECTION

Studies describing EP infants undergoing PDA surgery and reporting incidence of LVCP were included.

DATA EXTRACTION AND SYNTHESIS

Study details, demographics, incidence of LVCP, diagnostic method and reported outcomes were extracted. DerSimonian and Laird random effect models with inverse variance weighting were used for all analyses.

STUDY APPRAISAL

The Newcastle-Ottawa scale for observational studies was used for quality assessment.

RESULTS

21 publications including 2067 infants were studied. The overall pooled summary estimate of LVCP incidence was 9.0% (95% CI 5.0, 15.0). However, the pooled incidence increased to 32% when only infants examined with laryngoscopy were included. The overall risk ratio for negative outcomes was higher in the LVCP group (2.20, 95% CI 1.69, 2.88, p = 0.01) compared to the non-LVCP-group.

CONCLUSIONS

Reported incidence of LVCP varies widely. This may be explained by differences in study designs and lack of routine vocal cords postoperative assessment. LVCP is associated with negative outcomes in EP infants. The understanding of long-term outcomes is scarce. Routine laryngoscopy may be necessary to identify all cases of LVCP, and to provide correct handling for infants with LVCP.

PDA ligation and health outcomes: a meta-analysis

BACKGROUND AND OBJECTIVE

Patent ductus arteriosus (PDA) ligation has been variably associated with neonatal morbidities and neurodevelopmental impairment (NDI). The objective was to systematically review and meta-analyze the impact of PDA ligation in preterm infants at <32 weeks' gestation on the risk of mortality, severe neonatal morbidities, and NDI in early childhood.

METHODS

Medline, Embase, Cochrane Central Register of Controlled Trials, Education Resources Information Centre (ERIC), Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO, and the Dissertation database were searched (1947 through August 2013). Risk of bias was assessed by using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool. Meta-analyses were performed by using a random-effects model. Unadjusted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were pooled when appropriate.

RESULTS

Thirty-nine cohort studies and 1 randomized controlled trial were included. Nearly all cohort studies had at least moderate risk of bias mainly due to failure to adjust for survival bias and important postnatal preligation confounders such as ventilator dependence, intraventricular hemorrhage, and sepsis. Compared with medical treatment, surgical ligation was associated with increases in NDI (aOR: 1.54; 95% CI: 1.01-2.33), chronic lung disease (aOR: 2.51; 95% CI: 1.98-3.18), and severe retinopathy of prematurity (aOR: 2.23; 95% CI: 1.62-3.08) but with a reduction in mortality (aOR: 0.54; 95% CI: 0.38-0.77). There was no difference in the composite outcome of death or NDI in early childhood (aOR: 0.95; 95% CI: 0.58-1.57).

CONCLUSIONS

Surgical ligation of PDA is associated with reduced mortality, but surviving infants are at increased risk of NDI. However, there is a lack of studies addressing survival bias and confounding by indication.

The timing of surgical ligation for patent ductus arteriosus is associated with neonatal morbidity in extremely preterm infants born at 23-25 weeks of gestation

The purpose of this study was to evaluate prognostic factors associated with surgical ligation for patent ductus arteriosus (PDA) in extremely preterm infants born at the limits of viability. Ninety infants who were born at 23-25 weeks of gestation and who received surgical ligation were included and their cases were retrospectively reviewed. Infants were classified into two different groups: survivors with no major morbidity (N), and non-survivors or survivors with any major morbidity (M). Clinical characteristics were compared between the groups. Possible prognostic factors were derived from this comparison and further tested by logistic regression analysis. The mean gestational age and the mean birth weight of M were significantly lower than those of N. Notably, the mean postnatal age at time of ligation in N was significantly later than that of the other group (17 ± 12 vs 11 ± 8 days in N and M, respectively). An adjusted analysis showed that delayed ligation (>2 weeks) was uniquely associated with a significantly decreased risk for mortality or composite morbidity after surgical ligation (OR, 0.105; 95% CI, 0.012-0.928). In conclusion, delayed surgical ligation for PDA (>2 weeks) is associated with decreased mortality or morbidities in extremely preterm infants born at 23-25 weeks of gestation.

Primary surgical closure should be considered in premature neonates with large patent ductus arteriosus

BACKGROUND

Treatment for patent ductus arteriosus (PDA) in premature infants can consist of medical or surgical approaches. The appropriate therapeutic regimen remains contentious. This study evaluated the role of surgery in improving the survival of premature neonates weighing less than 1,500 g with PDA.

MATERIALS AND METHODS

From January 2008 to June 2011, 68 patients weighing less than 1,500 g with PDA were enrolled. The patients were divided into three groups: a group managed only by medical treatment (group I), a group requiring surgery after medical treatment (group II), and a group requiring primary surgical treatment (group III).

RESULTS

The rate of conversion to surgical methods due to failed medical treatment was 67.6% (25/37) in the patients with large PDA (≥2 mm in diameter). The number of patients who could be managed with medical treatment was nine which was only 20.5% (9/44) of the patients with large PDA. There was no surgery-related mortality. Group III displayed a statistically significantly low rate of development of bronchopulmonary dysplasia (BPD) (p=0.008). The mechanical ventilation time was significantly longer in group II (p=0.002).

CONCLUSION

Medical treatment has a high failure rate in infants weighing less than 1,500 g with PDA exceeding 2.0 mm. Surgical closure following medical treatment requires a longer mechanical ventilation time and increases the incidence of BPD. Primary surgical closure of PDA exceeding 2.0 mm in the infants weighing less than 1,500 g should be considered to reduce mortality and long-term morbidity events including BPD.

Therapeutic management of patent ductus arteriosus

Management of patent ductus arteriosus (PDA) in premature neonates has always been a challenge to the neonatologist and continues to be a controversial topic. Indications for treatment are not clear. Approximately 40% of ductus arteriosus close spontaneously even in extremely-low-birth-weight neonates. Prophylactic or early pre-symptomatic treatment may unnecessarily expose these babies, in whom the ductus might close spontaneously, to pharmacologic agents and their adverse effects. On the other hand, with advancing postnatal age, delaying treatment could potentially decrease successful medical closure thereby increasing the rate of surgical ligation and the complications associated with surgery. We tried to develop some clinical guidelines for management of PDA in premature neonates based on evidence, or lack thereof, and experience.

Predictors of ductal closure and intestinal complications in very low birth weight infants treated with indomethacin

OBJECTIVE

To describe factors associated with failure of patent ductus arteriosus closure and development of gastrointestinal complications in subjects treated with indomethacin.

STUDY DESIGN

Infants <or=30 weeks and <1,500 g delivered between 1997-2003 with patent ductus arteriosus treated with indomethacin were included in this single-center retrospective study. Risk factors for failed ductal closure rates and gastrointestinal complications were identified with uni- and multivariable analyses.

RESULTS

Among 210 subjects treated with indomethacin, ductal closure increased from 43% at 23 weeks to 87% at 27 weeks (OR 1.51 per week gestation, 95% CI 1.14-2.01, p = 0.004) and was unchanged thereafter. Gastrointestinal complications decreased with increasing gestational age (OR 0.67/week, 95% CI 0.52-0.84) but increased with male gender (OR 2.41, 95% CI 1.07-5.45). SNAP-II (Score for Neonatal Acute Physiology-II) scores at birth and at the time of first indomethacin therapy were not associated with likelihood of closure or with gastrointestinal complications. Duration of ductal patency was not associated with risk of necrotizing enterocolitis or intestinal perforation after adjusting for gestational age and gender.

CONCLUSIONS

Ductal closure with indomethacin is linearly associated with gestational age in infants <or=27 weeks. Illness severity at the time of treatment is not predictive of treatment outcome or gastrointestinal complications. The duration of ductal patency is not associated with an increase in adjusted risk of necrotizing enterocolitis or intestinal perforation in patients treated with indomethacin.

Neurosensory impairment after surgical closure of patent ductus arteriosus in extremely low birth weight infants: results from the Trial of Indomethacin Prophylaxis in Preterms

OBJECTIVES

To determine whether surgical closure of a patent ductus arteriosus (PDA) is a risk factor for bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP), and neurosensory impairment in extremely low birth weight (ELBW) infants.

STUDY DESIGN

We studied 426 infants with a symptomatic PDA, 110 of whom underwent PDA ligation and 316 of whom received medical therapy only. All infants participated in the multicenter Trial of Indomethacin Prophylaxis in Preterms (TIPP) and were observed to a corrected age of 18 months.

RESULTS

Of the 95 infants who survived after PDA ligation, 50 (53%) had neurosensory impairment, compared with 84 of the 245 infants (34%) who survived after receiving only medical therapy (adjusted odds ratio, 1.98; 95% CI, 1.18-3.30; P = .0093). BPD (adjusted odds ratio, 1.81; 95% CI, 1.09-3.03; P = .023) and severe ROP (adjusted odds ratio, 2.20; 95% CI, 1.19-4.07; P = .012) were also more common after surgical PDA closure.

CONCLUSIONS

PDA ligation may be associated with increased risks of BPD, severe ROP, and neurosensory impairment in ELBW infants.

Prolonged treatment with prostaglandin in an infant born with extremely low weight

We describe an infant with duct-dependent cardiac disease diagnosed prenatally who was born prematurely, and at extremely low weight. Treatment by infusion of prostaglandin maintained ductal patency for 66 days, permitting weight to be gained whilst under the care of a regional unit for neonatal intensive care prior to transfer for palliative cardiac surgery.

Tolerance to early human milk feeding is not compromised by indomethacin in preterm infants with persistent ductus arteriosus

AIM

Early human milk feeding is beneficial for gut and brain development. Persistent ductus arteriosus (PDA) and indomethacin may compromise enteral function in preterm infants. For many years enteral milk feedings have continued in preterm infants receiving indomethacin for PDA. The aim of this study was to investigate whether this strategy is efficient in terms of risks and tolerance to early enteral feeding.

METHODS

This retrospective study included 64 inborn infants of <29 wk gestational age (GA), 32 infants who received indomethacin for symptomatic PDA (case infants) and 32 matched controls. Case infants had a mean (SD) GA of 26.3 wk (1.3) and body weight 839 g (203) versus controls GA 26.4 wk (1.2) and body weight 896 g (213) (p = 0.82 and 0.27, respectively). Case infants had higher respiratory morbidity; 90.6% versus 50% of controls needed mechanical ventilation (p = 0.000).

RESULTS

Case infants received human milk from a median (range) age of 4.0 h (1.5-27.5), and controls from 5.3 h (2.0-38.0) (p = 0.092). The first dose of indomethacin was given at a mean age of 1.7 d (1.0). There were no differences between the two groups in feeding volumes or gastric residuals on days 1 to 7. Mean (SD) feeding volume on day 7 was 64 ml/kg (31) in case infants and 76 ml/kg (30) in controls (p = 0.23). Four infants developed necrotizing enterocolitis: two case infants and two controls (p = 1.00).

CONCLUSION

Early enteral feeding with human milk, starting within the first hours of life, seems to be as well tolerated in preterm infants treated with indomethacin for PDA as in their matched controls.

Necrotizing enterocolitis and gastrointestinal complications after indomethacin therapy and surgical ligation in premature infants with patent ductus arteriosus

BACKGROUND

Indomethacin is the most frequently used pharmacological agent for closure of a patent ductus arteriosus (PDA) in premature infants. However, reports of complications, particularly, necrotizing enterocolitis (NEC) and isolated gastrointestinal perforation have generated concerns about the use of this medication.

OBJECTIVES

A retrospective study to compare the incidence of NEC, NEC-related gastrointestinal complications and isolated gastrointestinal perforation among premature infants treated for a PDA with either, indomethacin alone (I), surgical ligation alone (L), or indomethacin followed by surgical ligation (I-L).

METHODS

The medical records of 224 infants that underwent treatment, either pharmacological or surgical, for a PDA, confirmed by echocardiography, over a 4-year period (1995 to 1998) were analyzed. Treatment history and gastrointestinal complications were reviewed.

RESULTS

Of the 224 infants, 108 (48.2%) were treated with I, 50 (22.3%) by L, 66 (29.5%) with I-L. The clinical characteristics of the three treatment groups were similar and no differences in the incidence of NEC were observed between groups. NEC occurred in 14 (13%) of the I group, seven (14%) of the L group, and eight (12%) of the I-L group. The rate of NEC related gastrointestinal complications and isolated gastrointestinal perforation were also similar among groups.

CONCLUSION

In this large retrospective study, indomethacin treatment for a significant PDA in premature infants was not associated with a greater risk for NEC or NEC-related gastrointestinal complications than surgical ligation.

Patent ductus arteriosus in very low birthweight infants: complications of pharmacological and surgical treatment

AIMS

To evaluate complications of surgical and pharmacological treatment of symptomatic patent ductus arteriosus (PDA) in very low birthweight (VLBW) infants.

PATIENTS AND METHODS

Of 931 VLBW infants consecutively admitted 1987-1998, a significant PDA prompted first-choice treatment by indomethacin in 101 infants, and surgery in 55 infants. PDA closed or became asymptomatic after indomethacin in 64 patients (63%), while 34 went on to surgery. PDA closure was achieved in all 61 infants after ligation and in 26 of 28 infants after clipping.

RESULTS

Transient renal impairment after indomethacin treatment was recorded in 40 of 101 infants (40%), compared to renal impairment in 9 of 55 infants (16%) undergoing surgery without prior indomethacin. No differences in necrotizing enterocolitis and intracranial hemorrhage rates were seen. Air leak occurred in 6 of 89 infants after surgery, two of which had fatal tension pneumothorax. Intraoperative hemorrhage requiring emergency transfusion occurred in 2 infants, wound infection occurred in 2 infants and phrenic palsy in one infant. Based on an intention-to-treat analysis, the overall fatality rates were 16 of 101 (16%) for indomethacin and 14 of 55 (25%) for surgery.

CONCLUSIONS

Despite the short-comings inherent to retrospective analyses, we propose that surgery should be reserved for infants not responding to pharmacological PDA closure.

Cost-effectiveness of prophylactic indomethacin in very-low-birth-weight infants

OBJECTIVE

To perform cost-effectiveness analysis to facilitate the decision-making process surrounding use of indomethacin in preterm infants to lower the incidence of patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH), and death.

METHODS

A MEDLINE literature search from 1966 to July 2000 was performed to identify relevant randomized, controlled trials (RCTs), as well as cohort and retrospective case-control studies. A decision tree was built representing the choice to use or not use indomethacin, and the potential outcome costs. Probabilities of being in each chance node were obtained from this search. Where data probabilities were not clear, a sensitivity analysis was conducted.

RESULTS

There was no difference in the expected survival per year; however, there was a significant difference when effectiveness was measured as quality-adjusted life years (QALYs), resulting in 11 and 10 years for the indomethacin and control groups, respectively. The indomethacin treatment cost was $95,157 and that of the control groups was $99,955. The cost effectiveness per life expectancy of being in the indomethacin and control groups was $7142 and $7727, respectively. The sensitivity analysis for PDA closure and prevention of IVH for infants eventually developing PDA versus those without PDA showed no difference. The cost-effectiveness analysis per QALY was $8443 for the indomethacin treatment and $9168 for the control group.

CONCLUSIONS

The prophylactic use of indomethacin is less costly and more effective within an important range of certainty. However, this analysis does not include several potentially confounding factors, such as antenatal steroid use or indomethacin-induced renal toxicity. Depending on the frequency with which these factors arise, economic projections may be considerably altered against the early use of indomethacin.

Indomethacin-associated bowel perforations: a study of possible risk factors

BACKGROUND

The association between indomethacin administration and bowel perforation in premature infants is well known. The goal of this study was to examine possible risk factors for this complication.

METHODS

Fifteen cases of indomethacin-associated bowel perforation occurred from 1993 to 1996. All had a birth weight < or = 1,100 g. These patients were compared with a control group of 51 infants who were cared for contemporaneously, had birth weights < or = 1,100 g and received indomethacin.

RESULTS

Survival rate in the control group was 96%. For the group with perforations, it was 53%. Two types of perforation were seen, one occurring in the setting of necrotizing enterocolitis, and the other, a simple perforation in an otherwise normal-appearing bowel. For the latter group, the survival rate was 86%, and, when possible, primary repair was the procedure of choice. Use of aminophylline was greater in the control group. Otherwise, there were no significant differences between the two groups in any of the variables observed. However, when the simple perforations were observed separately, these patients had, on average, received indomethacin at a younger age than the controls (P < .05). The clustering of perforation cases from May through August suggests an infectious agent might be involved.

CONCLUSIONS

Earlier administration of indomethacin correlates with an increased risk of focal perforation. It is unclear, however, whether the risk factor is the drug itself or the earlier need for it. Aminophylline use was somewhat more in the control group, but this is not likely to reflect a protective role for that drug. The possible involvement of an infectious agent should be considered.

Ligation of medically refracted patent ductus arteriosus (PDA) in an extremely low body weight premature infant

Medically refracted patent ductus arteriosus (PDA) in an extremely low birth weight (ELBW) preterm (gestation 24 weeks 2 days) infant was successfully ligated under general anesthesia in the neonatal intensive care unit (NICU). Pharmacological agents are more effective to close PDA in preterm infants than in full-term infants, although within 48 h three doses of indomethacin were not sufficient to close PDA in this case. At the age of 69 h the infant developed severe symptoms including bradycardia, systemic hypotension, pulmonary hypertension, diastolic steal (reverse distal aorta flow velocity), and anuria. A PDA ligation was thus performed surgically at 72 h of age. General anesthesia and surgical stress were tolerated by this 531 g infant. Postoperatively all symptoms improved dramatically and the general conditions were stable. On the 38th day the endotracheal tube was extubated and on the 50th day nasogastric milk feeding was started. The oxygen supply was weaned on the 78th day. Growth and development until 6 months were within the normal range of very low birth weight infants. A surgical ligation as early as possible in medically refracted PDA in an ELBW infant is thus considered to be a safe and effective treatment. It prevents the development of further complications of cardiopulmonary vascular problems. Color Doppler echocardiography can reliably measure the PDA size, flow velocity, and hemodynamic changes of persistent PDA, even in tiny infants.