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Koo J, Torres N, Katheria A. Early Echocardiographic Predictors of Eventual Need for Patent Ductus Arteriosus Treatment: A Retrospective Study. Am J Perinatol 2024; 41:1673-1679. [PMID: 38237629 DOI: 10.1055/a-2249-1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Hemodynamically significant patent ductus arteriosus (hsPDA) in preterm neonates is associated with end-organ injury including intraventricular hemorrhage. Early treatment may reduce morbidities but may result in overtreatment. This study aimed to examine the association between commonly obtained echocardiographic markers within the first 12 hours of life and eventual treatment of an hsPDA. STUDY DESIGN Patients with <32 weeks' gestational age had blinded echocardiograms done within the first 12 hours of life as part of research protocols. Subsequent treatment of the patent ductus arteriosus (PDA) was determined by the clinical team independent of echocardiogram results. t-tests and chi-square tests were done for continuous data and categorical outcomes. A receiver operating curve was created to optimize cutoff values. RESULTS Among 199 neonates studied (mean time of echocardiogram 6.7 h after birth), those needing PDA treatment had higher left ventricular output (LVO), right ventricular output (RVO), and superior vena cava (SVC) flow (p-values 0.007, 0.044, and 0.012, respectively). Cutoffs for predicting PDA treatment were LVO > 204 mL/kg/min (63% sensitivity, 66% specificity), RVO > 221 mL/kg/min or SVC flow > 99 mL/kg/min (sensitivities 70 and 43%, specificities 48 and 73%, respectively). CONCLUSION Preterm neonates with higher markers of cardiac output in the first 12 hours of birth later required PDA treatment. These data are the first to use standard cardiac output measures in the first 12 hours of life to predict the need for future PDA treatment. Further prospective studies will need to be performed to corroborate these associations between echocardiographic markers and clinical outcomes/morbidities. KEY POINTS · Early diagnosis of hsPDA may prevent severe morbidity and death.. · There are echocardiographic markers beyond duct size and flow direction that may aid early diagnosis.. · Cardiac output markers within the first 12 hours of life may predict need for treatment of hsPDA..
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Affiliation(s)
- Jenny Koo
- Department of Neonatology, Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, California
| | - Nohemi Torres
- Department of Pediatric Cardiology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, California
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de Waal K, Prasad R, Kluckow M. Patent ductus arteriosus management and the drift towards therapeutic nihilism - What is the evidence? Semin Fetal Neonatal Med 2021; 26:101219. [PMID: 33653600 DOI: 10.1016/j.siny.2021.101219] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The published literature on patent ductus arteriosus (PDA) management is challenging to interpret due to poorly designed trials with high rates of open label treatments, homogenisation of patients with varying physiological subtypes, poor treatment efficacy, and spontaneous closure in more mature infants. The perceived lack of clinical benefit has led to a drift away from medical and surgical treatment of all infants with a PDA. This therapeutic nihilism as a default response to PDA management fails to recognise the physiological relevance of a left-to-right shunt with early haemodynamic instability after birth and subsequent pulmonary volume overload with prolonged exposure. Clinicians need to know if therapeutic nihilism is safe. This review will provide an overview of the available data on the efficacy of known PDA treatments, conservative management and supportive care measures that are currently applied.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Rahul Prasad
- Randwick Children's Hospital Department of Neonatology, Sydney, NSW, Australia
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
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Hundscheid T, Jansen EJS, Onland W, Kooi EMW, Andriessen P, de Boode WP. Conservative Management of Patent Ductus Arteriosus in Preterm Infants-A Systematic Review and Meta-Analyses Assessing Differences in Outcome Measures Between Randomized Controlled Trials and Cohort Studies. Front Pediatr 2021; 9:626261. [PMID: 33718300 PMCID: PMC7946967 DOI: 10.3389/fped.2021.626261] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/14/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aims to evaluate outcome after conservative management (no pharmacological/surgical intervention other than fluid restriction, diuretics, or ventilator adjustments) compared with active (pharmacological and/or surgical) treatment for patent ductus arteriosus (PDA) in preterm infants and analyze differences in outcome between randomized controlled trials (RCTs) and cohort studies. Study Design: This is a systematic literature review using PubMed, EMBASE, and Cochrane library. RCTs and cohort studies comparing conservative management with active treatment were included. Meta-analysis was used to compare conservative management with any active (pharmacological and/or surgical), any pharmacological (non-prophylactic and prophylactic), and/or surgical treatment for mortality as primary and major neonatal morbidity as secondary outcome measure. Fixed-effect analysis was used, unless heterogeneity (I 2) was >50%. Outcome is presented as relative risk (RR) with 95% confidence interval. Results: Twelve cohort studies and four RCTs were included, encompassing 41,804 and 720 patients, respectively. In cohort studies, conservative management for PDA was associated with a significantly higher risk for mortality (RR, 1.34 [1.12-1.62]) but a significantly lower risk for bronchopulmonary dysplasia (RR, 0.55 [0.46-0.65]), necrotizing enterocolitis (RR, 0.85 [0.77-0.93]), intraventricular hemorrhage (RR, 0.88 [0.83-0.95]), and retinopathy of prematurity (RR, 0.47 [0.28-0.79]) compared with any active PDA treatment. Meta-analysis of the RCTs revealed no significant differences in outcome between conservative management and active treatment. Conclusion: No differences in mortality or morbidity for conservative management compared with active treatment regimens were observed in RCTs. Findings from cohort studies mainly highlight the lack of high-quality evidence for conservative management for PDA in preterm infants.
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Affiliation(s)
- Tim Hundscheid
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Esther J S Jansen
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Wes Onland
- Department of Neonatology, Amsterdam University Medical Centers, VU University Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands
| | - Elisabeth M W Kooi
- Division of Neonatology, University Medical Center Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, Netherlands
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Center Veldhoven, Eindhoven, Netherlands.,Department of Applied Physics, School of Medical Physics and Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
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Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
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Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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Berenstein A, Paramasivam S, Sorscher M, Molofsky W, Meila D, Ghatan S. Vein of Galen Aneurysmal Malformation: Advances in Management and Endovascular treatment. Neurosurgery 2019; 84:469-478. [PMID: 29860355 DOI: 10.1093/neuros/nyy100] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 05/26/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Vein of Galen aneurysmal malformation (VGAM) is a rare congenital vascular malformation representing <1% of all arteriovenous malformations. The knowledge and strategies in the management are constantly evolving. OBJECTIVE To review our series of postneonatal VGAM patients treated over 11-yr period. METHODS Retrospective analysis of 113 VGAM treated between January 2004 and April 2015. After exclusions, 45 patients were included: 33 choroidal and 12 mural types. RESULTS Presenting symptom in the order of frequency: enlarged head circumference, antenatal diagnosis, mild CHF, and PHT at birth. Older patients were diagnosed following trauma, headache, cognitive decline, and incidentally during workup for other diseases. Hydrocephalus due to hydrodynamic disorder was present in 70% of choroidal and 58% of mural types. Only a quarter needed cerebrospinal fluid diversion procedure. Radiological cure was achieved in 82%; the outcome graded on a 5-point scale: 0 (death) to 4 (normal). A total of 66.6% are neurologically and developmentally intact with outcome score 4, 20% had outcome score of 3, and 8.9% had outcome score of 2. There was 4.4% mortality. Dural feeders to VGAM were found either in the initial or during the treatment in 22.2% in the current series. Angiogenesis from pial vessels developed after partial embolization in 17.7% that resolved completely following complete obliteration of VGAM. CONCLUSION Technical and technological advancements in endovascular embolization along with better understanding of clinical, anatomic, and pathophysiological aspects have resulted in significantly improved outcome and prognosis in VGAM. Most patients with proper treatment can now survive and most develop normally following appropriately timed treatment.
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Affiliation(s)
- Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Srinivasan Paramasivam
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Michelle Sorscher
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Walter Molofsky
- Depa-rtment of Neurology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Dan Meila
- Hannover Medical School, Institute of Neuroradiology, Hannover, Germany
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
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Ding Y, Wang X, Wu Y, Li H, Xu J, Wang X. Effects of prophylactic oral ibuprofen on the closure rate of patent ductus arteriosus in premature infants. Medicine (Baltimore) 2018; 97:e12206. [PMID: 30212951 PMCID: PMC6155941 DOI: 10.1097/md.0000000000012206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to investigate the effects of prophylactic oral ibuprofen on the closure rate of patent ductus arteriosus (PDA).This was a retrospective study and data on infants born before 36 weeks were collected. The prophylactic group was treated with ibuprofen (10, 5, and 5 mg/kg) from days 1 to 3 after birth, respectively. The conventional group was treated with the same dose of ibuprofen from days 4 to 6 once they were echocardiographically confirmed with PDA on day 3 after birth. The placebo group was treated with 5% glucose.The closure rate of PDA in the prophylactic group significantly increased on day 7 compared with the placebo group (P = .02), but showed no difference compared with the conventional group (P = .12). Serum NT-proBNP in the prophylactic and conventional groups decreased compared with the placebo group (P = .03 vs P = .07).Prophylactic oral ibuprofen can increase the closure rate of PDA in premature infants; however, it showed no significant advantages compared with conventional treatment. Serum NT-proBNP can be used to observe PDA treatment responses in premature infants.
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Mileder LP, Müller T, Baik-Schneditz N, Pansy J, Schwaberger B, Binder-Heschl C, Urlesberger B, Pichler G. Influence of ductus arteriosus on peripheral muscle oxygenation and perfusion in neonates. Physiol Meas 2017; 39:015003. [DOI: 10.1088/1361-6579/aa9c3b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Sallmon H, Koehne P, Hansmann G. Recent Advances in the Treatment of Preterm Newborn Infants with Patent Ductus Arteriosus. Clin Perinatol 2016; 43:113-29. [PMID: 26876125 DOI: 10.1016/j.clp.2015.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A patent ductus arteriosus (PDA) is associated with several adverse clinical conditions. Several strategies for PDA treatment exist, although data regarding the benefits of PDA treatment on outcomes are sparse. Moreover, the optimal treatment strategy for preterm neonates with PDA remains subject to debate. It is still unknown whether and when PDA treatment should be initiated and which approach (conservative, pharmacologic, or surgical) is best for individual patients (tailored therapies). This article reviews the current strategies for PDA treatment with a special focus on recent developments such as oral ibuprofen, high-dose regimens, and the use of paracetamol (oral, intravenous).
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Affiliation(s)
- Hannes Sallmon
- Department of Neonatology, Charité University Medical Center, Augustenburger Platz 1, Berlin 13353, Germany
| | - Petra Koehne
- Department of Neonatology, Charité University Medical Center, Augustenburger Platz 1, Berlin 13353, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
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Abstract
Optimal management of the patent ductus arteriosus (PDA) in the premature infant remains controversial. Despite considerable historical and physiological data indicating that a persistent PDA may be harmful, robust evidence of long-term benefits or harms from treatment is lacking. This has been equated to a lack of benefit but is also a reflection of the fact that most clinical trials were designed to assess the effects of short-term (2-8 days) rather than prolonged exposure to a PDA. No clinical trials have been designed to assess the effects of prolonged exposure of persistent PDA on morbidity and mortality of very premature infants in the era of antenatal corticosteroids, surfactant and non-invasive respiratory support. Further research is required, but new insights and novel therapies are evolving, which will allow greater individual patient assessment, understanding of risk and optimisation of treatment. In this paper, we review the current literature, evidence for treatment options, including a non-interventional approach, and research directions for infants <28 weeks' gestational age.
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Affiliation(s)
- Anne Marie Heuchan
- Department of Neonatology, Royal Hospital for Sick Children, Glasgow, UK
| | - Ronald I Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California, San Francisco, USA
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