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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. [PMID: 38237629 DOI: 10.1055/a-2249-1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Surak A, Sidhu A, Ting JY. Should we "eliminate" PDA shunt in preterm infants? A narrative review. Front Pediatr 2024; 12:1257694. [PMID: 38379909 PMCID: PMC10876852 DOI: 10.3389/fped.2024.1257694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
The patent ductus arteriosus frequently poses a significant morbidity in preterm infants, subjecting their immature pulmonary vascular bed to substantial volume overload. This, in turn, results in concurrent hypoperfusion to post-ductal organs, and subsequently alters cerebral blood flow. In addition, treatment has not demonstrated definitive improvements in patient outcomes. Currently, the optimal approach remains a subject of considerable debate with ongoing research controversy regarding the best approach. This article provides a comprehensive review of existing literature.
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Affiliation(s)
- Aimann Surak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Amneet Sidhu
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Joseph Y. Ting
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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3
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Liguori MB, Ali SKM, Bussman N, Colaizy T, Hundscheid T, Phad N, Clyman R, de Boode WP, de Waal K, El-Khuffash A, Gupta S, Laughon M. Patent Ductus Arteriosus in Premature Infants: Clinical Trials and Equipoise. J Pediatr 2023; 261:113532. [PMID: 37269903 DOI: 10.1016/j.jpeds.2023.113532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Macrina B Liguori
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sanoj K M Ali
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar
| | - Neidín Bussman
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Tarah Colaizy
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Tim Hundscheid
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Ronald Clyman
- Department of Pediatrics and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Willem-Pieter de Boode
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar; Department of Neonatology, Durham University, Durham, United Kingdom
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Huang CP, Hung YL, Hsieh WS, Shen CM. Fresh Frozen Plasma Transfusion: An Independent Risk Factor for Hemodynamically Significant Patent Ductus Arteriosus in Premature Infants. Am J Perinatol 2022; 39:1426-1432. [PMID: 33486746 DOI: 10.1055/s-0040-1722649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The incidence of patent ductus arteriosus (PDA), a major complication of prematurity, may be reduced by restricting fluid administration. Prophylactic fresh frozen plasma (FFP) transfusion may reduce the incidence of intraventricular hemorrhage in these infants, but risks transfusion-related volume overload. We conducted a retrospective study to investigate whether FFP transfusion is a risk factor for hemodynamically significant PDA (hsPDA) in very low birth weight (BW) premature infants. STUDY DESIGN From January 2009 to December 2014, 102 premature infants with gestational age (GA) less than or equal to 30 weeks were admitted to a level III neonatal intensive care unit, and 88 patients were enrolled. Patients were further divided into non-hsPDA (n = 29) and hsPDA groups (n = 59). We retrospectively reviewed demographic characteristics and various perinatal and postnatal variables. Univariate and multivariable analyses were performed to identify risk factors for hsPDA. RESULTS Compared with non-hsPDA patients, hsPDA patients had lower mean BW and GA, a higher incidence of severe respiratory distress symptoms, perinatal infection, use of surfactant, and need for FFP transfusion. However, multivariable logistic regression analysis showed that only FFP transfusion remained an independent risk factor for hsPDA (adjusted odds ratio = 3.880, 95% confidence interval: 1.214-12.402, p = 0.022) after adjusting for confounding factors. CONCLUSION FFP transfusion is a significant risk factor for the subsequent development of hsPDA in our study population. FFP transfusion may complicate the fluid management of premature infants and increase the risk of hsPDA. KEY POINTS · Hemodynamic significant PDA is an important complication of preterm infant.. · FFP transfusion may complicate the fluid management of premature infants.. · FFP transfusion is an independent risk factor for hsPDA in very low birth weight premature infants..
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Affiliation(s)
- Chun-Pin Huang
- Department of Pediatrics, Cathay General Hospital, Hsinchu Branch, Hsinchu, Taiwan.,Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Yi-Li Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Children's Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-Min Shen
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.,School of Medical, Fu-Jen Catholic University, Taipei, Taiwan
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Katsaras DN, Katsaras GN, Chatziravdeli VI, Papavasileiou GN, Touloupaki M, Mitsiakos G, Doxani C, Stefanidis I, Dardiotis E. Comparative safety and efficacy of paracetamol versus non-steroidal anti-inflammatory agents in neonates with patent ductus arteriosus: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2022; 88:3078-3100. [PMID: 35203104 DOI: 10.1111/bcp.15291] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
AIM Ibuprofen and indomethacin are the preferred drug treatment for patent ductus arteriosus (PDA) in preterm neonates. The comparative safety and efficacy of paracetamol as an alternative has not yet been well-established. The aim of our study was to define the comparative efficacy and safety of paracetamol versus ibuprofen and indomethacin for PDA METHODS: We performed a systematic literature search in Pubmed, Scopus and Cochrane databases on randomized controlled trials comparing the efficacy and/or the safety of paracetamol versus ibuprofen and/or indomethacin and meta-analyzed the available data. RESULTS There were 1718 neonates from 20 eligible studies. Paracetamol did not differ from ibuprofen or indomethacin regarding the primary [OR: 0.93 (95% CI: 0.69-1.26), p-value: 0.650, when compared to ibuprofen, and OR: 0.78 (95% CI: 0.20-3.02), p-value: 0.716, when compared to indomethacin] and overall [OR: 1.17 (95% CI: 0.82-1.66), p-value: 0.394, when compared to ibuprofen, and OR: 1.12 (95% CI: 0.58-2.15), p-value: 0.733, when compared to indomethacin] PDA closure rates. Paracetamol resulted in significantly reduced risk of oliguria and a tendency towards less gastrointestinal bleeding. CONCLUSION There was no significant difference between paracetamol and ibuprofen or indomethacin in the PDA closure rates. However, paracetamol caused less adverse effects.
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Affiliation(s)
- Dimitrios N Katsaras
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece.,Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.,Sixth Cardiology Department, "Hygeia" Hospital, Marousi, Athens, Greece
| | - Georgios N Katsaras
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece.,Second Neonatal Department and Neonatal Intensive Care Unit, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece.,Paediatric Department, General Hospital of Pella - Hospital Unit of Edessa, Edessa, Greece
| | | | | | - Maria Touloupaki
- Sixth Cardiology Department, "Hygeia" Hospital, Marousi, Athens, Greece
| | - Georgios Mitsiakos
- Second Neonatal Department and Neonatal Intensive Care Unit, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Chrysoula Doxani
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece
| | - Ioannis Stefanidis
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece.,Department of Nephrology, University of Thessaly School of Medicine, Larissa, Greece
| | - Efthimios Dardiotis
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece.,Department of Neurology, Laboratory of Neurogenetics, University Hospital of Larissa, University of Thessaly School of Medicine, Larissa, Greece
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Schreiner C, Sappler M, Höck M, Hammerl M, Neubauer V, Kiechl-Kohlendorfer U, Griesmaier E. Prophylactic Low-Dose Paracetamol Administration for Ductal Closure and Amplitude-Integrated Electroencephalography in Preterm Infants. Front Pediatr 2022; 10:887614. [PMID: 35676901 PMCID: PMC9168321 DOI: 10.3389/fped.2022.887614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/04/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Prophylactic low-dose paracetamol administration is used to induce closure of the ductus arteriosus in preterm infants. In our recent study we found no impairment on microstructural maturation processes in the brain of preterm infants at term-equivalent age following prophylactic low-dose paracetamol administration. We now assessed amplitude-integrated electroencephalography (aEEG) signals in preterm infants with and without exposure to prophylactic low-dose paracetamol administration. METHODS Infants <32 gestational weeks born between 10/2014 and 12/2018 received prophylactic paracetamol (10 mg/kg intravenously every 8 h until echocardiography after at least 72 h) and form the paracetamol group; infants born between 02/2011 and 09/2014 formed the control group. Four single parameters (continuity, cyclicity, amplitude of lower border, bandwidth span) together with their sum (Burdjalov total score) and presence of sleep-wake cycles were compared between the groups. RESULTS Included in the study were 338 infants. Two-hundred and seventeen infants received prophylactic paracetamol and 121 formed the control group. The paracetamol group showed a significantly higher number of sleep-wake cycles per hour and a significantly higher total scores compared to the control group (p < 0.05). CONCLUSION Paracetamol exposure has been regarded critically with respect to safety in preterm infants in recent years. We found no impairment on amplitude-integrated electroencephalography signals in preterm infants receiving low-dose prophylactic paracetamol compared to controls. Growing awareness and greater availability of data may encourage the clinicians to administer prophylactic paracetamol for ductal closure in preterm infants. The clinical relevance of our findings has to be evaluated in long-term follow up studies on neurodevelopmental outcome.
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Affiliation(s)
- Christina Schreiner
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Sappler
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Höck
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Marlene Hammerl
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Vera Neubauer
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elke Griesmaier
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
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7
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Korkmaz L, Ozdemir A, Pamukçu Ö, Güneş T, Ozturk MA. Which Inotropic Drug, Dobutamine or Milrinone, Is Clinically More Effective in the Treatment of Postligation Cardiac Syndrome in Preterm Infants? Am J Perinatol 2022; 39:204-215. [PMID: 32781477 DOI: 10.1055/s-0040-1715118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to detect which of the two main medicines suggested in the treatment of postligation cardiac syndrome (PLCS)-dobutamine or mirinone-possesses a more therapeutic effect. While doing this, clinicians are provided with a broader perspective on the treatment and follow-up of cases. The desire was to increase the treatability and monitor ability of the cases in question and hence their survivability. STUDY DESIGN A retrospective review of a cohort of infants with PLCS was conducted between March 2012 and December 2018. In the treatment of infants with PLCS, dobutamine (dobutamine study group-DSG) or milrinone (milrinone study group-MSG) was used. The respiration, cardiac, echocardiography, and perfusion parameters of the cases were assessed both before and after ligation. Based on the data obtained, both the effects of the medicines on PLCS and the difference between their therapeutic effects were studied. The accuracy of prognostication was assessed with receiver operating characteristic analyses. RESULTS PLCS was detected in 29 (34.1%) of 85 patent ductus arteriosus ligation cases in total. Of all the PLCS cases, 13 (44.8%) were treated with dobutamine and 16 (55.2%) with milrinone. It was observed that the effects of the medicines on the respiratory system and cardiovascular system manifested in the third and 6th hour, respectively. It was detected that both medicines had more effect on the systolic blood pressure (SBP) (area under the curve [AUC]: 0.997/0.996, p = 0.001/0.002) than on the diastolic blood pressure (AUC: 0.911/0.843, p = 0.032/0.046). CONCLUSION Dobutamine and milrinone, two primary medicines that can be used in the treatment of cases with PLCS, possess similar therapeutic effects on this pathology. In addition, their postoperative therapeutic effects on the SBP are more in the foreground.
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Affiliation(s)
- Levent Korkmaz
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Ahmet Ozdemir
- Neonatology Unit, Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Özge Pamukçu
- Division of Pediatric Cardiology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Tamer Güneş
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Mehmet Adnan Ozturk
- Division of Neonatology, Department of Pediatrics, Erciyes University Medical Faculty, Kayseri, Turkey
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8
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Abstract
Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.
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Mitra S, Jain A, Ting JY, Ben Fadel N, Drolet C, Abou Mehrem A, Soraisham A, Jasani B, Louis D, Lapointe A, Dorling J, Khurshid F, Hyderi A, Kumaran K, Bodani J, Weisz D, Alvaro R, Adie M, Stavel M, Morin A, Bhattacharya S, Kanungo J, Canning R, Ye XY, Hatfield T, Gardner CE, Shah P. Relative effectiveness and safety of pharmacotherapeutic agents for patent ductus arteriosus (PDA) in preterm infants: a protocol for a multicentre comparative effectiveness study (CANRxPDA). BMJ Open 2021; 11:e050682. [PMID: 33952559 PMCID: PMC8103361 DOI: 10.1136/bmjopen-2021-050682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) is the most common cardiovascular problem that develops in preterm infants and evidence regarding the best treatment approach is lacking. Currently available medical options to treat a PDA include indomethacin, ibuprofen or acetaminophen. Wide variation exists in PDA treatment practices across Canada. In view of this large practice variation across Canadian neonatal intensive care units (NICUs), we plan to conduct a comparative effectiveness study of the different pharmacotherapeutic agents used to treat the PDA in preterm infants. METHODS AND ANALYSIS A multicentre prospective observational comparative-effectiveness research study of extremely preterm infants born <29 weeks gestational age with an echocardiography confirmed PDA will be conducted. All participating sites will self-select and adhere to one of the following primary pharmacotherapy protocols for all preterm babies who are deemed to require treatment.Standard dose ibuprofen (10 mg/kg followed by two doses of 5 mg/kg at 24 hours intervals) irrespective of postnatal age (oral/intravenous).Adjustable dose ibuprofen (oral/intravenous) (10 mg/kg followed by two doses of 5 mg/kg at 24 hours intervals if treated within the first 7 days after birth. Higher doses of ibuprofen up to 20 mg/kg followed by two doses of 10 mg/kg at 24 hours intervals if treated after the postnatal age cut-off for lower dose as per the local centre policy).Acetaminophen (oral/intravenous) (15 mg/kg every 6 hours) for 3-7 days.Intravenous indomethacin (0.1-0.3 mg/kg intravenous every 12-24 hours for a total of three doses). OUTCOMES The primary outcome is failure of primary pharmacotherapy (defined as need for further medical and/or surgical/interventional treatment following an initial course of pharmacotherapy). The secondary outcomes include components of the primary outcome as well as clinical outcomes related to response to treatment or adverse effects of treatment. SITES AND SAMPLE SIZE The study will be conducted in 22 NICUs across Canada with an anticipated enrollment of 1350 extremely preterm infants over 3 years. ANALYSIS To examine the relative effectiveness of the four treatment strategies, the primary outcome will be compared pairwise between the treatment groups using χ2 test. Secondary outcomes will be compared pairwise between the treatment groups using χ2 test, Student's t-test or Wilcoxon rank sum test as appropriate. To further examine differences in the primary and secondary outcomes between the four groups, multiple logistic or linear regression models will be applied for each outcome on the treatment groups, adjusted for potential confounders using generalised estimating equations to account for within-unit-clustering. As a sensitivity analysis, the difference in the primary and secondary outcomes between the treatment groups will also be examined using propensity score method with inverse probability weighting approach. ETHICS AND DISSEMINATION The study has been approved by the IWK Research Ethics Board (#1025627) as well as the respective institutional review boards of the participating centres. TRIAL REGISTRATION NUMBER NCT04347720.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, IWK Heath Centre & Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amish Jain
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Joseph Y Ting
- Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Christine Drolet
- Centre Hospitalier de l'Université Laval, Quebec City, Québec, Canada
| | | | | | - Bonny Jasani
- Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deepak Louis
- Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Anie Lapointe
- Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Faculty of Medicine, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Abbas Hyderi
- Stollery Children Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Kumar Kumaran
- Stollery Children Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jaya Bodani
- Regina General Hospital, Regina, Saskatchewan, Canada
| | - Dany Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ruben Alvaro
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Miroslav Stavel
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Alyssa Morin
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Soume Bhattacharya
- Western University, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Jaideep Kanungo
- Victoria General Hospital, Victoria, British Columbia, Canada
| | - Rody Canning
- Moncton Hospital, Moncton, New Brunswick, Canada
| | - Xiang Y Ye
- MiCare Research Center, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tara Hatfield
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, IWK Heath Centre & Dalhousie University, Halifax, Nova Scotia, Canada
| | - Courtney E Gardner
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, IWK Heath Centre & Dalhousie University, Halifax, Nova Scotia, Canada
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Comparison of standard versus high-dose ibuprofen for the treatment of hemodynamically significant patent ductus arteriosus in preterm infants. J Perinatol 2021; 41:1142-1148. [PMID: 33795792 DOI: 10.1038/s41372-021-01046-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/17/2021] [Accepted: 03/11/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of standard vs. high-dose ibuprofen for the treatment of hemodynamically significant patent ductus arteriosus(hs-PDA). STUDY DESIGN A retrospective study of preterm infants who received either standard (10-5-5 mg/kg/day) or high (postnatal age 1-3 days: 10-5-5 mg/kg/day; 3-5 days: 15-7.5-7.5 mg/kg/day; >5 days: 20-10-10 mg/kg/day) dose ibuprofen for hs-PDA was conducted. RESULT Sixty preterm infants with a mean birthweight of 898.2 (±262.6) g and mean gestational age of 26.3 (±0.6) weeks were included. High-dose ibuprofen was associated with a 21%(95% CI, -1.87 to 39.06%; p = 0.07) absolute reduction in PDA ligation compared to standard-dose ibuprofen. On adjusted analysis, receipt of standard-dose ibuprofen (OR 7.37, 95% CI, 1.2-45.27; p = 0.03) independently predicted increased PDA ligation risk. There were no differences in oliguria, NEC, or BPD between groups. CONCLUSION High-dose ibuprofen may significantly reduce PDA ligations. No difference in the safety profile with high-dose ibuprofen as compared to the standard-dose regimen was demonstrated.
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Vaidya R, Knee A, Paris Y, Singh R. Predictors of successful patent ductus arteriosus closure with acetaminophen in preterm infants. J Perinatol 2021; 41:998-1006. [PMID: 32879417 PMCID: PMC7463098 DOI: 10.1038/s41372-020-00803-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Evaluate predictors of successful PDA closure following acetaminophen treatment. STUDY DESIGN Retrospective cohort study of ≤30 weeks GA infants born from 1 January 2013-30 September 2019, and treated with single course acetaminophen by symptomatic PDA treatment strategy. Multiple maternal and neonatal variables were identified as potential predictors. Univariate analysis and multivariable regression models were applied to evaluate the strongest predictors. RESULTS Sixty-six patients were included, 28 (42.4%) had successful PDA closure following acetaminophen. Success was associated with GA > 26 weeks (65% vs. 33%, AUC = 0.64), birthweight >750 g (53% vs. 32%, AUC = 0.61), PDA size ≤0.2 cm (63% vs. 32%, AUC = 0.64), and no prior indomethacin use (56% vs. 33%, AUC = 0.61). Multivariable model identified GA > 26 weeks (RR = 1.92, CI 1.20-3.09) and PDA size ≤0.2 cm (RR: 1.82, CI 1.11-2.98) as the strongest predictors. CONCLUSION Acetaminophen may be more successful in targeted PDA closure in >26 weeks GA infants with PDA size ≤0.2 cm.
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Affiliation(s)
- Ruben Vaidya
- Division of Newborn Medicine, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA, 01199, USA.
| | - Alexander Knee
- grid.266683.f0000 0001 2184 9220Epidemiology and Biostatistics Research Core, Office of Research, Baystate Medical Center, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA ,grid.266683.f0000 0001 2184 9220Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
| | - Yvonne Paris
- grid.266683.f0000 0001 2184 9220Division of Pediatric Cardiology, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
| | - Rachana Singh
- grid.266683.f0000 0001 2184 9220Division of Newborn Medicine, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
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12
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Patra A, Thakkar PS, Makhoul M, Bada HS. Objective Assessment of Physiologic Alterations Associated With Hemodynamically Significant Patent Ductus Arteriosus in Extremely Premature Neonates. Front Pediatr 2021; 9:648584. [PMID: 33718311 PMCID: PMC7946992 DOI: 10.3389/fped.2021.648584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Delay in closure of ductus arteriosus in postnatal life may lead to serious consequences and complications in an extremely premature neonate secondary to hemodynamic alterations in regional blood flow pattern in various organs. Despite the widespread recognition amongst neonatologists to identify a hemodynamically significant patent ductus arteriosus (hsPDA) early in the postnatal course, there is lack of consensus in its definition and thus the threshold to initiate treatment. Echocardiographic assessment of PDA shunt size and volume combined with neonatologists' impression of clinical significance is most frequently used to determine the need for treatment of PDA. Common clinical signs of hsPDA utilized as surrogate for decreased tissue perfusion may lag behind early echocardiographic signs. Although echocardiogram allows direct assessment of PDA shunt and hemodynamic alterations in the heart, it is limited by dependence on pediatric cardiologist availability, interobserver variation and isolated time point assessment. Electrical cardiometry (EC) is a non-invasive continuous real time measurement of cardiac output by applying changes in thoracic electrical impedance. EC has been validated in preterm newborns by concomitant transthoracic echocardiogram assessments and may be beneficial in studying changes in cardiac output in premature newborns with hsPDA. Alterations in perfusion index derived from continuous pulse oximetry monitoring has been used to study changes in cardiac performance and tissue perfusion in infants with PDA. Near infrared spectroscopy (NIRS) has been used to objectively and continuously assess variations in renal, mesenteric, and cerebral oxygen saturation and thus perfusion changes due to diastolic vascular steal from hsPDA in preterm neonates. Doppler ultrasound studies measuring resistive indices in cerebral circulation indicate disturbance in cerebral perfusion secondary to ductal steal. With recent trends of change in practice toward less intervention in care of preterm newborn, treatment strategy needs to be targeted for select preterm population most vulnerable to adverse hemodynamic effects of PDA. Integration of these novel ways of hemodynamic and tissue perfusion assessment in routine clinical care may help mitigate the challenges in defining and targeting treatment of hsPDA thereby improving outcomes in extremely premature neonates.
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Affiliation(s)
- Aparna Patra
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Pratibha S Thakkar
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Majd Makhoul
- Division of Pediatric Cardiology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
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Gonen I, Babayigit A, Bornaun H, Yasa B, Memur S, Semerci SY, Cetinkaya M. SIMPLE: A Novel Scoring System for Predicting Hemodynamically Significant Patent Ductus Arteriosus Without Echocardiographic Evaluation in Extremely Low Birth Weight Infants. Front Pediatr 2021; 9:649515. [PMID: 33834011 PMCID: PMC8021724 DOI: 10.3389/fped.2021.649515] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: To develop a novel clinical scoring system for predicting hemodynamically significant patent ductus arteriosus (hsPDA) in extremely low birth weight (ELBW) infants. Methods: A prospective observational study was conducted among ELBW infants born in the study center during a 6-month period. Fourteen items were selected on a literature review basis and weighed by severity on an arbitrary 1-4 scale, the sum of which represented the Scoring preterm Infants for PDA cLinically without Echocardiographic evaluation (SIMPLE) score. The SIMPLE scores were compared at several time points during the first 3 days of life between two groups of patients: those with an hsPDA at echocardiography and those without. Results: A total of 48 ELBW infants were enrolled, of which 30 infants developed hsPDA. The SIMPLE scores of the infants with hsPDA were significantly greater than those of the infants who did not develop hsPDA. Cut-off SIMPLE scores that were significantly associated with detection of symptomatic hsPDA at each evaluation time point were identified. Conclusions: SIMPLE is the first scoring system that depends on the risk factors and clinical findings of ELBW infants for early prediction of hsPDA. It is simple, objective and easy to perform, and it does not require any additional tests and/or echocardiographic evaluation. We suggest that SIMPLE can be used as a screening tool for determining the need for echocardiographic evaluation in ELBW infants in order to minimize the number of unnecessary pediatric cardiology consultations.
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Affiliation(s)
- Ilker Gonen
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Aslan Babayigit
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Helen Bornaun
- Department of Pediatric Cardiology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Beril Yasa
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Seyma Memur
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Seda Yilmaz Semerci
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Merih Cetinkaya
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, Health Sciences University, Istanbul, Turkey
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14
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Lenoir M, Wanert C, Bonnet D, Méot M, Tosello B, Fouilloux V, Ovaert C, Malekzadeh-Milani S. Anterior Minithoracotomy vs. Transcatheter Closure of Patent Ductus Arteriosus in Very Preterm Infants. Front Pediatr 2021; 9:700284. [PMID: 34869092 PMCID: PMC8640484 DOI: 10.3389/fped.2021.700284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patent ductus arteriosus (PDA) is common in preterm infants and contributes to morbidity and mortality. Several studies have shown the feasibility and safety of percutaneous PDA closure. Minimally invasive surgical ligation by anterior thoracotomy is an alternative, bedside technique for PDA closure in very low birth weight preterm infants. Our study aimed to compare short- and medium-term morbidity and mortality between anterior minithoracotomy and transcatheter PDA closure. Methods: From 2010 to 2020, 92 preterm infants <1,600 g underwent PDA closure in two centers: 44 surgical anterior minithoracotomies (center 1) and 48 transcatheter closures (center 2). Using a 1:1 propensity score match analysis, 22 patients in each group were included. The primary outcome was time to extubation after intervention. Results: Preoperative characteristics were similar in both groups after propensity matching (mean weight at procedure, 1,171 ± 183 g; p = 0.8). Mean time to extubation was similar: 10 ± 15 days in the surgical group vs. 9 ± 13 days in the transcatheter group (p = 0.9). Mean age at hospital discharge was 114 ± 29 days vs. 105 ± 19 days (p = 0.2). Two deaths occurred in the surgical group and one in the transcatheter group (p = 0.61). Five complications (pneumothorax n = 2, chylothorax n = 2, phrenic nerve injury n = 1) occurred in three patients after surgery. Three complications (chylothorax n = 1, endocarditis n = 1, renal vein thrombosis n = 1) occurred in two patients after percutaneous closure (p = 0.63). Conclusion: Equivalent efficiency and safety of surgical mini-invasive vs. transcatheter PDA closure in preterm infants <1,600 g are in favor of applying these alternative techniques according to centers' facilities and competences.
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Affiliation(s)
- Marien Lenoir
- Department of Pediatric Cardiac Surgery, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Chloé Wanert
- Department of Pediatric Cardiology, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Paris, France.,University of Paris, Paris, France
| | - Mathilde Méot
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, AP-HP, Paris, France
| | - Barthélémy Tosello
- Department of Neonatology, Hôpital Nord, AP-HM, Marseille, France.,Aix-Marseille University, MMG, INSERM, Marseille, France
| | - Virginie Fouilloux
- Department of Pediatric Cardiac Surgery, Hôpital Timone Enfant, AP-HM, Marseille, France
| | - Caroline Ovaert
- Department of Pediatric Cardiology, Hôpital Timone Enfant, AP-HM, Marseille, France.,Aix-Marseille University, MMG, INSERM, Marseille, France
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15
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Mitra S, Scrivens A, von Kursell AM, Disher T. Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants. Cochrane Database Syst Rev 2020; 12:CD013278. [PMID: 33301630 PMCID: PMC8812277 DOI: 10.1002/14651858.cd013278.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is associated with significant morbidity and mortality in preterm infants. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to prevent or treat a PDA. There are concerns regarding adverse effects of NSAIDs in preterm infants. Controversy exists on whether early targeted treatment of a hemodynamically significant (hs) PDA improves clinical outcomes. OBJECTIVES To assess the effectiveness and safety of early treatment strategies versus expectant management for an hs-PDA in reducing mortality and morbidity in preterm infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 6) in the Cochrane Library; MEDLINE via PubMed (1966 to 31 May 2019), Embase (1980 to 31 May 2019), and CINAHL (1982 to 31 May 2019). An updated search was run on 2 October 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCT) and quasi-randomized trials. SELECTION CRITERIA We included RCTs in which early pharmacological treatment, defined as treatment initiated within the first seven days after birth, was compared to no intervention, placebo or other non-pharmacological expectant management strategies for treatment of an hs-PDA in preterm (< 37 weeks' postmenstrual age) or low birth weight (< 2500 grams) infants. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of Cochrane Neonatal. Our primary outcome was all-cause mortality during hospital stay. We used the GRADE approach to assess the certainty of evidence for selected clinical outcomes. MAIN RESULTS We included 14 RCTs that enrolled 910 infants. Seven RCTs compared early treatment (defined as treatment initiated by seven days of age) versus expectant management and seven RCTs compared very early treatment (defined as treatment initiated by 72 hours of age) versus expectant management. No difference was demonstrated between early treatment versus expectant management (no treatment initiated within the first seven days after birth) for an hs-PDA for the primary outcome of 'all-cause mortality' (6 studies; 500 infants; typical RR 0.80, 95% CI 0.46 to 1.39; typical RD -0.02; 95% CI -0.07 to 0.03; moderate-certainty evidence), or other important outcomes such as surgical PDA ligation (4 studies; 432 infants; typical RR 1.08, 95% CI 0.65 to 1.80; typical RD -0.03; 95% CI -0.09 to 0.03; very low-certainty evidence), chronic lung disease (CLD) (4 studies; 339 infants; typical RR 0.90, 95% CI 0.62 to 1.29; typical RD -0.03; 95% CI -0.10 to 0.03; moderate-certainty evidence), severe intraventricular hemorrhage (IVH) (2 studies; 171 infants; typical RR 0.83,95% CI 0.32 to 2.16; typical RD -0.01; 95% CI -0.08 to 0.06; low-certainty evidence), and necrotizing enterocolitis (NEC) (5 studies; 473 infants; typical RR 2.34,95% CI 0.86 to 6.41; typical RD 0.04; 95% CI 0.01 to 0.08; low-certainty evidence). Infants receiving early treatment in the first seven days after birth were more likely to receive any PDA pharmacotherapy compared to expectant management (2 studies; 232 infants; typical RR 2.30, 95% CI 1.86 to 2.83; typical RD 0.57; 95% CI 0.48 to 0.66; low-certainty evidence). No difference was demonstrated between very early treatment versus expectant management (no treatment initiated within the first 72 hours after birth) for an hs-PDA for the primary outcome of 'all-cause mortality' (7 studies; 384 infants; typical RR 0.94, 95% CI 0.58 to 1.53; typical RD -0.03; 95% CI -0.09 to 0.04; moderate-certainty evidence) or other important outcomes such as surgical PDA ligation (5 studies; 293 infants; typical RR 0.88, 95% CI 0.36 to 2.17; typical RD -0.01; 95% CI -0.05 to 0.02; moderate-certainty evidence), CLD (7 studies; 384 infants; typical RR 0.83, 95% CI 0.63 to 1.08; typical RD -0.05; 95% CI -0.13 to 0.04; low-certainty evidence), severe IVH (4 studies, 240 infants; typical RR 0.64, 95% CI 0.21 to 1.93; typical RD -0.02; 95% CI -0.07 to 0.04; moderate-certainty evidence), NEC (5 studies; 332 infants; typical RR 1.08, 95% CI 0.53 to 2.21; typical RD 0.01; 95% CI -0.04 to 0.06; moderate-certainty evidence) and neurodevelopmental impairment (1 study; 79 infants; RR 0.27, 95% CI 0.03 to 2.31 for moderate/severe cognitive delay at 18 to 24 months; RR 0.54, 95% CI 0.05 to 5.71 for moderate/severe motor delay at 18 to 24 months; RR 0.54, 95% CI 0.10 to 2.78 for moderate/severe language delay at 18 to 24 months; low-certainty evidence). Infants receiving very early treatment in the first 72 hours after birth were more likely to receive any PDA pharmacotherapy compared to expectant management (4 studies; 156 infants; typical RR 1.64, 95% CI 1.31 to 2.05; typical RD 0.69; 95% CI 0.60 to 0.79; very low-certainty evidence). Very early treatment, however, shortened the duration of hospitalization compared to expectant management (4 studies; 260 infants; MD -5.35 days; 95% CI -9.23 to -1.47; low-certainty evidence). AUTHORS' CONCLUSIONS Early or very early pharmacotherapeutic treatment of an hs-PDA probably does not reduce mortality in preterm infants (moderate-certainty evidence). Early pharmacotherapeutic treatment of hs-PDA may increase NSAID exposure (low-certainty evidence) without likely reducing CLD (moderate-certainty evidence), severe IVH or NEC (low-certainty evidence). We are uncertain whether very early pharmacotherapeutic treatment of hs-PDA also increases NSAID exposure (very low-certainty evidence). Very early treatment probably does not reduce surgical PDA ligation, severe IVH or NEC (moderate-certainty evidence), and may not reduce CLD or neurodevelopmental impairment (low-certainty evidence). Additional large trials that specifically include preterm infants at the highest risk of PDA-attributable morbidity, are adequately powered for patient-important outcomes and are minimally contaminated by open-label treatment are required to explore if early targeted treatment of hs-PDA improves clinical outcomes. There are currently two trials awaiting classification and two ongoing trials exploring this question.
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Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada
| | - Alexandra Scrivens
- Neonatal Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Tim Disher
- Evidence Synthesis and Data Analytics, EVERSANA Inc, Sydney, Canada
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16
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Soliman RM, Mostafa FA, Abdelmassih A, Sultan E, Mosallam D. Patent ductus arteriosus in preterm infants; experience of a tertiary referral neonatal intensive care unit: prevalence, complications, and management. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2020. [DOI: 10.1186/s43054-020-00046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patent ductus arteriosus poses diagnostic and therapeutic dilemma for clinicians, diagnosis of persistent PDA, and determination of its clinical and hemodynamic significance are challenging. The aim of this study is to determine the prevalence of PDA in preterm infants admitted to our NICU, to report cardiac and respiratory complications of PDA, and to study the management strategies and their subsequent outcomes.
Result
Echocardiography was done for 152 preterm babies admitted to neonatal intensive care unit (NICU) on day 3 of life. Eighty-seven (57.2%) preterms had PDA; 54 (62.1%) non-hemodynamically significant PDA (non-hsPDA), and 33 (37.9%) hemodynamically significant PDA. Hemodynamically significant PDA received medical treatment (paracetamol 15 mg/kg/6 h IV for 3 days). Follow-up echocadiography was done on day 7 of life. Four babies died before echo was done on day 7. Twenty babies (68.9%) achieved closure after 1st paracetamol course. Nine babies received 2nd course paracetamol. Follow-up echo done on day 11 of life showed 4 (13.7%) babies achieved successful medical closure after 2nd paracetamol course; 5 babies failed closure and were assigned for surgical ligation. The group of non-hsPDA showed spontaneous closure after conservative treatment. Pulmonary hemorrhage was significantly higher in hsPDA group. Mortality was higher in hsPDA group than non-hsPDA group.
Conclusion
Echocardiographic evaluation should be done for all preterms suspected clinically of having PDA. We should not expose vulnerable population of preterm infants to medication with known side effects unnecessarily; we should limit medical closure of PDA to hsPDA. Paracetamol offers several important therapeutic advantages options being well tolerated and having more favorable side effects profile.
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17
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Prince B, Hoffman S, Pietris N, Vashist S, Driscoll C, Chaves AH. Use of feedback and structured reporting improves neonatal provider satisfaction and reduces variation in echocardiogram reports of patent ductus arteriosus. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
More than 70 randomized controlled trials have been conducted on the management of patent ductus arteriosus (PDA) in preterm infants. Yet, clinicians are unsure if treating a PDA improves clinically important outcomes. Earlier clinical trials have primarily explored which pharmacotherapeutic agent effectively closes the PDA. Because many of these trials included older infants, had widely varying PDA definitions, and provided open-label treatment, it is difficult to draw inferences on clinical outcomes based on the results of these trials. These flaws in trial design might have contributed to the growing notion that "no treatment" is a feasible option irrespective of the clinical characteristics of the infant and the PDA shunt volume.
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19
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den Harink T, Clur SAB, van der Lee R, van Deutekom AW. Ductus arteriosus and failed medical therapy. J Neonatal Perinatal Med 2020; 13:39-45. [PMID: 32039865 DOI: 10.3233/npm-180152] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Management of a patent ductus arteriosus (PDA) after pharmacological therapy failure in preterm neonates is controversial and shows marked practice variation. To evaluate which factors motivate the decision to ligate a PDA in clinical practice we examined several clinical and echocardiographic variables. METHODS We conducted a retrospective single center cohort study. We included infants born at less than 37 weeks of gestation, admitted to our neonatal intensive care between 01.01.2008 and 31.12.2015 with a PDA detected on echocardiography after two or three courses of medical therapy. Logistic regression analyses were used to predict surgical ligation for twelve clinical and nine echocardiographic variables separately. We used the multiple imputation technique for missing values. RESULTS A total of 89 neonates were included of which forty (45%), underwent surgical ligation of their PDA. In our final multivariate regression model, invasive respiratory support (OR 3.6, 95% CI 1.29-10.03), left atrial/aortic root ratio (OR 5.48, 95% CI 1.66-18.11) and presence of ductal steal (OR 3.82, 95% CI 1.47-9.91) were significant predictors for surgical ligation. The prediction model using clinical and echocardiographic variables explained 9% and 24% of the variability to ligate respectively, indicating significant residual variation due to unmeasured factors. CONCLUSIONS Our results indicate that invasive respiratory support, increased left atrial/aortic root ratio and the presence of ductal steal were important predictors for surgical ligation in our center. However, this explained only a small proportion of the variability, which emphasizes the need for evidence-based guidelines in the management of preterm neonates after failed pharmacological therapy for a PDA.
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Affiliation(s)
- Tamara den Harink
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Cardiology, Amsterdam, The Netherlands
| | - Sally-Ann B Clur
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Cardiology, Amsterdam, The Netherlands.,The Center for Congenital Heart Disease Amsterdam-Leiden, Leiden, The Netherlands
| | - Robin van der Lee
- Amalia Children's Hospital, Department of Neonatology, Radboudumc, Nijmegen, The Netherlands.,Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Neonatology, Amsterdam, The Netherlands
| | - Arend W van Deutekom
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Cardiology, Amsterdam, The Netherlands.,The Center for Congenital Heart Disease Amsterdam-Leiden, Leiden, The Netherlands
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20
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Medikal Tedaviye Yanıtsız Duktus Arteriosuslu Preterm İnfantların Tedavisinde Güvenli Bir Yöntem: Yatakbaşı Cerrahi ligasyon. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.568276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Escobar HA, Meneses-Gaviria G, Revelo-Jurado N, Villa-Rosero JF, Ijají Piamba JE, Burbano-Imbachí A, Cedeño-Burbano AA. Tratamiento farmacológico del conducto arterioso permeable en recién nacidos prematuros. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.64146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Por lo general, el manejo farmacológico del conducto arterioso permeable (CAP) comprende inhibidores no selectivos de la enzima ciclooxigenasa, en especial indometacina e ibuprofeno. En años recientes también se ha sugerido al acetaminofén como alternativa terapéutica.Objetivo. Realizar una revisión narrativa de la literatura acerca del manejo farmacológico del CAP.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos “Ductus Arteriosus, patent AND therapeutics”; “Ductus Arteriosus, patent AND indometacin”; “Ductus Arteriosus, Patent AND ibuprofen”, y “Ductus Arteriosus, patent AND acetaminophen”. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 69 artículos con información relevante para llevar a cabo la presente revisión.Conclusiones. En neonatos prematuros, la base del tratamiento farmacológico del CAP continúa siendo los inhibidores no selectivos de la ciclooxigenasa, indometacina e ibuprofeno, ambos con perfiles similares de seguridad y eficacia. La evidencia disponible sugiere que el acetaminofén podría constituir una alternativa útil para el manejo, pero resulta insuficiente para realizar recomendaciones definitivas respecto a la eficacia y seguridad de este medicamento.
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22
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Katheria V, Poeltler DM, Brown MK, Hassen KO, Patel D, Rich W, Finer NN, Katheria AC. Early prediction of a significant patent ductus arteriosus in infants <32 weeks gestational age. J Neonatal Perinatal Med 2019; 11:265-271. [PMID: 29843271 DOI: 10.3233/npm-1771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The optimal thresholds for identification of preterm infants at greatest risk for adverse sequelae related to patent ductus arteriosus have not been well delineated. Our aim was to determine hemodynamic parameters in the first 24 hours using continuous non-invasive vital and structural measurements to predict which infants required PDA treatment in our institution. METHODS Retrospective secondary analysis of data from infants born 23 to 32 weeks gestational age with cardiac output and stroke volume via electrical cardiometry, cerebral tissue oximetry measurements, mean arterial blood pressure (BP), heart rate, and oxygen saturation and functional echocardiography results at 12 hours of life were recorded when available (93 percent of subjects). RESULTS A total of 292 infants, of which 55 (26±2 weeks, 862±268 grams) were treated for PDA. Treated infants demonstrated increased left ventricular output (p < 0.001) and lower mean BP (p = 0.010). The optimal area under the receiver operating characteristic curve (AUC) for predicting PDA treatment in our all gestations cohort is a mean BP at 15 hours of life of <33 mm Hg (AUC = 0.854, p < 0.001, 95% CI 0.792, 0.916). For infants <28 weeks a mean BP at 13 hours of life of <33 mm Hg (AUC = 0.741, p < 0.050, 95% CI 0.642, 0.839). CONCLUSIONS In our cohort increased left ventricular output and lower mean BP predicted a clinically significant PDA requiring treatment.
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Affiliation(s)
- V Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D M Poeltler
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - M K Brown
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - K O Hassen
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D Patel
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - W Rich
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - N N Finer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - A C Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
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23
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Mitra S, Disher T. Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Souvik Mitra
- Dalhousie University & IWK Health Care; Division of Neonatal Perinatal Medicine, Department of Pediatrics; G-2214, 5850/5980 University Avenue Halifax Nova Scotia Canada B3K 6R8
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Köksal N, Aygün C, Uras N. Turkish Neonatal Society guideline on the management of patent ductus arteriosus in preterm infants. Turk Arch Pediatr 2018; 53:S76-S87. [PMID: 31236021 PMCID: PMC6568296 DOI: 10.5152/turkpediatriars.2018.01808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ductus arteriosus is a physiologic phenomenon in utero and it closes spontaneously in term babies. The closure is problematic in preterm infants due to the intrinsic properties of the preterm ductus arteriosus tissue. Although patent ductus arteriosus has been reported to be associated with many adverse outcomes in this population, treatment has not led to a decrease in outcomes such as bronchopulmonary dysplasia. Treatment modalities also have their own risks and restrictions. The aim of the "Turkish Neonatal Society guidelines for the management of patent ductus arteriosus in preterm babies" is to standardize the diagnosis and treatment of patent ductus arteriosus in preterm infants by combining the current scientific data and the resources of our country.
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Affiliation(s)
- Nilgün Köksal
- Division of Neonatology, Department of Pediatrics, Uludağ University, Faculty of Medicine, Bursa, Turkey
| | - Canan Aygün
- Division of Neonatology, Department of Pediatrics, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
| | - Nurdan Uras
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
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A. Karatza A, Sinopidis X. Patent Arterial Duct. CONGENIT HEART DIS 2018. [DOI: 10.5772/intechopen.79956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Early neonatal morbidities and neurological functioning of preterm infants 2 weeks after birth. J Perinatol 2018; 38:1518-1525. [PMID: 30177861 DOI: 10.1038/s41372-018-0211-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the association between potential neonatal risk factors and the quality of general movements (GMs) in preterm infants. STUDY DESIGN Prospective cohort study in 67 preterm infants. From video recordings made on Days 8 and 15, we scored the GMs as normal/abnormal and detailed aspects using the general movement optimality score (GMOS). Risk factors included respiratory insufficiency requiring mechanical ventilation, patent ductus arteriosus (PDA), and abnormal blood glucose levels. We used multiple regression analyses. RESULT On Day 8 after birth, the presence of a PDA remained in the multivariable model, explaining 17.1% of the variance in GMOS (beta, -0.414). On Day 15, duration of mechanical ventilation and frequency of hypoglycemic episodes explained 38.8% of the variance (betas, -0.382 and -0.466, respectively). CONCLUSION In preterm infants, PDA, duration of mechanical ventilation, and frequency of hypoglycemic episodes were associated with poorer neurological functioning during the first 2 weeks after birth.
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Patent ductus arteriosus in preterm infants born before 30 weeks' gestation: high rate of spontaneous closure after hospital discharge. Cardiol Young 2018; 28:995-1000. [PMID: 29954463 DOI: 10.1017/s1047951118000641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED AimThe aim of this study was to determine the spontaneous closure rate of patent ductus arteriosus at a 2-year follow-up, following failed medical therapy and beyond initial hospital discharge, and to evaluate in-hospital spontaneous or pharmacological closure rates.Materials and methodsA retrospective evaluation was conducted in a cohort of preterm infants admitted to the Neonatal ICU of Ancona between January, 2004 and June, 2013. Inclusion criteria were gestational age between 24+0 and 29+6 weeks or birth weight 1.5 mm, a left atrium-to-aorta ratio >1.4, and/or reversal of end-diastolic flow in the aorta >30% of the anterograde. First-line treatment was intravenous ibuprofen. Intravenous indomethacin was used if ibuprofen failed. Surgical ligation was considered in haemodynamically significant patent ductus arteriosus after medical treatment. RESULTS A total of 593 infants met the inclusion criteria, and patent ductus arteriosus was diagnosed in 317 (53.4%). Among them, 283 (89.3%) infants had haemodynamically significant patent ductus arteriosus, with pharmacological closure achieved in 228 (80.6%) infants and surgical ligation performed in 20 (7.1%). Follow-up at 24 months was available for 39 (81.3%) of 48 infants with patent ductus arteriosus at the hospital discharge: 36 (92.3%) underwent spontaneous closure, two (5.1%) underwent surgical ligation, and one (2.6%) had a patent ductus arteriosus.DiscussionA significant number of patent ductus arteriosus that fail pharmacological closure undergo spontaneous closure by the age of 2 years. This information should be taken into account when considering surgery or additional attempts of pharmacological closure.
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Mitra S, Florez ID, Tamayo ME, Mbuagbaw L, Vanniyasingam T, Veroniki AA, Zea AM, Zhang Y, Sadeghirad B, Thabane L. Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-analysis. JAMA 2018; 319:1221-1238. [PMID: 29584842 PMCID: PMC5885871 DOI: 10.1001/jama.2018.1896] [Citation(s) in RCA: 199] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Despite increasing emphasis on conservative management of patent ductus arteriosus (PDA) in preterm infants, different pharmacotherapeutic interventions are used to treat those developing a hemodynamically significant PDA. OBJECTIVES To estimate the relative likelihood of hemodynamically significant PDA closure with common pharmacotherapeutic interventions and to compare adverse event rates. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until August 15, 2015, and updated on December 31, 2017, along with conference proceedings up to December 2017. Randomized clinical trials that enrolled preterm infants with a gestational age younger than 37 weeks treated with intravenous or oral indomethacin, ibuprofen, or acetaminophen vs each other, placebo, or no treatment for a clinically or echocardiographically diagnosed hemodynamically significant PDA. DATA EXTRACTION AND SYNTHESIS Data were independently extracted in pairs by 6 reviewers and synthesized with Bayesian random-effects network meta-analyses. MAIN OUTCOMES AND MEASURES Primary outcome: hemodynamically significant PDA closure; secondary: included surgical closure, mortality, necrotizing enterocolitis, and intraventricular hemorrhage. RESULTS In 68 randomized clinical trials of 4802 infants, 14 different variations of indomethacin, ibuprofen, or acetaminophen were used as treatment modalities. The overall PDA closure rate was 67.4% (2867 of 4256 infants). A high dose of oral ibuprofen was associated with a significantly higher odds of PDA closure vs a standard dose of intravenous ibuprofen (odds ratio [OR], 3.59; 95% credible interval [CrI], 1.64-8.17; absolute risk difference, 199 [95% CrI, 95-258] more per 1000 infants) and a standard dose of intravenous indomethacin (OR, 2.35 [95% CrI, 1.08-5.31]; absolute risk difference, 124 [95% CrI, 14-188] more per 1000 infants). Based on the ranking statistics, a high dose of oral ibuprofen ranked as the best pharmacotherapeutic option for PDA closure (mean surface under the cumulative ranking [SUCRA] curve, 0.89 [SD, 0.12]) and to prevent surgical PDA ligation (mean SUCRA, 0.98 [SD, 0.08]). There was no significant difference in the odds of mortality, necrotizing enterocolitis, or intraventricular hemorrhage with use of placebo or no treatment compared with any of the other treatment modalities. CONCLUSIONS AND RELEVANCE A high dose of oral ibuprofen was associated with a higher likelihood of hemodynamically significant PDA closure vs standard doses of intravenous ibuprofen or intravenous indomethacin; placebo or no treatment did not significantly change the likelihood of mortality, necrotizing enterocolitis, or intraventricular hemorrhage. TRIAL REGISTRATION PROSPERO Identifier: CRD42015015797.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health Center, Halifax, Nova Scotia, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ivan D. Florez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Maria E. Tamayo
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Thuva Vanniyasingam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | | | - Adriana M. Zea
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- HIV/STI Surveillance Research Center and WHO Collaborating Center for HIV Surveillance, Kerman University of Medical Sciences, Kerman, Iran
- Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Borszewska-Kornacka MK, Hożejowski R, Rutkowska M, Lauterbach R. Shifting the boundaries for early caffeine initiation in neonatal practice: Results of a prospective, multicenter study on very preterm infants with respiratory distress syndrome. PLoS One 2017; 12:e0189152. [PMID: 29261723 PMCID: PMC5738066 DOI: 10.1371/journal.pone.0189152] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/20/2017] [Indexed: 12/20/2022] Open
Abstract
Background There is growing evidence that supports the benefits of early use of caffeine in preterm neonates with RDS; however, no formal recommendations specifying the exact timing of therapy initiation have been provided. Objectives We compared neonatal outcomes in infants receiving early (initial dose on the 1st day of life) and late (initial dose on day 2+ of life) caffeine therapy. Methods Using data from a prospective, cohort study, we identified 986 infants ≤32 weeks’ gestation with RDS and assessed the timing of caffeine therapy initiation, need for ventilatory support, mortality and incidence of typical complications of prematurity. To adjust for baseline severity, the early and late caffeine groups were propensity score (PS) matched to 286 infants (1:1). Clinical outcomes were compared between the PS-matched groups. Results Early treatment with caffeine citrate was associated with a significantly reduced need for invasive ventilation (71.3% vs 83.2%; P = 0.0165) and total duration of mechanical ventilation (mean 5 ± 11.1 days vs 10.8 ± 14.6 days; P = 0.0000) and significantly lower odds of intraventricular hemorrhage (IVH) (OR 0.4827; 95% CI 0.2999–0.7787) and patent ductus arteriosus (PDA) (OR 0.5686; 95% CI 0.3395–0.9523). The incidence of bronchopulmonary dysplasia (BPD) (36.4% vs 45.8%) and rates of moderate and severe BPD were not significantly different between the two groups. The mortality rates were comparable between the two groups (8.6% vs 8.5%, P = ns) Conclusion Early caffeine initiation was associated with a decreased need for invasive ventilatory support and lower incidence of IVH and PDA.
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Affiliation(s)
| | | | - Magdalena Rutkowska
- Clinic of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Warsaw, Poland
| | - Ryszard Lauterbach
- Department of Neonatology, Jagiellonian University Medical College, Cracow, Poland
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Abstract
A patent ductus arteriosus is a common condition, particularly in premature infants. Many spontaneously resolve but those that lead to clinical instability require closure. Conservative measures can be highly successful in selected groups. Surgical repair is effective and both open and minimally invasive approaches can be used. The minimally invasive approach may result in less long-term morbidity from a thoracotomy and may prove advantageous for these fragile infants, including less pain, shorter time on the ventilator, and shorter hospital stays.
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Affiliation(s)
- Alejandro V Garcia
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, 1800 Orleans Street, Bloomberg Building Suite 7310, Baltimore, MD 21287, USA.
| | - Jeffrey Lukish
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, 1800 Orleans Street, Bloomberg Building Suite 7310, Baltimore, MD 21287, USA
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Ngo S, Profit J, Gould JB, Lee HC. Trends in Patent Ductus Arteriosus Diagnosis and Management for Very Low Birth Weight Infants. Pediatrics 2017; 139:peds.2016-2390. [PMID: 28562302 PMCID: PMC5369670 DOI: 10.1542/peds.2016-2390] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine yearly trends of patent ductus arteriosus (PDA) diagnosis and treatment in very low birth weight infants. METHODS In this retrospective cohort study of very low birth weight infants (<1500 g) between 2008 and 2014 across 134 California hospitals, we evaluated PDA diagnosis and treatment by year of birth. Infants were either inborn or transferred in within 2 days after delivery and had no congenital abnormalities. Intervention levels for treatment administered to achieve ductal closure were categorized as none, pharmacologic (indomethacin or ibuprofen), both pharmacologic intervention and surgical ligation, or ligation only. Multivariable logistic regression was used to assess risk factors for PDA diagnosis and treatment. RESULTS PDA was diagnosed in 42.8% (12 002/28 025) of infants, with a decrease in incidence from 49.2% of 4205 infants born in 2008 to 38.5% of 4001 infants born in 2014. Pharmacologic and/or surgical treatment was given to 30.5% of patients. Between 2008 and 2014, the annual rate of infants who received pharmacologic intervention (30.5% vs 15.7%) or both pharmacologic intervention and surgical ligation (6.9% vs 2.9%) decreased whereas infants who were not treated (60.5% vs 78.3%) or received primary ligation (2.2% vs 3.0%) increased. CONCLUSIONS There is an increasing trend toward not treating patients diagnosed with PDA compared with more intensive treatments: pharmacologic intervention or both pharmacologic intervention and surgical ligation. Possible directions for future study include the impact of these trends on hospital-based and long-term outcomes.
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Affiliation(s)
- Samantha Ngo
- School of Public Health, University of California, Berkeley, Berkeley, California;
| | - Jochen Profit
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and,California Perinatal Quality Care Collaborative, Stanford, California
| | - Jeffrey B. Gould
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and,California Perinatal Quality Care Collaborative, Stanford, California
| | - Henry C. Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and,California Perinatal Quality Care Collaborative, Stanford, California
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de Waal K, Phad N, Collins N, Boyle A. Cardiac remodeling in preterm infants with prolonged exposure to a patent ductus arteriosus. CONGENIT HEART DIS 2017; 12:364-372. [DOI: 10.1111/chd.12454] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/02/2017] [Accepted: 01/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital; University of Newcastle; Newcastle NSW Australia
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital; University of Newcastle; Newcastle NSW Australia
| | - Nick Collins
- Department of Cardiology, John Hunter Hospital; University of Newcastle; Newcastle NSW Australia
| | - Andrew Boyle
- Department of Cardiology, John Hunter Hospital; University of Newcastle; Newcastle NSW Australia
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Abstract
BACKGROUND The incidence of hemodynamically significant patent ductus arteriosus (hsPDA) increases with decreasing gestational age and is associated with many common morbidities of extreme prematurity. Controversies remain surrounding the definition of hsPDA, the population of infants requiring treatment, the appropriate timing and method of treatment, and the outcomes associated with PDA and its therapies. PURPOSE This integrative literature review focuses on diagnostic and treatment recommendations derived from the highest levels of evidence. SEARCH STRATEGY PubMed and CINAHL were searched using key words "neonatal" and "patent ductus arteriosus" to discover the highest levels of evidence surrounding diagnosis, treatment methods, and outcomes. FINDINGS/RESULTS The lack of consensus surrounding the diagnosis and clinical significance of PDA hinders meta-analysis across studies and confounds understanding of appropriate management strategies. Novel biomarkers, pharmaceutical choices, and transcatheter closure methods are expanding diagnostic and treatment options. IMPLICATIONS FOR PRACTICE Infants weighing less than 1000 g are at highest risk. Prophylactic closure is no longer recommended, although early asymptomatic therapy is still preferred by some to avoid prolonged pulmonary overcirculation or decreased renal and gut perfusion. Conservative treatment measures such as fluid restriction and diuretic administration have not consistently proven effective and are in some instances detrimental. Cyclooxygenase inhibitors are effective but have adverse renal and mesenteric effects. Oral ibuprofen is associated with lower instance of necrotizing enterocolitis. IMPLICATIONS FOR RESEARCH Well-defined staging criteria would aid in comparison and meta-analysis. Trials that include a control group that receives no therapy may help separate the outcomes associated with prematurity from those associated with PDA.
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Pourarian S, Sharma D, Farahbakhsh N, Cheriki S, Bijanzadeh F. To evaluate the prevalence of symptomatic and non-symptomatic ductus arteriosus and accuracy of physical signs in diagnosing PDA in preterm infants using blinded comparison of clinical and echocardiographic findings during the first week of life: a prospective observational study from Iran. J Matern Fetal Neonatal Med 2016; 30:1666-1670. [PMID: 27494450 DOI: 10.1080/14767058.2016.1220532] [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: 10/21/2022]
Abstract
AIMS To evaluate the prevalence of symptomatic and non-symptomatic ductus arteriosus (PDA) and accuracy of physical signs in diagnosing PDA in preterm infants using blinded comparison of clinical and echocardiographic findings during the first week of life. METHODS AND MATERIAL This prospective observational cross-sectional study enrolled 200 preterm infants, who underwent echocardiography on 4th-7th postnatal day. The neonates who were diagnosed to have PDA on echo were observed for clinical features of PDA to label it symptomatic PDA. Symptomatic PDA was defined as detecting one or all of these symptoms in a neonate with PDA: bounding pulse, pericardial hyperactivity, systolic or continuous murmur. RESULTS Forty-five infants had PDA on echocardiography. 66.7% neonates with PDA were symptomatic and the most prevalent symptom in them was heart murmur (100%) either alone or combined with other clinical features. Isolated murmur was seen in 31.2%, murmur and hyperdynamic precordium was seen in 8.8%, murmur and bounding pulses were seen in 6.67% and all three features simultaneously were seen in 20% of infants. The sensitivity of murmur for diagnosing symptomatic PDA was highest. CONCLUSION Presence of murmur is the most important clinical feature for diagnosis of symptomatic PDA and has good specificity.
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Affiliation(s)
- Shahnaz Pourarian
- a Neonatal Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Deepak Sharma
- b NEOCLINIC, Plot number 3 & 4, Everest Vihar, Opposite Krishna Heart Hospital, TN Mishra Marg, Nirman Nagar , Jaipur , Rajasthan , India
| | - Nazanin Farahbakhsh
- c Department of Pediatrics , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Sirous Cheriki
- d Department of Pediatric Cardiology , Shiraz University of Medical Sciences , Shiraz , Iran , and
| | - Farhad Bijanzadeh
- e Department of Orthopedics , Shiraz University of Medical sciences , Shiraz , Iran
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Mitra S, Florez ID, Tamayo ME, Aune D, Mbuagbaw L, Veroniki AA, Thabane L. Effectiveness and safety of treatments used for the management of patent ductus arteriosus (PDA) in preterm infants: a protocol for a systematic review and network meta-analysis. BMJ Open 2016; 6:e011271. [PMID: 27456327 PMCID: PMC4964163 DOI: 10.1136/bmjopen-2016-011271] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Management of patent ductus arteriosus (PDA) in preterm infants is one of the most controversial topics in neonatal medicine. The availability of different pharmacotherapeutic options often poses a practical challenge to the practising neonatologist as to which one to choose as a therapeutic option. Our objectives are to determine the relative merits of the available pharmacotherapeutic options for the management of PDA. METHODS AND ANALYSIS We will conduct a systematic review of all randomised controlled trials evaluating the use of intravenous or oral: indomethacin, ibuprofen and acetaminophen for the treatment of PDA in preterm infants. The primary outcome is failure of closure of the PDA. Secondary outcomes are neonatal mortality, need for surgical closure, duration of ventilator support, chronic lung disease, intraventricular haemorrhage, periventricular leukomalacia, necrotising enterocolitis, gastrointestinal bleeding, time to full enteral feeds and oliguria. We will search Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information, and assess the risk of bias (ROB) and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach). Subgroup analysis according to gestational age, birth weight, different doses of interventions, time of administration of the first dose of the intervention, and echocardiographic definition of haemodynamically significant PDA and ROB are planned. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, if adequate data are available. ETHICS AND DISSEMINATION The results will help to reduce the uncertainty about the safety and effectiveness of the interventions, will identify knowledge gaps or will encourage further research for other therapeutic options. Therefore, its results will be disseminated through peer-reviewed publications and conference presentations. On the basis of the nature of its design, no ethics approval is necessary for this study. TRIAL REGISTRATION NUMBER CRD42015015797.
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Affiliation(s)
- Souvik Mitra
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ivan D Florez
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Maria E Tamayo
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Dagfinn Aune
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Areti-Angeliki Veroniki
- Knowledge Translation program, Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Mitra S, Chan AK, Paes BA. The association of platelets with failed patent ductus arteriosus closure after a primary course of indomethacin or ibuprofen: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2016; 30:127-133. [DOI: 10.3109/14767058.2016.1163684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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AlFaleh K, Alluwaimi E, AlOsaimi A, Alrajebah S, AlOtaibi B, AlRasheed F, AlKharfi T, Paes B. A prospective study of maternal preference for indomethacin prophylaxis versus symptomatic treatment of a patent ductus arteriosus in preterm infants. BMC Pediatr 2015; 15:47. [PMID: 25895495 PMCID: PMC4414008 DOI: 10.1186/s12887-015-0353-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 03/20/2015] [Indexed: 12/04/2022] Open
Abstract
Background The management of a patent ductus arteriosus in preterm infants continues to be debated among neonatologists due to the absence of concrete evidence that precisely weighs the long term outcomes of active, early intervention against a conservative approach. In the majority of institutions, parents are encouraged to play an active role in the complex, decision –making processes with regard to the care of their infants. The objective of this study is to elicit maternal preferences for indomethacin prophylaxis versus treatment of a patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants, utilizing a decision aid instrument (DAI). Methods Healthy and high risk pregnant women at 23–28 weeks gestation, and mothers of admitted ELBW infants were enrolled. A computer based, validated DAI was utilized during interviews. The DAI first provides information about prematurity and concurrent morbidities with comprehensive facts of the pros and cons about prophylactic versus treatment options. It subsequently coaches participants how to select values and preferences based on their decisions. A 17-item questionnaire assessed and valued each short and long term morbidity of extreme prematurity and preferred choice for PDA management. Results Two hundred ninety nine subjects were enrolled; 75% were healthy women at 23–28 weeks gestation, 19% were high risk and 6% recently delivered an ELBW infant. Eighty-two percent preferred a prophylactic indomethacin strategy versus symptomatic treatment for the management of PDA. Across a spectrum of potential morbidities, the occurrence of severe intraventricular hemorrhage was viewed by mothers as the most un-wanted outcome irrespective of the two proposed options. Conclusions In contrast to neonatal practitioners, mothers who used this particular DAI strongly endorsed prophylactic indomethacin versus a treatment intervention for the management of PDA in preterm infants. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0353-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khalid AlFaleh
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Eman Alluwaimi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Ahlam AlOsaimi
- Department of Pediatrics, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Sheikha Alrajebah
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Bashayer AlOtaibi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Fatima AlRasheed
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Turki AlKharfi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada.
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Smith A, Maguire M, Livingstone V, Dempsey EM. Peak systolic to end diastolic flow velocity ratio is associated with ductal patency in infants below 32 weeks of gestation. Arch Dis Child Fetal Neonatal Ed 2015; 100:F132-6. [PMID: 25406463 DOI: 10.1136/archdischild-2014-306439] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early diagnosis and effective treatment of the patent ductus arteriosus (PDA) in infants less than 32 weeks gestation remains contentious. OBJECTIVE To determine which clinical and echocardiographic parameters are associated with PDA patency in preterm infants less than 32 weeks gestation. DESIGN/METHODS This was a prospective cohort study. An echocardiography (echo) was performed within 12-48 h of birth and a follow-up echo at 1 month of life. Parental consent was obtained. RESULTS 55 babies were enrolled. Median (range) gestation was 28 (24-31) weeks and birth weight 1090 g (470-1800 g). ECHO 1 demonstrated that 50 babies had a PDA present within 48 h of birth, of which 19 were large (≥2 mm) (36%) and 31 were small (59%) on colour Doppler assessment of duct diameter. Three babies died before 1 month. At 1 month 30 babies still had a PDA (58%), 10 of which were large (19%) and 19 were small (36%). Parameters significantly associated with large PDAs versus no PDA at 1 month were gestational age (26 weeks vs 30 weeks, p=0.002), birth weight (860 g vs 1290 g, p=0.007) and ventilator support at 48 h (80% vs 17%, p=0.001). Echo parameters revealed that ductal size on colour Doppler (2.5 mm vs 1.5 mm, p=0.003), end diastolic flow velocity (57 m/s vs 147 m/s, p<0.001) and peak systolic to end diastolic flow velocity ratio (2.29 vs 1.23, p=0.001) at 48 h were associated with large PDAs at 1 month. CONCLUSIONS For infants less than 32 weeks gestation a peak systolic to end diastolic flow velocity ratio>2 within 48 h of birth is associated with a persistent large PDA at 1 month of age.
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Affiliation(s)
- A Smith
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland
| | - M Maguire
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - V Livingstone
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland Infant Centre, University College Cork, Cork, Ireland
| | - E M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland Infant Centre, University College Cork, Cork, Ireland
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Guthrie JD. A Novel Echocardiographic Marker (PDAM) Incorporating the Diameter of the Patent Foramen Ovale to Assess Hemodynamically Significant Patent Ductus Arteriosus. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2015. [DOI: 10.1177/8756479314563539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Persistent hemodynamically significant patent ductus arteriosus (PDA) in preterm infants may lead to significant morbidity and increased mortality. This report proposes a new composite marker to predict a hemodynamically significant PDA, termed the PDA marker (PDAM) score, which incorporates the diameter of the patent foramen ovale (PFO) in addition to the ratio of the diameter of the left atrium to the diameter of the root of the aorta (LA/Ao) and ratio of the size of the patent ductus arteriosus to the left pulmonary artery (PDA/LPA) diameter. PDA was suspected in 191 infants between 2009 and 2013. Analysis of the data indicated that there was no significant difference between the accuracy of the PDA diameter and the PDAM score as markers of either a hemodynamically significant PDA or a very hemodynamically significant PDA that needed ligation. These data did show that the PDAM score provided slightly higher sensitivity (93.3%) and specificity (75.6%) than the PDA diameter to identify a PDA that needed ligation at the specified cutoff level of PDAM = 5.1. Consequently, clinicians may be more confident using the PDAM score, rather than the PDA diameter alone, when selecting PDA cases for surgical intervention.
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Flood T, Guthrie JD. Echocardiographic Markers for the Prediction of Nonclosure of the Patent Ductus Arteriosus in Premature Neonates. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2014. [DOI: 10.1177/8756479314563538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Four echocardiographic markers—left ventricular ejection fraction (LVEF), the ratio of the left atrial diameter to the aortic root diameter (LA/Ao), the ratio of the patent ductus arteriosus (PDA) diameter to the left pulmonary arterial diameter (PDA/LPA), and the patent foramen ovale (PFO) diameter—were explored to predict a PDA in 221 premature neonates (53% male). There were 182 cases with PDA (mean diameter = 2.49 mm); 39 control subjects were observed with a closed ductus arteriosus. Although 104 of the cases (57.1 %) were diagnosed when 0 to 3 days old (median age = 1 day), 78 (42.9%) were diagnosed when 4 to 86 days old (median age = 13 days). Birth weights of the neonates ranged from 0.5 to 4.8 kg (mean = 1.68 kg). After controlling for age and birth weight, the mean LVEF (%) was not significantly different in the cases versus controls ( P > .05); the mean LA/Ao and mean PFO diameter were significantly larger ( P < .001) in the cases. The mean PDA/LPA was consistently ≥ .7 in the cases. The sensitivity of the LA/Ao ratio as a positive test for PDA (cutoff = 1.5) varied with age but not birth weight. When the neonatal age was 0 to 3 days, the sensitivity was 56% with a specificity of 88%; when the neonatal age was > 3 days, the sensitivity of LA/Ao was 82% with a specificity of 63%. The sensitivity of PFO (cutoff = 3.0 mm) was 61% with a specificity of 48%, irrespective of age or birth weight. These data suggest that LVEF is not a significant predictor of the presence of PDA, but a combination of the LA/Ao ratio, PDA/LPA ratio, and PFO diameter is predictive of the presence of PDA.
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Affiliation(s)
- Thuan Flood
- Community Regional Medical Center, Fresno, CA, USA
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41
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Yajamanyam PK, Kanani AN, Rasiah SV. Management of Patent Ductus Arteriosus in Preterm Infants-Where Do We Stand? A UK National Perspective. CONGENIT HEART DIS 2014; 10:86-7. [DOI: 10.1111/chd.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Phani Kiran Yajamanyam
- Department of Neonatology; Birmingham Women's Hospital NHS Foundation Trust; Birmingham UK
| | - Anand Nitin Kanani
- Department of Neonatology; Birmingham Women's Hospital NHS Foundation Trust; Birmingham UK
| | - Shree Vishna Rasiah
- Department of Neonatology; Birmingham Women's Hospital NHS Foundation Trust; Birmingham UK
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