Feasibility, Safety, and Short‐Term Outcomes of Transcatheter Patent Ductus Arteriosus Closure in Premature Infants on High‐Frequency Jet Ventilation

Background

Prolonged exposure to a hemodynamically significant patent ductus arteriosus (PDA) is associated with major morbidity, particularly in infants born at <27 weeks’ gestation. High‐frequency jet ventilation (HFJV) is a standard of care at our center. There are no data about transcatheter PDA closure while on HFJV. The aim of this study was to assess the feasibility, safety, and outcomes of HFJV during transcatheter PDA closure.

Methods and Results

This is a retrospective cohort study of premature infants undergoing transcatheter device closure on HFJV. The primary outcome was successful device placement. Secondary outcomes included procedure time, fluoroscopy time and dose, time off unit, device complications, need for escalation in respiratory support, and 7‐day survival. Subgroup comparative evaluation of patients managed with HFJV versus a small cohort of patients managed with conventional mechanical ventilation was performed. Thirty‐eight patients were included in the study. Median age and median weight at PDA device closure for the HFJV cohort were 32 days (interquartile range, 25.25–42.0 days) and 1115 g (interquartile range, 885–1310 g), respectively. There was successful device placement in 100% of patients. There were no device complications noted. The time off unit and the procedure time were not significantly different between the HFJV group and the conventional ventilation group. Infants managed by HFJV had shorter median fluoroscopy times (4.5 versus 6.1 minutes; P<0.05) and no increased risk of adverse respiratory outcomes.

Conclusions

Transcatheter PDA closure in premature infants on HFJV is a safe and effective approach that does not compromise device placement success rate and does not lead to secondary complications.

First intention high-frequency jet ventilation for periviable infants

PURPOSE OF REVIEW

Ventilation of periviable infants born at 22-23 weeks gestation remains a challenge in neonatology. This review highlights the evidence surrounding the use of first intention high-frequency jet ventilation (HFJV) in infants born near the limits of viability with a review of pulmonary fetal development and a focused overview of HFJV strategies including an in-depth analysis of the management strategies used in the initial randomized trials.

RECENT FINDINGS

A paucity of recent trials exists, with no randomized control trials assessing the use of first intention HFJV performed in the last 25 years. A retrospective observational cohort trial of the use of HFJV for infants born at less than 750 g has been recently published demonstrating the efficacy of HFJV for this population even with 2.0-mm endotracheal tubes.

SUMMARY

The lack of recent randomized trials contributes to the controversy surrounding the use of first intention HFJV. Although new research is needed in the area, this review includes the ventilation strategy of an experienced center with a focus on the use of first intention HFJV for the care of premature infants born less than 24 weeks gestation.

Lung Ultrasound Score Predicts the Extravascular Lung Water Content in Low-Birth-Weight Neonates with Patent Ductus Arteriosus

BACKGROUND Patent ductus arteriosus (PDA) is a common congenital cardiac abnormality in premature infants. In low-birth-weight infants weighing less than 2500 g, if the PDA continues to open, abnormal circulation hemodynamics and pulmonary edema may occur. This study aimed to investigate the role of lung ultrasound score in the assessment of pulmonary edema in low-weight neonates with PDA. MATERIAL AND METHODS Two hundred and twenty-one neonates with low birth weight were selected as the subjects, children with PDA as the observation group, and children with closed ductus arteriosus as the control group. On the fourth postnatal day, lung ultrasound examination and 6-segment lung ultrasound scoring were performed. RESULTS All 221 infants (94 in the observation group, 127 controls) underwent ultrasound examinations of the lungs. Intergroup differences in gestational age, birth weight, length of hospital stay, and left ventricular ejection fraction were not statistically significant. There was a significant difference in lung ultrasound score (t=0.005, P=0.000) and aortic root ratio to left atrial (t=0.085, P=0.000), which was negatively correlated with gestational age (r=-0.235, P=0.000) and positively correlated with PDA diameter (r=0.261, P=0.011). CONCLUSIONS Low-birth-weight children often have PDA. Its continued opening changes the circulation hemodynamics in children. Lung ultrasound score can semi-quantitatively evaluate the extravascular lung water content, identifying the need to intervene and follow up the hemodynamic significance of PDA over time.

Contemporary ventilatory strategies for surgical patients

Respiratory failure affects a significant percentage of critically ill children, necessitating both invasive and non-invasive respiratory support. As the outcomes of these patients have improved, children with higher acuity and more complex respiratory pathophysiology require mechanical ventilation. Despite growing understanding of lung-protective strategies and ventilation induced lung injury, certain patients still require harmful ventilatory settings with conventional mechanical ventilation (CMV). High frequency ventilation, neurally adjusted ventilatory assist, and airway pressure release ventilation offer feasible alternatives to CMV. In addition to minimizing the risk of ventilatory induced lung injury when used appropriately, they provide a unique environment to facilitate operations on certain neonates and older children. Finally, non-invasive ventilation is now commonly employed in children with surgical conditions.

Surgical management of a patent ductus arteriosus: Is this still an option?

The evolution of neonatal intensive care over the past decade has seen the role of surgical patent ductus arteriosus (PDA) ligation in preterm infants both decrease in scope and become laden with uncertainty. Associations of ligation with adverse neonatal and neurodevelopmental outcomes have rendered the ligation decision more challenging for clinicians and have been associated with a decline in surgical treatment, but these findings may be due to bias from confounding by indication in observational studies rather than a causal detrimental effect of ligation. Accordingly, ligation may still be indicated for infants with large ductal shunts and moderate-severe respiratory insufficiency in whom the prospect of timely spontaneous closure appears low. Ultimately a randomized trial of surgical ligation versus conservative management is necessary to assess the efficacy of this invasive intervention in a population of extremely preterm infants with large ductal shunts. Simultaneously, the transcatheter approach to ductal closure in the very immature infant represents an exciting therapeutic alternative but which is still in its infancy. Insights into the pathophysiology of postoperative cardiorespiratory deterioration, including the importance of left ventricular afterload, may help clinicians avoid instability and mitigate a potentially injurious aspect of surgical treatment. This review examines the evidence regarding the benefits and risks of PDA surgery in preterm neonates and provides a pathophysiology-based management paradigm to guide perioperative care in high-risk infants.