Patent ductus arteriosus in premature neonates

Efficiency and Safety of Patent Ductus Arteriosus Surgical Ligation in Extremely Low Birth Weight Infants Without Chest Tube Placement

Patent ductus arteriosus (PDA) has been associated with increased morbidity and mortality in preterm infants. Surgical ligation (SL) is generally performed in symptomatic infants when medical management is contraindicated or has failed. We retrospectively reviewed our institution's experience in surgical management of PDA for extremely low birth weight (ELBW) infants without chest tube placement assessing its efficiency and safety. We evaluated 17 consecutive ELBW infants undergoing SL for symptomatic PDA (January 2012-January 2018) with subsequent follow-up for 6 months postdischarge. Patients consisted of 9 (53%) females and 8 (47%) males. Mean gestational age (GA) at birth was 27.9 ± 2.1 weeks. Median values for surgical age (SA) from birth to operation was 10 days (interquartile range [IQR]: 8-12); PDA diameter 3.4 mm (IQR: 3.2-3.5); surgical weight (SW) 750 g (IQR: 680-850); and days of mechanical ventilation (DMV) as estimated by Kaplan-Meier curve 22 days (95% confidence interval: 14.2-29.8). We observed a statistically significant negative association between DMV and GA at birth (rho = - 0.587, p  = 0.017), SA (rho = - 0.629, p  = 0.009) and SW (rho = - 0.737, p  = 0.001). One patient experienced left laryngeal nerve palsy confirmed by laryngoscopy. Otherwise, there were no adverse events to include surgical-related mortality, recurrence of PDA, or need for chest tube placement during follow-up. SL of PDA in ELBW infants without chest tube placement is both efficient and safe. Universal consensus recommendations for the management of PDA in ELBW neonates are needed. Further study is required regarding the use of the less invasive option of percutaneous PDA closure in ELBW infants.

Perioperative anesthetic management of premature neonates weighing less than 1500 grams undergoing transcatheter PDA (TC-PDA) closure: An institutional anesthetic experience

Objectives

The aim of our study is to describe the various anesthetic techniques and intraoperative management used during transcatheter closure of hemodynamically significant PDAs in VLBW premature infants weighing less than 1.5 kg and their potential impact on postoperative outcomes using a retrospective chart review.

Design

A retrospective electronic medical chart review was performed in infants who underwent Transcatheter Patent Ductus Arteriosus (TC-PDA) closure at an academic institution between January 1, 2008 and October 4th 2019. Only premature patients with isolated PDA weighing less than 1500 g at the time of the procedure were included in the study.

Setting

Single Institutional Hospital.

Participants

Premature patients with isolated PDA weighing less than 1500 g at the time of the procedure.

Interventions

None.

Measurements and main results

Interprocedurally, there was no evidence of device embolization or clinically significant vascular obstruction on follow-up echocardiography, and inotropic or vasoactive infusions were not required. All patients survived and were discharged from the hospital after a mean of 86.4 ± 48.49 days (median 74, range 40-180) following initial admission to the NICU. At 7 post-operative days, freedom from ventilatory support reached 70% in all patients. Incidences of device embolization or clinically significant vascular obstruction were not noted on follow-up echocardiography.

Conclusions

Though our preliminary findings show promising outcomes following TC-PDA closure relative to traditional surgical approaches, further investigations with higher patient volume are needed to validate these promising observations.

Echocardiographic parameters predicting spontaneous closure of ductus arteriosus in preterm infants

Objective

To evaluate the value of echocardiographic parameters in predicting early spontaneous closure of ductus arteriosus in premature infants.

Methods

222 premature infants admitted to the neonatal ward of our hospital were selected, and patent ductus arteriosus was detected by echocardiography 48 h after birth. On the 7th day, whether the ductus arteriosus was closed naturally in this cohort was observed. The infants whose ductus arteriosus were not closed were identified as the PDA group (n = 109), and the other infants were included in the control group (n = 113). The echocardiographic parameters of the two groups of premature infants at 48 h after birth were single-factor statistically and Pearson correlation analyzed, and the parameters with statistically significant differences in single-factor analyzed were selected for multivariate logistic stepwise regression analysis.

Results

The ductus arteriosus shunt velocity and the pressure difference between the descending aorta and the pulmonary artery (ΔPs) in the PDA group were lower than those in the control group (P < 0.05). The pulmonary artery pressure (PASP) in the PDA group was higher than that in the control group (P < 0.05). According to the multivariate logistic stepwise regression analysis, only the maximum shunt velocity of ductus arteriosus was correlated with early spontaneous closure of ductus arteriosus in 48 h first echocardiographic parameters (P = 0.049). The receiver operating characteristic (ROC) curve indicates the optimal critical point of echocardiographic ductus arteriosus shunt velocity in premature infants 48 h after birth was 1.165 m/s.

Conclusion

Echocardiographic parameters are of great value in predicting the early spontaneous closure of ductus arteriosus in premature infants. In particular, the ductus arteriosus shunt velocity is correlated with the early spontaneous closure of ductus arteriosus.

Cost-effectiveness Analysis of Ibuprofen versus Indomethacin or Paracetamol for the Treatment of Patent Ductus Arteriosus in Preterm Neonates

OBJECTIVE

This was a first-time evaluation that sought to analyze the cost-effectiveness of oral paracetamol and intravenous (IV) indomethacin as alternatives to ibuprofen for PDA in neonates.

METHODS

Decision-analytic, literature-based, economic simulation models were constructed, to follow up the use and consequences of oral/IV ibuprofen versus IV indomethacin, and oral/IV ibuprofen versus oral paracetamol, as first-line therapies for PDA closure. Model outcomes of interest were 'success', defined as PDA closure with/without adverse events, or 'failure' due to no response to the first course of treatment, death or premature discontinuation of therapy due to AEs.

RESULTS

Oral ibuprofen is dominant/cost-effective over IV indomethacin in 97.9% of simulated cases, but oral paracetamol was 75.2% dominant/cost-effective over oral ibuprofen. Against IV ibuprofen, IV indomethacin was 55.3% dominant/cost-effective, whereas oral paracetamol was dominant/cost-effective in 98.5% of the cases. Sensitivity analyses confirmed the robustness of the study results.

CONCLUSION

For PDA closure, while IV indomethacin was cost-effective against IV ibuprofen, oral paracetamol was cost-effective against both oral and IV ibuprofen.

Fresh Frozen Plasma Transfusion: An Independent Risk Factor for Hemodynamically Significant Patent Ductus Arteriosus in Premature Infants

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..

Massive Gastric Hemorrhage after Indomethacin Therapy: A Rare Presentation and Critical Management in an Extremely Preterm Infant

Indomethacin has been widely used in preterm infants with hemodynamically significant patent ductus arteriosus (PDA). Gastrointestinal complications of indomethacin have been reported in 5% of treated neonates. However, massive gastric mucosa hemorrhage is a rarely reported complication. To the best of our knowledge, the infant in this report is the smallest reported in the literature to have undergone successful surgery for such a complication. A male preterm infant weighing 566 g was born at 25^2/7 weeks of gestational age without a complicated maternal history. Soon after birth, he received nasal noninvasive respiratory support and minimal feeding. PDA was observed since the first day of life (DOL), treatments were initiated on the second DOL for the hemodynamical significance, and PDA was closed after two courses of indomethacin therapy (0.2 mg/kg). At midnight on the seventh DOL, generalized pallor, bloody gastric drainage, and a distended stomach were observed. Massive gastric bleeding was suspected. He suffered from intermittent hypotension, which was corrected with blood products and fluid resuscitation under monitoring with a radial arterial line. Gastric lavage with cooling saline was performed twice but in vain. Prior to surgical consultation, intravascular volume transfusion was given twice. An exploratory laparotomy was arranged after obtaining the parents' consent. Blood oozing from the gastric mucosa was observed through gastrostomy and was successfully stopped via epinephrine-soaked gauze compression. After the operation, his clinical course remained uneventful, and he was discharged without neurological anomaly at two-year follow-up. Physicians need to be cautious of indomethacin's effect on platelet dysfunction in preterm infants with multiple predisposing factors. The tendency for mucosal bleeding should be continuously monitored after indomethacin therapy.

Respiratory Trajectory after Invasive Interventions for Patent Ductus Arteriosus of Preterm Infants

Invasive interventions have been conducted in preterm infants with significant patent ductus arteriosus (PDA) when medical treatment has failed, and methods of invasive intervention have been reported. Surgical ligation via lateral thoracotomy has been a well-established procedure for decades. Recently, transcatheter occlusion has been safely and feasibly applied to the premature population. However, little research has been conducted on the benefits of transcatheter occlusion in very-low-birth-weight (VLBW) infants compared to surgical ligation. This study compared transcatheter and surgical techniques in VLBW infants in terms of short-term respiratory outcomes. The medical records of 401 VLBW infants admitted to a tertiary hospital between September 2014 and January 2019 were retrospectively reviewed. Patients who were diagnosed with a congenital anomaly, a chromosomal anomaly, or congenital heart disease, except for an inter-atrial shunt, were excluded. The perinatal conditions, neonatal morbidities, periprocedural vital signs, and respiratory support trajectories were compared between the transcatheter-treated and surgically ligated group. A total of 31 eligible VLBW infants received invasive intervention: 14 were treated with transcatheter occlusion (Group A), and 17 infants were treated with surgical ligation (Group B). Respiratory outcomes were not statistically significant between the two groups, despite Group A showing a trend toward early improvement in post-intervention respiratory trajectory. In this small case study, a different trend in post-intervention respiratory trajectories was observed. Future research with larger case numbers should be conducted to address our preliminary observations in more detail.

Short-Term Complications Associated with Surgical Ligation of Patent Ductus Arteriosus in ELBW Infants: A 25-Year Cohort Study

OBJECTIVE

This article aims to determine the incidence of short-term complications of surgical patent ductus arteriosus (PDA) ligations, the factors associated with those complications, and whether complications are associated with poor long-term outcomes.

STUDY DESIGN

Retrospective cohort study of all extremely low birth weight (ELBW, < 1,000 g) infants who underwent surgical PDA ligation at a single-center neonatal intensive care unit from 1989 to 2015. Demographic, clinical, and laboratory data were reviewed. The primary outcome was development of a short-term (< 2 weeks from ligation) surgical complication. Secondary outcomes include bronchopulmonary dysplasia (BPD), length of stay, and mortality.

RESULTS

A total of 180 ELBW infants were included; median gestational age and birth weight was 24 weeks and 683 g, respectively, and 44% of infants had at least one short-term complication. Need for vasopressors (33%) was the most common medical complication and vocal cord paralysis (9%) was the most common surgical complication. Younger corrected gestational age at time of repair was associated with increased risk for complications. Mortality, length of stay, and BPD rates were similar between infants with and without complications.

CONCLUSION

Serious complications were seen in a minority of infants. Additional research is needed to determine if short-term complications are associated with long-term adverse outcomes.

Evaluation of the Risk Factors for Acute Kidney Injury in Neonates Exposed to Antenatal Indomethacin

OBJECTIVE

Evidence is limited about important maternal and neonatal risk factors that affect neonatal renal function. The incidence of acute kidney injury (AKI) and identification of associated risk factors in neonates exposed to antenatal indomethacin was studied.

METHODS

A retrospective cohort of neonates exposed to antenatal indomethacin within 1 week of delivery was analyzed for development of AKI up to 15 days of life. Adjusted hazard ratios (HRs) and 95% CIs for AKI risk were calculated in time-dependent Cox proportional hazards models.

RESULTS

Among 143 neonates with mean gestational age of 28.3 ± 2.4 weeks, AKI occurred in 62 (43.3%), lasting a median duration of 144 hours (IQR, 72-216 hours). Neonates with AKI had greater exposure to postnatal NSAIDs (48.4% vs 9.9%, p < 0.001) and inotropes (37.1% vs 3.7%, p < 0.001) compared with neonates without AKI. In multivariable-adjusted models, increased AKI risk was observed with antenatal indomethacin doses received within 24 to 48 hours (HR, 1.6; 95% CI, 1.28-1.94; p = 0.036) and <24 hours (HR, 2.33; 95% CI, 1.17-4.64; p = 0.016) prior to delivery. Further, postnatal NSAIDs (HR, 2.8; 95% CI, 1.03-7.61; p = 0.044), patent ductus arteriosus (HR, 4.04; 95% CI, 1.27-12.89; p = 0.018), and bloodstream infection (HR, 3.01; 95% CI, 1.37-6.60; p = 0.006) were associated significantly with increased risk of AKI following antenatal indomethacin. Neonates with AKI experienced more bloodstream infection, severe intraventricular hemorrhage, patent ductus arteriosus, respiratory distress syndrome, and longer hospitalization.

CONCLUSIONS

Extended risk of AKI with antenatal indomethacin deserves clinical attention among this population at an already increased AKI risk.

Influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in the prematurity

BACKGROUND

This study aims at evaluating the influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in prematurity.

METHODS

All preterm babies were divided into two groups, including Group 1 with "open PDA" and Group 2 with "closed PDA". The variables of platelet count, mean platelet volume, platelet mass index, and platelet function were analyzed and compared between two groups of patients to identify the factors that significantly influenced spontaneous closure of ductus arteriosus.

RESULTS

Twenty-four patients were in the "open PDA" group, whereas 36 patients were in the "closed PDA" group. Mean GA and BW were 27.6 ± 1.8 (23.1-30.4) and 28 ± 1.6 (23.4-30.6) weeks and 1009 ± 270 (585-1480) g and 1035 ± 298 (505-1500) g in "open PDA" and "closed PDA" groups, respectively (p > 0.05). The incidence of "Collagen-ADP > 130 s" was significantly higher in the "open PDA" group, and the levels of hemoglobin and hematocrit were significantly lower in the "open PDA" group (p < 0.05). Multivariate logistic regression analysis showed that respiratory distress syndrome (OR: 9, CI: 1.5-51.8) and collagen-ADP > 130 s (OR: 5.7 CI: 1.55-21.3) are two independent factors associated with ductal patency.

CONCLUSION

This is the first study in the English literature providing evidence of the influence of platelet dysfunction on the spontaneous closure of ductus arteriosus in prematurity. Longer collagen-ADP duration is identified as a risk factor of ductal closure.

Cord blood levels of osteopontin as a phenotype marker of gestational age and neonatal morbidities

OBJECTIVES

Osteopontin (OPN) is a proinflammatory cytokine associated with metabolic syndrome. Extreme birth weight categories including small for gestational age (SGA), and large for gestational age (LGA) are risk factors for metabolic syndrome. However normal levels of plasma OPN in neonates and the relationship of OPN to fetal growth remain unknown. We evaluated the association of umbilical cord blood OPN with gestational age, birth weight, and neonatal outcomes.

METHODS

A cross-sectional study of 261 newborns of all gestational ages beginning at week 26, and 26 adults for comparison was performed. Umbilical cord blood from newborns and analyzed plasma for OPN by ELISA was collected.

RESULTS

Plasma OPN was significantly higher in neonates (414.65 ± 136.72 ng/mL) compared to adults (33.37 ± 14.66 ng/mL, P < 0.001). There was an inverse correlation between OPN and gestational age (r = -0.48, P < 0.0001). LGA infants had lower OPN than appropriate for gestational age (AGA) infants, but LGA was not an independent predictor of OPN in multivariate analysis. Among preterm infants, patent ductus arteriosus (PDA) was independently associated with higher OPN (OR = 2.49, P = 0.02).

CONCLUSION

Our results raise the possibility that OPN has a physiologic role in fetal growth and development, and may be a useful biomarker for PDA.

Patent ductus arteriosus in preterm infants: do we have the right answers?

Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.

Management of patent ductus arteriosus in preterm infants: clinical judgment might be a fair option

OBJECTIVE

The objective of this study was to find out the percentage of preterm infants that needed treatment for patent ductus arteriosus (PDA), when treatment decision was based on clinical signs and symptoms, besides echocardiographic findings.

METHODS

Daily echocardiographic evaluation was conducted in 39 preterms ≤29(6/7) weeks' gestation. Patients with ductus arteriosus were closely followed-up for clinical symptoms of PDA for treatment decision until ductus arteriosus was closed either spontaneously or by treatment.

RESULTS

PDA was found in 25 (64%) infants. Mean gestational age and birth weight (BW) of the patients with PDA were 27.8 ± 1.2 and 998 ± 221 g, respectively. PDA closed spontaneously or had minimal ductal shunting before any signs and symptoms attributable to PDA were observed in 16 (41%) infants. Mean ductus size/BW ratio and mean left atrial/aortic root ratio were significantly higher in 9 (23%) symptomatic patients (2.06 ± 0.75 versus 1.32 ± 0.75 mm, p = 0.012 and 1.31 ± 0.52 versus 1.19 ± 0.2 mm, p = 0.043, respectively). PDA closure was observed after the first dose of ibuprofen in six of nine patients.

CONCLUSION

Correlation of clinical signs with echocardiographic findings for the decision of PDA treatment can be appropriate to prevent unnecessary medical treatments.