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Pediatric Research Dec 2022To develop a model for prediction of severe intracranial hemorrhage (ICH) or death based on variables from the first 12 h of age and to compare mortality and...
BACKGROUND
To develop a model for prediction of severe intracranial hemorrhage (ICH) or death based on variables from the first 12 h of age and to compare mortality and morbidities with and without exposure to early indomethacin.
METHODS
This retrospective cohort study included extreme preterm (22-26 weeks) infants born at National Institute of Child Health and Human Development Neonatal Research Network sites. Primary outcome was a composite of severe ICH and/or death.
RESULTS
Of 4624 infants, 1827 received early indomethacin. Lower gestation, lack of antenatal steroids exposure, lower 1-min Apgar, male sex, and receipt of epinephrine were associated with severe ICH or death. Early indomethacin was associated with a lower risk of patent ductus arteriosus, bronchopulmonary dysplasia, and higher risk of spontaneous intestinal perforation.
CONCLUSIONS
A model for early prediction of severe ICH/death was developed and validated. Early indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of spontaneous intestinal perforation.
CLINICAL TRIAL REGISTRATION
Not applicable.
IMPACT
Modern data on severe ICH and neonatal morbidities in relation to prophylactic indomethacin are scarce in the published literature. Prophylactic indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of intestinal perforation. A risk estimator for severe intracranial hemorrhage/death was developed in a large cohort of extremely preterm infants. The risk estimator developed based on a large cohort of patients provides an estimate of severe intracranial bleeding for an individual infant.
Topics: Pregnancy; Infant; Child; Humans; Infant, Newborn; Male; Female; Indomethacin; Ductus Arteriosus, Patent; Bronchopulmonary Dysplasia; Retrospective Studies; Intestinal Perforation; Infant, Extremely Premature; Intracranial Hemorrhages
PubMed: 35301420
DOI: 10.1038/s41390-022-02012-z -
Journal of the American Society of... Apr 2021High-volume systemic-to-pulmonary ductus arteriosus shunts in premature infants are associated with adverse neonatal outcomes. The role of an atrial communication (AC)...
BACKGROUND
High-volume systemic-to-pulmonary ductus arteriosus shunts in premature infants are associated with adverse neonatal outcomes. The role of an atrial communication (AC) in modulating the effects of a presumed hemodynamically significant patent ductus arteriosus (PDA) is poorly studied. The objective of this study was to characterize the relationship between early AC and echocardiographic indices of PDA shunt volume and clinical neonatal outcomes.
METHODS
A retrospective review of preterm infants (born at <32 weeks' gestation) who underwent echocardiography in the first postnatal week was performed. The cohort was divided into four groups on the basis of presence of a presumed hemodynamically significant PDA (≥1.5 vs <1.5 mm) and AC size (≤1 vs >1 mm), and echocardiographic measures of PDA shunt volume were then compared. Clinical outcomes, including chronic lung disease and intraventricular hemorrhage, were also compared among all four groups.
RESULTS
A total of 199 preterm infants (mean birth weight, 928 ± 632 g; mean gestational age, 26.6 ± 1.5 weeks) were identified; 159 infants had PDAs ≥ 1.5 mm, of whom 52 had ACs ≤ 1 mm and 107 had ACs > 1 mm. The remaining 40 infants had PDAs < 1.5 mm, of whom 23 had ACs ≤ 1 mm and 17 had ACs > 1 mm. Infants with PDAs ≥ 1.5 mm and ACs > 1 mm had higher pulmonary vein D-wave velocities (P < .05), higher left ventricular output (P < .005), higher PDA scores (P < .001), and increased rates of reversed diastolic flow in the descending aorta (P < .001), celiac artery (P < .001), and middle cerebral artery (P < .001) than infants with either PDAs < 1.5 mm or PDAs ≥ 1.5 mm and ACs ≤ 1 mm. There was no difference in the incidence of intraventricular hemorrhage, but infants with PDAs ≥ 1.5 mm and ACs > 1 mm had a higher risk for a composite outcome of chronic lung disease or death before hospital discharge (P < .05).
CONCLUSIONS
Echocardiographic evidence of ACs > 1 mm in patients with PDAs ≥ 1.5 mm during the first postnatal week may be a marker of a more pathologic hemodynamically significant PDA in premature infants. Future investigations should evaluate if early identification and treatment of patients with both high-volume PDAs and larger atrial-level communications may help mitigate adverse outcomes, such as chronic lung disease or death, in this high-risk patient population.
Topics: Adult; Communication; Ductus Arteriosus, Patent; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Retrospective Studies
PubMed: 33227390
DOI: 10.1016/j.echo.2020.11.008 -
Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants.Jornal de Pediatria 2020Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main...
OBJECTIVE
Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation.
METHOD
Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared.
RESULTS
This study included 188 patients (27±2 weeks, 973±272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p<0.001) and surgical closure (34.5% P1 versus 16.1% P2, p<0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p=0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p=0.403), necrotizing enterocolitis (15.5% versus 6.9%, p=0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p=0.264), mortality (17.5% versus 15.2%, p=0.690) or survival-without-morbidity adjusted OR=1.10 (95% CI: 0.55-2.22); p=0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n=82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p=0.019) and more survival-without-morbidity (20% versus 45.6%, p=0.028) were found.
CONCLUSION
A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.
Topics: Conservative Treatment; Ductus Arteriosus, Patent; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Ligation; Treatment Outcome
PubMed: 30423323
DOI: 10.1016/j.jped.2018.10.004 -
Archives of Cardiovascular Diseases 2016Transcatheter therapy is the first-line treatment for closure of patent ductus arteriosus (PDA). A range of different devices have been used.
BACKGROUND
Transcatheter therapy is the first-line treatment for closure of patent ductus arteriosus (PDA). A range of different devices have been used.
AIM
To report our experience using the new Occlutech(®) PDA occluder for closure of PDA.
METHODS
All consecutive patients receiving an Occlutech(®) PDA occluder for closure of PDA from March 2014 to May 2015 were included in the study. Occluders were implanted using a conventional technique. After cardiac catheterization, transthoracic echocardiography was performed sequentially. Residual shunting and procedural and mid-term complications, including embolization, device-induced left pulmonary artery stenosis and aortic coarctation, were systematically assessed and reported.
RESULTS
Fifty-six patients (35 females) with a median age of 1 year (range: 29 days to 24 years) were included in the study. PDAs were closed successfully using device number 5/3.5 in 17 patients, 6/4 in 28 patients, 7/5 in four patients, 8/6 in six patients and 10/8 in one patient. Post-implantation angiography showed no residual shunt in 10 patients (17.8%), moderate intraprosthetic shunt in 43 patients (76.8%) and severe shunt in three patients (5.4%). One device embolized in the right pulmonary artery 1hour after successful closure; the device was retrieved surgically after unsuccessful snaring. After a mean follow-up of 10 months (range: 3-17.8 months), no residual shunt or device-related complications were noted.
CONCLUSION
The new Occlutech(®) PDA occluder allows safe and efficient PDA closure, similar to existing devices.
Topics: Adolescent; Cardiac Catheterization; Child; Child, Preschool; Coronary Angiography; Device Removal; Ductus Arteriosus, Patent; Echocardiography; Female; Foreign-Body Migration; Humans; Infant; Infant, Newborn; Male; Paris; Prosthesis Design; Pulmonary Embolism; Septal Occluder Device; Time Factors; Treatment Outcome; Young Adult
PubMed: 26988839
DOI: 10.1016/j.acvd.2015.12.003 -
Journal of the Formosan Medical... May 2023Contrast pooling (CP) reconstruction is widely used in computed tomography (CT) studies of congenital heart diseases. However, endovascular devices are usually obscured...
Contrast pooling (CP) reconstruction is widely used in computed tomography (CT) studies of congenital heart diseases. However, endovascular devices are usually obscured in CP. To improve visualization of the vascular lumen, we developed jellyfish angiography (JFA), a semitransparent blood pool inversion technique. Ten CT studies of patent ductus arteriosus (PDA) or coarctation of the aorta (CoA) were selected retrospectively for reconstruction using both CP and JFA. Four of the studies were conducted before the endovascular intervention, and six were conducted after the intervention. Radiology residents and pediatric cardiologists completed questionnaires regarding the reconstruction models. For radiology residents, JFA was superior to CP in postintervention PDA diagnosis, device evaluation, and overall satisfaction. For pediatric cardiologists, JFA outperformed CP in both PDA and CoA postintervention cases. Our findings show that JFA overcomes the disadvantages of CP and can improve the visualization of intraluminal devices which is essential for endovascular treatment evaluation.
Topics: Child; Humans; Retrospective Studies; Tomography, X-Ray Computed; Angiography; Ductus Arteriosus, Patent; Heart Defects, Congenital
PubMed: 36609102
DOI: 10.1016/j.jfma.2022.12.014 -
European Journal of Pediatrics Jun 2022To gain insight in the availability of guidelines, diagnostic criteria, and treatment strategies and whether clinical equipoise regarding optimal treatment for patent...
To gain insight in the availability of guidelines, diagnostic criteria, and treatment strategies and whether clinical equipoise regarding optimal treatment for patent ductus arteriosus (PDA) in prematurity is present. We hypothesized that (co-)authors of PDA-related papers were more likely to screen for a PDA and would treat earlier and more aggressively. An international internet-based survey between September 2019 and March 2020 in which we collected (1) baseline characteristics; (2) availability of guidelines; (3) screening strategy for PDA; (4) diagnostic criteria for hemodynamic significance; (5) treatment strategy; and (6) metrics of treatment efficacy. Finally, ten clinical equipoise statements were posed on a Likert scale. In total, 144 surveys were sent, of which 71/144 (49%) surveys could be analyzed with 56/71 (79%) fully completed surveys. The respondents, mainly neonatologists in a level III neonatal intensive care unit, of whom 36/71 (51%) had (co-)authored a publication on the PDA, highlighted a lack of national guidelines, heterogeneous approach to screening strategies, and marked variability in diagnostic criteria to assess hemodynamic significance, treatment strategies and effect measurement. No major significant differences were observed between respondents who did or did not (co-)author a publication on the PDA. Respondents who screened for PDA scored significantly higher on the need for screening, early and aggressive treatment. Remarkably, the scores of all statements regarding clinical equipoise varied widely. Conclusions: Our survey highlights the lack of guidelines and enormous heterogeneity in current practice. Current evidence is not robust enough to harmonize current treatment strategies into (inter)national guidelines. What is Known: • Patent ductus arteriosus (PDA) incidence is inversely related to gestational age. • Although early pharmacological treatment induces PDA closure, optimal treatment is debated due to the lack of beneficial effects on outcome. What is New: • In the absence of (inter)national guidelines, diagnostic and treatment strategies are heterogeneous and contradictory, even in a selected hemodynamically- interested group. • Different PDA screening strategies did, while PDA publication status did not, show significant differences in treatment strategy and responses to equipoise statements.
Topics: Consensus; Ductus Arteriosus, Patent; Humans; Ibuprofen; Indomethacin; Infant, Newborn; Infant, Premature; Surveys and Questionnaires
PubMed: 35305143
DOI: 10.1007/s00431-022-04441-8 -
The Journal of Pediatrics Oct 2016To determine whether a nonintervention approach for treating hemodynamically significant patent ductus arteriosus (PDA) is associated with decreased mortality and/or...
OBJECTIVE
To determine whether a nonintervention approach for treating hemodynamically significant patent ductus arteriosus (PDA) is associated with decreased mortality and/or morbidity compared with a mandatory closure approach in extremely low birth weight infants.
STUDY DESIGN
We reviewed the medical records of 178 infants of 23-26 weeks' gestational age with PDA, requiring ventilator treatment, and with hemodynamically significant PDA ≥2 mm in size. Mandatory closure was used during period I (July 2009 to December 2011, n = 81), and nonintervention was used during period II (January 2012 to June 2014, n = 97).
RESULTS
During period I, 64% of infants were first treated with indomethacin, and 82% were ultimately ligated surgically. During period II, no infant was treated with indomethacin and/or ligation. The average postnatal day of PDA closure was day 13 and day 44 during periods I and II, respectively. There was significantly more use of diuretics and fluid restriction during period II compared with period I. There was no difference in mortality or morbidities such as necrotizing enterocolitis or intraventricular hemorrhage. The incidence of bronchopulmonary dysplasia (BPD) and the propensity score adjusted OR of BPD were significantly lower during period II compared with period I.
CONCLUSIONS
Despite longer PDA exposure, nonintervention was associated with significantly less BPD compared with mandatory closure. Additional study is warranted to determine the benefits and risks of non-intervention for the hemodynamically significant PDA in extremely low birth weight infants.
Topics: Cyclooxygenase Inhibitors; Ductus Arteriosus, Patent; Female; Gestational Age; Humans; Indomethacin; Infant, Newborn; Infant, Premature; Infant, Very Low Birth Weight; Male; Propensity Score; Plastic Surgery Procedures; Retrospective Studies
PubMed: 27453374
DOI: 10.1016/j.jpeds.2016.06.046 -
BMC Pediatrics Jun 2021Patent ductus arteriosus (PDA) is a common complication in very preterm infants. It is known that there is an association between PDA and development of bronchopulmonary... (Randomized Controlled Trial)
Randomized Controlled Trial
Patent ductus arteriosus, systemic NT-proBNP concentrations and development of bronchopulmonary dysplasia in very preterm infants: retrospective data analysis from a randomized controlled trial.
BACKGROUND
Patent ductus arteriosus (PDA) is a common complication in very preterm infants. It is known that there is an association between PDA and development of bronchopulmonary dysplasia (BPD) or death before the postmenstrual age (PMA) of 36 weeks, but this association remains one of the most controversial aspects of the problem. The study aimed to evaluate the relationship between PDA, serum NT-proBNP levels at 2-3 and 8-9 days of life, and BPD/death in very preterm infants.
METHODS
Data of 52 preterm infants with a gestational age < 32 weeks, chronological age < 72 h, and PDA diameter > 1.5 mm, enrolled in a randomized controlled trial, were used for the retrospective analysis. All patients underwent daily echocardiographic and two serum NT-proBNP measurements within the first 10 days after birth. Two groups of infants were formed retrospectively at PMA of 36 weeks depending on the outcome, BPD (n = 18)/death (n = 7) or survival without BPD (n = 27). Receiver operator characteristic (ROC) curve was used to evaluate the predictive performance of serum NT-proBNP levels for BPD/death occurrence.
RESULTS
The percentage of infants who received pharmacological treatment for PDA did not differ between the groups. Based on the area under the ROC curve, serum NT-proBNP levels on the 2-3 day of life (AUC = 0.71; 95% confidence interval (CI): 0.56-0.9; p = 0.014)) and on the 8-9 day of life (AUC = 0.76; 95% CI: 0.6-0.9; p = 0.002) could reliably predict BPD/death in very preterm infants who had PDA diameter > 1.5 mm in the first 72 h of life. Hemodynamically significant PDA (hsPDA) was significantly more often detected in newborns with BPD/death, however, treatment of infants with hsPDA did not reduce the incidence of BPD/death.
CONCLUSIONS
In very preterm infants with PDA > 1.5 mm at the age of 24-48 h, serum NT-proBNP concentration could reliably predict the development of BPD or death, regardless of the persistence of PDA, with the highest diagnostic value at 8-9 days.
TRIAL REGISTRATION
This study is registered in ClinicalTrials.gov - NCT03860428 on March 4, 2019.
Topics: Biomarkers; Bronchopulmonary Dysplasia; Data Analysis; Ductus Arteriosus, Patent; Humans; Infant; Infant, Newborn; Infant, Premature; Natriuretic Peptide, Brain; Peptide Fragments; Retrospective Studies
PubMed: 34147090
DOI: 10.1186/s12887-021-02750-9 -
Archives of Cardiovascular Diseases Mar 2022Transcatheter closure of a patent ductus arteriosus in children is widely performed to reduce symptoms and decrease the risk of endocarditis. Most arterial ducts are... (Observational Study)
Observational Study
BACKGROUND
Transcatheter closure of a patent ductus arteriosus in children is widely performed to reduce symptoms and decrease the risk of endocarditis. Most arterial ducts are closed successfully with dedicated devices. However, in a tubular or "type C" patent ductus arteriosus with congestive heart failure, the occlusion is more challenging with these devices, with a higher risk of complications, such as aortic or left pulmonary stenosis and device embolization.
AIM
To report our experience with muscular ventricular septal defect devices for patent ductus arteriosus occlusion in small children.
METHODS
Retrospective observational series of patients weighing<10kg, with a tubular patent ductus arteriosus (typeC) and congestive heart failure, who underwent transcatheter closure with a muscular ventricular septal defect device between 2017 and 2019.
RESULTS
Eight patients were included. The mean age and weight at closure were 6.3 months (range 1-18 months) and 5.3kg (range 2.4-8.2kg), respectively. All patent ductus arteriosus were occluded successfully using Occlutech® (N=3) or Amplatzer® (N=5) muscular ventricular septal defect devices. In four cases, the muscular ventricular septal defect device was used after failure to close the patent ductus arteriosus with a dedicated patent ductus arteriosus device. Two patients had mild left pulmonary artery stenosis, with a maximum velocity on continuous Doppler of 3m/s and 2.7m/s, respectively. After a mean follow-up of 28 months (range 14-41 months), all patients were asymptomatic with excellent results. The mild pulmonary stenosis improved, with a maximum velocity of 2.3m/s in both patients.
CONCLUSIONS
Closure of tubular patent ductus arteriosus in small children with congestive heart failure using a muscular ventricular septal defect device is safe in this preliminary experience. Further studies with more patients are warranted.
Topics: Cardiac Catheterization; Child; Ductus Arteriosus, Patent; Heart Failure; Heart Septal Defects, Ventricular; Humans; Infant; Pulmonary Valve Stenosis; Retrospective Studies; Septal Occluder Device; Treatment Outcome
PubMed: 35249850
DOI: 10.1016/j.acvd.2022.01.003 -
Italian Journal of Pediatrics Jan 2021Association between persistency of a patent ductus arteriosus (PDA) and morbidity in preterm newborns is still controversial. We aimed to investigate the relation...
INTRODUCTION
Association between persistency of a patent ductus arteriosus (PDA) and morbidity in preterm newborns is still controversial. We aimed to investigate the relation between PDA and morbidity in a large retrospective study.
METHODS
A case-control study including neonates consecutively admitted to the Neonatal Intensive Care Unit (NICU), with gestational age (GA) < 32 weeks or body birth weight (BW) < 1500 g, over a 5-year period. Newborns were divided into Cases and Controls, according with the presence or absence of a hemodynamically significant PDA (hs-PDA).
RESULTS
We enrolled 85 Cases and 193 Controls. Subjects with hs-PDA had significantly (p < 0.001) lower GA (26.7 w, 95%CI 27.1-28.0 vs. 30.1 w, 95%CI 29.7-30.4), BW (1024 g, 95% CI 952-1097 vs. 1310 g 95%CI 1263-1358) and an increased morbidity (60.0% vs. 18.7%). In a sub-group of extremely preterm newborns (GA ≤ 28 weeks and BW ≤ 1000 g), the rate of bronchopulmonary dysplasia (BPD) was significantly increased in Cases (31.7%) compared with Controls (5.9%, p = 0.033). Multivariate analysis showed that morbidity significantly depended on hs-PDA, GA and BW, and that, in extremely preterms, the hs-PDA represented an independent risk factor for BPD.
CONCLUSIONS
Occurrence of the main morbidities of prematurity depended by hs-PDA, in association with GA, BW, and use of prenatal steroids. In extremely premature babies, hs-PDA is a risk factor for BPD, one of the most important morbidity of prematurity, independently by other confounding variables.
Topics: Ductus Arteriosus, Patent; Female; Humans; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Infant, Very Low Birth Weight; Italy; Logistic Models; Male; Morbidity; Respiration, Artificial; Retrospective Studies; Risk Factors
PubMed: 33446244
DOI: 10.1186/s13052-021-00956-2