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Journal of the American Heart... Feb 2016Percutaneous closure of patent ductus arteriosus (PDA) in term neonates is established, but data regarding outcomes in infants born very preterm (<32 weeks of gestation)...
BACKGROUND
Percutaneous closure of patent ductus arteriosus (PDA) in term neonates is established, but data regarding outcomes in infants born very preterm (<32 weeks of gestation) are minimal, and no published criteria exist establishing a minimal weight of 4 kg as a suitable cutoff. We sought to analyze outcomes of percutaneous PDA occlusion in infants born very preterm and referred for PDA closure at weights <4 kg.
METHODS AND RESULTS
Retrospective analysis (January 2005-January 2014) was done at a single pediatric center. Procedural successes and adverse events were recorded. Markers of respiratory status (need for mechanical ventilation) were determined, with comparisons made before and after catheterization. A total of 52 very preterm infants with a median procedural weight of 2.9 kg (range 1.2-3.9 kg) underwent attempted PDA closure. Twenty-five percent (13/52) of infants were <2.5 kg. Successful device placement was achieved in 46/52 (88%) of infants. An adverse event occurred in 33% of cases, with an acute arterial injury the most common complication. We observed no association between weight at time of procedure and the risk of an adverse event. No deaths were attributable to the PDA closure. Compared to precatheterization trends, percutaneous PDA closure resulted in improved respiratory status, including less exposure to mechanical ventilation (mixed effects logistic model, P<0.01).
CONCLUSIONS
Among infants born very preterm, percutaneous PDA closure at weights <4 kg is generally safe and may improve respiratory health, but risk of arterial injury is noteworthy. Randomized clinical trials are needed to assess clinically relevant differences in outcomes following percutaneous PDA closure versus alternative (surgical ligation) management strategies.
Topics: Birth Weight; Cardiac Catheterization; Ductus Arteriosus, Patent; Feasibility Studies; Female; Gestational Age; Humans; Infant, Low Birth Weight; Infant, Premature; Linear Models; Logistic Models; Male; Recovery of Function; Respiration; Respiration, Artificial; Retrospective Studies; Risk Factors; Septal Occluder Device; Time Factors; Treatment Outcome; Vascular System Injuries
PubMed: 26873689
DOI: 10.1161/JAHA.115.002923 -
The Journal of Maternal-fetal &... Dec 2023The evaluation of upcoming Aortic Coarctation (CoA) in new-borns with prenatal suspicion entails a close echocardiographic monitor until Arterial Duct (AD) closure, in a...
INTRODUCTION
The evaluation of upcoming Aortic Coarctation (CoA) in new-borns with prenatal suspicion entails a close echocardiographic monitor until Arterial Duct (AD) closure, in a department with pediatric cardiological and surgical expertise. The significant number of false-positive prenatal diagnoses causes parental stress and healthcare costs.
AIM
The aim of this study was to elaborate an echocardiographic prediction model to be employed at birth when PDA is still present, in patients suspected of CoA during fetal life in order to foretell CoA requiring neonatal surgical intervention.
METHODS
This retrospective monocentric study included consecutive full-term and late preterm neonates with prenatal suspicion of CoA born from 01 January 2007 to 31 December 2020. Patients were divided into two groups according to the need for aortic surgery (CoA - NoCoA). All patients underwent a comprehensive transthoracic echocardiographic exam in presence of PDA. Multivariable logistic regression was used to create a coarctation probability model (CoMOD) including isthmal (D4), transverse arch (D3) diameters, the distance between a left common carotid artery (LCA) and left subclavian artery (LSA), presence/absence of ventricular septal defect (VSD) and bicuspid aortic valve (BAV).
RESULTS
We enrolled 87 neonates (49 male, 56%). 44 patients developed CoA in need of surgical repair. Our index CoMOD showed an AUC = 0.9382, high sensitivity (91%) and specificity (86%) in the prediction of CoA in neonates with prenatal suspicion. We classified neonates with CoMOD > 0 to be at high risk for surgical correction of CoA, with good PPV (86.9%) and NPV (90.9%).
CONCLUSIONS
CoMOD > 0 is highly suggestive of the need for CoA corrective surgery in newborns with prenatal suspicion.
Topics: Child; Pregnancy; Female; Humans; Male; Infant, Newborn; Ductus Arteriosus, Patent; Aortic Coarctation; Retrospective Studies; Echocardiography; Aorta, Thoracic
PubMed: 37073133
DOI: 10.1080/14767058.2023.2201654 -
BMC Pediatrics Sep 2019Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term...
BACKGROUND
Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm.
METHODS
Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort.
DISCUSSION
The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit.
TRIAL REGISTRATION
ClinicalTrials.gov NCT03782610. Registered 20 December 2018.
Topics: Biomarkers; Data Collection; Ductus Arteriosus, Patent; Echocardiography, Doppler; Gestational Age; Humans; Infant; Infant, Newborn; Infant, Premature; Neurodevelopmental Disorders; Outcome Assessment, Health Care; Patient Selection; Prospective Studies; Remission, Spontaneous; Respiration Disorders; Severity of Illness Index; Time Factors; United States
PubMed: 31519154
DOI: 10.1186/s12887-019-1708-z -
Neonatology 2020Although patent ductus arteriosus (PDA) has been implicated to play a role in the development of cerebral ischemia and intraventricular hemorrhage (IVH) through a...
INTRODUCTION
Although patent ductus arteriosus (PDA) has been implicated to play a role in the development of cerebral ischemia and intraventricular hemorrhage (IVH) through a cerebral steal phenomenon, there is conflicting data on the impact of PDA size on cerebral blood flow (CBF). Cerebral autoregulation is the brain's innate protective mechanism to maintain constant CBF despite changes in blood pressure, and it is unclear if it is influenced by PDA hemodynamics.
OBJECTIVE
To delineate the relationship between PDA size and CBF velocity (CBFv) in premature infants.
METHODS
113 premature infants born at 23-29 weeks' gestation had echocardiograms performed during the first week after birth to evaluate for PDA. The infants were divided into 3 groups according to PDA size: none-to-small, moderate, or large. All infants had continuous recordings of umbilical artery blood pressure (ABP) and CBFv during the first week after birth. Critical closing pressure (CrCP) was calculated from ABP and CBFv tracings. Diastolic closing margin (DCM), defined as diastolic blood pressure minus CrCP, was calculated as a marker for the risk of developing IVH.
RESULTS
Infants with a large PDA (n = 16) had the lowest ABP across all phases of the cardiac cycle (systole [p = 0.003], mean [p = 0.005], and diastole [p = 0.012]) compared to infants with a moderate (n = 19) or none-to-small PDA (n = 78). Despite blood pressure being different, systolic, mean, and diastolic CBFv were not different across groups. Cerebral autoregulation, as measured during systole, was intact regardless of the PDA size. CrCP and DCM were also not different across groups.
CONCLUSIONS
In this cohort, CBFv and cerebral autoregulation during systole were not influenced by PDA size. Intact cerebral autoregulation may play a role in maintaining CBFv regardless of PDA size and differences in ABP.
Topics: Ductus Arteriosus, Patent; Hemodynamics; Humans; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases
PubMed: 32434188
DOI: 10.1159/000506835 -
Neonatology 2019The natural history and optimal management of a patent ductus arteriosus (PDA) among infants with established severe bronchopulmonary dysplasia (sBPD) remains uncertain. (Comparative Study)
Comparative Study
BACKGROUND
The natural history and optimal management of a patent ductus arteriosus (PDA) among infants with established severe bronchopulmonary dysplasia (sBPD) remains uncertain.
OBJECTIVES
To describe the characteristics of PDA present at ≥36 weeks' postmenstrual age (PMA) and the effects of late surgical PDA closure in a referral cohort of very preterm infants with sBPD.
STUDY DESIGN
This retrospective cohort study was performed in a tertiary neonatal intensive care unit. Study infants were born at <32 weeks' gestation between 2010 and 2016, diagnosed with sBPD, and had an echocardiographic PDA at ≥36 weeks' PMA. We reviewed echocardiograms performed closest to 3 time points (≥36 weeks' PMA, hospital discharge, and 1 year of age) and assessed clinical outcomes among infants with versus without late PDA treatment.
RESULTS
Among 329 infants with sBPD, 59 had a PDA at ≥36 weeks' PMA. Most PDAs were small (n = 33) and shunted left to right (n = 53). The PDA closed spontaneously prior to discharge in 5 of 21 infants who did not undergo surgical closure and decreased in size in 3. The PDA spontaneously closed by 1 year of age in 6 out of 12 infants with an open duct at discharge. PDA surgery (n = 23) at ≥36 weeks' PMA was not associated with increased risk for the composite outcome of tracheostomy, systemic vasodilator at discharge, or death after adjusting for potential confounders (OR 3.2, 95% CI 0.81-13.0).
CONCLUSIONS
The majority of conservatively treated late PDAs closed spontaneously or decreased in size.PDA surgery was not associated with severe adverse clinical outcomes.
Topics: Bronchopulmonary Dysplasia; Cardiac Surgical Procedures; Conservative Treatment; Ductus Arteriosus, Patent; Female; Gestational Age; Humans; Infant; Infant, Newborn; Infant, Premature; Male; Netherlands; Premature Birth; Retrospective Studies; Risk Factors; Severity of Illness Index; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 31269508
DOI: 10.1159/000500269 -
European Heart Journal Nov 2022
Topics: Humans; Ductus Arteriosus, Patent; Pulmonary Artery; Aneurysm; Pulmonary Circulation
PubMed: 35943890
DOI: 10.1093/eurheartj/ehac438 -
British Journal of Clinical Pharmacology Jul 2022Ibuprofen and indomethacin are the preferred drug treatment for patent ductus arteriosus (PDA) in preterm neonates. The comparative safety and efficacy of paracetamol as... (Meta-Analysis)
Meta-Analysis Review
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.
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-analysed the available data.
RESULTS
There were 1718 neonates from 20 eligible studies. Paracetamol did not differ from ibuprofen or indomethacin regarding the primary (odds ratio [OR]: 0.93; 95% confidence interval [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 fewer adverse effects.
Topics: Acetaminophen; Anti-Inflammatory Agents, Non-Steroidal; Ductus Arteriosus, Patent; Humans; Ibuprofen; Indomethacin; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Randomized Controlled Trials as Topic
PubMed: 35203104
DOI: 10.1111/bcp.15291 -
Annals of Noninvasive Electrocardiology... May 2022Numerous studies have shown that QT dispersion (QTd) can be a suitable criterion for risk assessment of arrhythmia in patients with congenital heart disease. Pulmonary...
BACKGROUND
Numerous studies have shown that QT dispersion (QTd) can be a suitable criterion for risk assessment of arrhythmia in patients with congenital heart disease. Pulmonary arterial hypertension (PAH) increases the risk of cardiac arrhythmia by changing ventricular repolarization homogeneity. In this study, we assessed QTd changes after PDA device closure and the effect of PAH on these changes.
METHODS
Between October 2018 and March 2021, 97 patients (48 males; 49 females; mean age 31.36 ± 4.26 months; range 3 months to 14 years) who satisfied the primary inclusion criteria and did not meet the exclusion criteria and underwent PDA device closure intervention were included in the study. Echocardiography was performed before the procedure. QT corrected (QTc), and QTd and PR intervals were measured according to the patients' standard 12-lead ECGs in two periods, preoperative (1 day) and after (3 months).
RESULTS
In the general group, QTc and QTd decreased significantly after PDA closure. Based on our classification of the patients in two groups of high PAP and normal PAP, the three parameters QTc, QTd, and PR interval were assessed separately in the two groups. All three parameters decreased significantly in the normal PAP and high PAP groups.
CONCLUSIONS
However, a left-to-right shunt through the patent ductus arteriosus can affect ventricular repolarization; this effect seems to be particularly more significant when there is pulmonary hypertension.
Topics: Arrhythmias, Cardiac; Child; Ductus Arteriosus, Patent; Echocardiography; Electrocardiography; Female; Humans; Hypertension, Pulmonary; Infant; Male; Pediatrics
PubMed: 35267238
DOI: 10.1111/anec.12945 -
Nutrients Dec 2019The management of enteral feeds in preterm infants with a hemodynamically significant patent ductus arteriosus (hs-PDA) is a major challenge for neonatologists due to... (Review)
Review
The management of enteral feeds in preterm infants with a hemodynamically significant patent ductus arteriosus (hs-PDA) is a major challenge for neonatologists due to the fear of gastrointestinal (GI) complications. This review aims to analyze the available evidence on the complex relation between the presence and management of PDA, enteral feeding practices, and GI outcomes in the preterm population. There is limited evidence, based on small and heterogeneous trials, that hs-PDA may affect the splanchnic hemodynamic response to enteral feeds. While the presence of PDA seems a risk factor for adverse GI outcomes, the benefits of feeding withholding during pharmacological PDA treatment are controversial. The lack of robust evidence in support of or against a timely feeding introduction or feeding withholding during pharmacological PDA closure in preterm neonates does not allow to draw any related recommendation. While waiting for further data, the feeding management of this population should be carefully evaluated and possibly individualized on the basis of the infants' hemodynamic and clinical characteristics. Large, multicentric trials would help to better clarify the physiological mechanisms underlying the development of gut hypoperfusion, and to evaluate the impact of enteral feeds on splanchnic hemodynamics in relation to PDA features and treatment.
Topics: Acetaminophen; Anti-Inflammatory Agents, Non-Steroidal; Cyclooxygenase Inhibitors; Ductus Arteriosus, Patent; Enteral Nutrition; Gastrointestinal Diseases; Hemodynamics; Humans; Ibuprofen; Indomethacin; Infant, Newborn; Infant, Premature; PubMed; Splanchnic Circulation
PubMed: 31892190
DOI: 10.3390/nu12010083 -
BMJ Paediatrics Open Dec 2023Dexamethasone is widely used as a systemic corticosteroid to treat and prevent bronchopulmonary dysplasia (BPD) in preterm infants. We evaluated the current epidemiology...
BACKGROUND
Dexamethasone is widely used as a systemic corticosteroid to treat and prevent bronchopulmonary dysplasia (BPD) in preterm infants. We evaluated the current epidemiology of dexamethasone use to prevent BPD and analyse the factors associated with the response to dexamethasone in very low birthweight infants using a nationwide database.
METHODS
We included very low birthweight infants born between January 2013 and December 2020 with a gestational age of 23-31 weeks using data from the Korean Neonatal Network registry. Patients were grouped based on their dexamethasone use into 'Dex' or 'No Dex' groups. Clinical variables and data were collected, and the annual trends of dexamethasone use and the proportion of patients who received dexamethasone according to gestational age were analysed. Respiratory outcomes were compared between the groups. Univariate and multivariate analyses were performed to analyse factors associated with the response to dexamethasone in BPD.
RESULTS
Of 11 261 eligible infants, 2313 (20.5%) received dexamethasone, and 1714 (74.1%) of them were diagnosed with moderate-to-severe BPD. The 8-year annual prevalence of dexamethasone use was 17.7-22.3%. The 'Dex' group had more moderate-to-severe BPD, more frequent invasive ventilation use at a postmenstrual age of 36 weeks and longer ventilator duration. Birth weight, 5-minute APGAR score, pulmonary hypertension within the first 28 days, surgical treatment of patent ductus arteriosus, medical treatment of patent ductus arteriosus, pathological chorioamnionitis, hydrocortisone or budesonide use, surgical management of necrotising enterocolitis and fungal sepsis were associated with BPD after dexamethasone use.
CONCLUSIONS
Approximately 20.5% of preterm infants received dexamethasone, and the frequency increased as gestational age decreased. Poor response to dexamethasone was associated with antenatal and postnatal inflammation, low birth weight and early pulmonary hypertension.
Topics: Infant; Infant, Newborn; Humans; Female; Pregnancy; Infant, Premature; Dexamethasone; Hypertension, Pulmonary; Cohort Studies; Ductus Arteriosus, Patent; Infant, Very Low Birth Weight; Bronchopulmonary Dysplasia
PubMed: 38114242
DOI: 10.1136/bmjpo-2023-002302