Abstract
Background: Patent ductus arteriosus (PDA) with a bidirectional shunt reflects critical clinical conditions. The operability of PDA with a bidirectional shunt in pre-term infants is still not clearly clarified. This study aimed to investigate the feasibility and the outcomes of PDA ligation in pre-term infants with a bidirectional shunt PDA.Methods: All pre-term infants receiving PDA ligation between 2013 and 2019 were enrolled in this prospective study. Patients were allocated into two groups based on the shunting direction of PDA, which were the left-to-right group (group A) and the bidirectional group (group B). Clinical characteristics and pre-op comorbidities were analyzed. Intraoperative complications, post-op neurological sequelae, necrotizing enterocolitis, survival, and mortality were compared between these two groups.Results: Thirty-seven pre-term infants were enrolled (18 in group A, 19 in group B). The mean post-menstrual age at PDA surgery was 32.0 ± 1.3 and 32.8 ± 1.5 weeks, respectively. Before surgery, 44.4 and 89.5% (group A vs. B) of the patients were using invasive mechanical ventilator (p < 0.01). The requirement of high-frequency oscillatory ventilatory support was significantly higher in group B. PDA rupture-related bleeding during exposing PDA or ligating PDA occurred in four infants, and all were all in group B, including one with delayed hemothorax. Early surgical mortality within 30 days of surgery was higher in group B (0 vs. 21.1%, p < 0.05), but only one death could be attributed to the surgery, which was caused by a pain-induced pulmonary hypertension crisis. The 5-year survival was 100% in group A, and 73.7% in group B (p < 0.05).Conclusion: We did not recommend routine PDA ligation in pre-term infants with a bidirectional shunt. However, a bidirectional shunt should not be an absolute contraindication if they fulfill indications of PDA closure. Unexpected intraoperative PDA rupture and delayed hemothorax in a bidirectional shunt PDA should be carefully monitored. Aggressive post-op pain control is also warranted to avoid pulmonary hypertension crisis. The post-op early mortality rate was higher in the bidirectional group, which could be inherent to their poor pre-operative lung condition. Only one death was directly related to the surgery.
Highlights
The first cry of the newborn results in lung expansion and the pulmonary pressure begins to decline soon after birth
Eisenmenger syndrome is an absolute contraindication for Patent ductus arteriosus (PDA) closure in children and adults because the procedure could lead to pulmonary hypertension crisis, acute right ventricular failure, and even death
Our study demonstrated the feasibility of PDA ligation in pre-term infants with a bidirectional shunt
Summary
The first cry of the newborn results in lung expansion and the pulmonary pressure begins to decline soon after birth. Untreated hemodynamically significant PDA with a left-to-right shunt can result in increased pulmonary blood flow, heart failure, and pulmonary arterial (PA) hypertension [4,5,6], and can even progress to Eisenmenger syndrome. The use of pulmonary vasodilator in pre-term infants with a bidirectional shunt will lead to a left-to-right ductal shunt and even pulmonary hemorrhage. This critical situation is more frequently encountered in extremely low-birth-weight pre-term infants. This study aimed to investigate the outcomes of hemodynamically significant PDA ligation in pre-term infants with a bidirectional shunt.
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