Patent Ductus Arteriosus Size Research Articles

PATENT DUCTUS ARTERIOSUS STENTING IN NEWBORNS AND INFANTS WITH CYANOTIC CONGENITAL HEART DEFECTS: EXPERIENCE AND OUTCOMES

Background. Among all congenital heart defects (CHD), one-third are cyanotic defects with duct-dependent pulmonary blood flow. Palliative interventions are necessary for children with complex cyanotic CHD, premature infants, and children with complex comorbidities. Ensuring a reliable source of pulmonary blood flow adequate for arterial oxygenation and native pulmonary artery branches growth are the primary goals of staged interventions. The classic approach to providing adequate pulmonary blood flow before total repair is systemic-to-pulmonary artery shunting. Currently, there is a growing trend towards the use of an alternative method - transcatheter patent ductus arteriosus (PDA) stenting. Aim: Demonstrate the experience of PDA stenting, immediate and long-term outcomes in newborns and infants. Materials and Methods. From 2009 to April 2024, PDA stenting was performed in 66 patients at the UCC. Among the all cohort, 49 (74.2%) were newborns (Group I), and 17 (25.7%) were infants (Group II). The average age was: Group I - 7.4±5.9 days (range 1 to 28 days), and Group II - 105.2±54.78 days (range 42 to 280 days). The average weight was: Group I - 3.0±0.49 kg (range 1.9 to 4.4 kg), and Group II - 5.2±1.4 kg (range 2.7 to 9 kg). This study analyzed pre-, intra-, and postoperative parameters including age, weight, presence of concomitant/genetic pathology, saturation level, pulmonary artery branches diameter, Nakata index, PDAs size, origin and type, duration of staying in the intensive care unit, duration of artificial lung ventilation and inotropic support, early and late postoperative complications, 30-day and inter-stage mortality rates in the two patient groups. Results. All cases of transcatheter stent implantation were performed by transfemoral access. The average ICU stay duration for Group I was 13.8±9.52 days (range 2 to 119 days), and for Group II was 6.4±3.64 days (range 2 to 20 days). The duration of artificial lung ventilation in Group I was 185.8±165.28 hours (range 2 to 2066 hours), and in Group II was 67.5±46.15 hours (range 4 to 248 hours). Inotropic support - on average for Group I - 151.6±81.06 hours (range 0 to 720 hours), and for Group II - 82.4±47 hours (range 0 to 211 hours). Saturation increased from an average of 65.7±11.03% to 85.2±5.7% in Group I (p<0.05), and from 66.8±10.9% to 87.4±4.24% in Group II (p<0.05). Early postoperative complications were observed in 34.6% (17/49) of Group I patients and 23.5% (4/17) of Group II patients. The early 30-day mortality rate was 8.1% (4/49) for Group I. The next stage of surgical treatment wasperformed on average after 12.9±10.2 months by 51% (25/49) of Group I patients and by 88% (15/17) of Group II patients, on average after 14.98±12 months post-stenting. The interstage (late) mortality rate was 6.1% (3/49) for Group I and 5.8% (1/17) for Group II. Conclusion. Considering the outcomes after PDA stenting in our cohort of patients, this procedure appears to be an effective operation for providing a reliable source of pulmonary blood flow in various anatomical variants of cyanotic CHD in both newborns and infants.

Abstract 15296: Incidence and Predictive Factors for Left Ventricular Dysfunction After Transcatheter Device Closure of Patent Ductus Arteriosus in Extremely Low Birth Weight Infants

Background: Left ventricular (LV) dysfunction is a known complication after ligation or device closure of patent ductus arteriosus (PDA). Recently, an increasing number of premature and extremely low birth weight (ELBW) infants undergo transcatheter device closure of PDAs. Afterload sensitivity of the immature myocardium may be expected to result in important changes in LV ejection fraction (EF) post-procedure. Aim: To evaluate incidence and magnitude of LV dysfunction after device closure of PDA in ELBW infants. Methods: Subjects undergoing PDA device closure from 2020-2022 who were ELBW (<1 kg) and extremely premature (gestational age <29 weeks) at birth were included. A single cardiologist reviewed each pre- and post-intervention echocardiogram and calculated LVEF. Mildly depressed function was defined as an LVEF <53%, moderately depressed as LVEF <40% and severely depressed as LVEF <30%. Results: There were 62 subjects who met inclusion criteria. Mean gestational age and birth weight were 24.8 weeks and 646 g, respectively. Mean age and weight at intervention were 7.9 weeks and 1718 g, respectively. All patients had normal LVEF pre-procedure (mean LVEF 68%) with a significant decline post-procedure to 60% (p<0.001) (Figure). Post-procedure, 80.6% of subjects maintained normal LVEF. Of 12 subjects who developed depressed function, 83% (n=10) had mildly depressed function and 17% (n=2) had moderately depressed function. There was no significant difference in post-procedure LV dysfunction in relation to pre-procedural PDA size, left atrial dilation, or LV dilation on univariate analysis. All subjects recovered function without additional inotropic support with a median time to observed normal LVEF of 5 days. Conclusions: LV dysfunction develops in 19% of ELBW infants undergoing PDA device occlusion, is usually mild in severity, and normalizes in all subjects. The size of PDA or degree of left heart dilation does not predict LV dysfunction in this population.

Evaluation of the Closure of Patent Ductus Arteriosus With Ibuprofen Compared to Indomethacin.

Limited data exist comparing indomethacin and ibuprofen for the treatment of patent ductus arteriosus (PDA). The objective was to compare the safety and efficacy of indomethacin and ibuprofen for treatment of PDA closure. This single-center, pre-test/post-test quasi-experiment included preterm infants admitted to the neonatal intensive care unit who received indomethacin (July 1, 2013-September 30, 2015) or ibuprofen (December 1, 2015-July 31, 2019) for PDA. Patients were excluded if they were thrombocytopenic, had existing kidney injury, unresolved intraventricular hemorrhage (IVH) or necrotizing enterocolitis (NEC) at treatment initiation. Data were obtained from the electronic health record. Study outcomes were complete PDA closure, degree of PDA closure, resolution of symptoms, and new-onset acute kidney injury (AKI), IVH, or NEC. A total of 114 patients were included: 44 (39%) received indomethacin and 70 (61%) received -ibuprofen. Twenty-one (21%) patients experienced successful PDA closure within 1 week: 13 (32%) indomethacin patients and 8 (13%) ibuprofen patients (p = 0.023). PDA size reduction occurred in 43 (46%) patients with 29 (25%) experiencing complete symptom resolution. Significantly more indomethacin patients compared with ibuprofen patients experienced new-onset AKI (48% vs 17%; p < 0.001) and received concomitant nephrotoxins (68% vs 39%; p = 0.002). There were no significant differences in new-onset IVH or NEC. Indomethacin administration successfully closed the PDA in more neonates than ibuprofen but resulted in higher rates of AKI. However, this was confounded by more frequent administration of concomitant nephrotoxins. Larger trials are needed to help elucidate the optimal drug for closure of the PDA in neonates.

Patent ductus arteriosus shunting direction and diameter predict inpatient outcomes in newborns with congenital diaphragmatic hernia.

To evaluate whether the patent ductus arteriosus (PDA) can serve as a predictive factor for inpatient outcomes in congenital diaphragmatic hernia (CDH) patients. A retrospective cohort study was conducted on 59 CDH patients at the Capital Institute of Pediatrics from January 2020 to August 2022. Echocardiography was performed at least three times: within 2-3 h after birth, pre-operatively, and post-operatively of CDH surgery. Based on the direction of the PDA shunt in the first echocardiogram, patients were classified into three groups: left-to-right shunting or closed PDA (L-R), bi-directional shunting, and right-to-left shunting (R-L). The mortality rate was 15.3% (9/59), with all non-survivors having R-L shunting and group mortality of 39.1% (9/23). The direction of the PDA shunt was significantly associated with the duration of ventilation and length of hospital stay (p < 0.05). Decreased PDA diameter or pre-operative shunting direction change towards L-R or bi-directional shunting were associated with higher survival rates, while increased PDA diameter or continuous R-L shunting were associated with higher mortality rates. Pre-operative PDA shunt direction, PDA size after birth and before surgery, gestational age of diagnosis, and shortening fraction before surgery were significantly correlated with patient outcomes. The direction of the preoperative PDA shunt was the most relevant factor among these relationships (p = 0.009, OR 20.6, CI 2.2∼196.1). Our findings highlight the importance of monitoring changes in PDA shunt directionality and diameter in the early stage after birth, as these parameters may serve as valuable predictors of patient outcomes.

Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study.

Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service. This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013-2016) versus Epoch-2 (TNE 2018-2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related) RESULTS: A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2. With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era. · TNE allows comprehensive hemodynamic assessment of PDA.. · Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.. · Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need..

Echocardiographic Predictors of Hospital Outcomes in Preterm Neonates with Patent Ductus Arteriosus and Clinical Suspicion of Pulmonary Hypertension.

Preterm neonates often have an echocardiogram performed in the first few days of life for suspicion of pulmonary hypertension and patent ductus arteriosus. The usefulness of this echocardiogram in predicting outcomes in this population are unknown. The objective of this study was to investigate associations between initial echocardiographic assessment and hospital outcomes in preterm neonates with patent ductus arteriosus and clinical suspicion of pulmonary hypertension. Premature neonates (<37 weeks gestational age) with patent ductus arteriosus and clinical suspicion of pulmonary hypertension born at our institution or transferred within 48 hours of life were included in this single center retrospective study. The primary outcome was in-hospital extracorporeal membrane oxygenation utilization or mortality. 86 patients were included. Median age at echocardiogram was 2 days (interquartile range 1,7), gestational age was 27 weeks (interquartile range 25,32), and birth weight was 878 grams (interquartile range 650,1818). 15 patients (17%) met the primary outcome. Larger patent ductus arteriosus size (p = .03), patent foramen ovale flow that was bidirectional or right to left (p = .047), and right atrial volume (p = .04) were independently associated with the primary outcome. Larger patent ductus arteriosus size, bidirectional or right to left flow at the patent foramen ovale, and lower right atrial volume are independently associated with in-hospital mortality. These findings on the initial echocardiogram of a preterm neonate can be used to risk stratify these patients for elevated risk for in-hospital extracorporeal membrane oxygenation utilization or mortality.

Role of angiography procedure for assessment the type of patent ductus arteriosus in children under 18 years.

Objective: To determine the role of angiography for the assessment the type of patent ductus arteriosus in children under 18 years. Study Design: Observational Retrospective study. Setting: Children’s Hospital Lahore. Period: October 2021 to February 2022. Material &amp; Methods: The sample size calculated was 245 but, at the end of the period of four months only 120 patients fulfilled the criteria and were included in this study convenient sampling technique was used to collect the data. Patients with patent ductus arteriosus were included in this study. Patients with other congenital heart diseases were excluded. Essential measurements included Types of Patent Ductus Arteriosus (PDA), (PDA) Size, Ampulla Size, Aortic and Pulmonary systolic and diastolic pressures. Results: In this study 120 patients with PDA were included. Out of 120, 38 (31.7%) patients were male and 82 (68.3%) patients were female. The age range of the patients was 8 months to 18 years (mean;5.44 ± 3.972 years). The weight range of the patients was 5.3 to 41 Kg (mean;16.05 ± 8.38Kg). The mean PDA size was 4.01 ± 1.80. The mean Ampulla size was 9.92 ± 3.13. The types of PDA detected by angiography were Type A 59(49%), Type B 15(12.5%), Type C 20(16.7%), Type D 20(16.7%), Type E 5(4%), Type F 1(0.8%). The mean Aortic systolic pressure was 105.5±18.99 and diastolic pressure was 57.2 ±14.4. The mean Pulmonary Artery systolic pressure was 47.4 ± 23.3 and diastolic pressure was 27.7 ±14.2. Conclusion: Angiography was found more accurate for the assessment of all the anatomical types of PDA especially TYPE B, C, D and F. More precise measurements of the ampulla and PDA sizes were obtained using angiography. We may conclude that Angiography is a much better and good modality than other modalities for the assessment of the types of PDA.

Identifying two distinct subphenotypes of patent ductus arteriosus in preterm infants using machine learning.

To use unsupervised machine learning to identify potential subphenotypes of preterm infants with patent ductus arteriosus (PDA). The study was conducted retrospectively at a neonatal intensive care unit in Brazil. Patients with a gestational age < 28weeks who had undergone at least one echocardiogram within the first two weeks of life and had PDA size > 1.5 or LA/AO ratio > 1.5 were included. Agglomerative hierarchical clustering on principal components was used to divide the data into different clusters based on common characteristics. Two distinct subphenotypes of preterm infants with hemodynamically significant PDA were identified: "inflamed," characterized by high leukocyte, neutrophil, and neutrophil-to-lymphocyte ratio, and "respiratory acidosis," characterized by low pH and high pCO2 levels. Conclusions: This study suggests that there may be two distinct subphenotypes of preterm infants with hemodynamically significant PDA: "inflamed" and "respiratory acidosis." By dividing the population into different subgroups based on common characteristics, it is possible to get a more nuanced understanding of the effectiveness of PDA interventions. What is Known: • Treatment of PDA in preterm infants has been controversial. • Stratification of preterm infants with PDA into subgroups is important in order to determine the best treatment. What is New: • Unsupervised machine learning was used to identify two subphenotypes of preterm infants with hemodynamically significant PDA. • The 'inflamed' cluster was characterized by higher values of leukocyte, neutrophil, and neutrophil-to-lymphocyte ratio. The 'respiratory acidosis' cluster was characterized by lower pH values and higher pCO2 values.

Correlation of Ductal size with Left Ventricular Systolic Function Changes by Echocardiography in Children after Transcatheter Closure of Patent Ductus Arteriosus in a Tertiary Care Hospital

Background: Transcatheter closure of Patent Ductus Arteriosus (PDA) is considered an excellent treatment option for children requiring PDA closure due to its low morbidity and mortality rates. Theoretically, after PDA closure, there should be a gradual improvement in left ventricular volume overload and remodeling. However, numerous studies have shown that there is a temporary decline in left ventricular function immediately following PDA closure. Objectives: To see the correlation of ductal size with changes in left ventricular systolic function by echocardiography in children undergoing transcatheter closure of PDA. Materials and methods: It was a cross sectional study. All pediatric inpatients ≥6 months of age, diagnosed as a case of PDA and planned for device closure were enrolled in the study. M-Mode, 2D, Color Doppler and 2D speckle tracking echocardiography was done by GE Echo machine Model VividS70N using probes 5MHz (5s) and 6MHz(6s). Electrocardiogram (ECG ) gated echo was done at base line (prior to closure of PDA), after 24 hour post closure and after 1 month post closure, in order to evaluate the immediate and short term changes in left ventricular systolic function from the baseline, using the following parameters: Left Ventricular Ejection Fraction (LVEF) and Left Ventricular Fractional Shortening (LVFS). The total sample size was 35. Data were collected on a pre-tested questionnaire. Data analysis was carried out by using the SPSS version 22.0 windows software. Continuous data were expressed as mean ±SD and analyzed by paired t-test. Categorical data were expressed as frequency and percentages. Correlation was seen using Pearson’s correlation. P-value &lt; 0.05 was considered statistically significant. Results: The mean age of the study subjects was 46.69 ± 41.8 months with mean body surface area of 0.56 ±0.25m² (0.32-1.3). Females were predominant with 74.3% and males were 25.7%. The mean PDA size was 3.35 ± 0.77mm and the LA: Aorta ratio was 1.45 ± 0.24. The LVEF, LVFS were reduced from 70.11±3.81 to 57.34±5.0, 39.28±3.14 to 32.0±4.54 respectively 24hours after device closure. This reduction of LVEF, LVFS were statistically significant (p&lt;0.01). At 1 month post device follow up all the parameters returned to near baseline level. PDA size was found to be negatively correlated with early changes in left ventricular functions i.e. larger the PDA size, greater is the reduction in LV function post PDA device. Conclusions: Transcatheter closure of PDA can lead to transient reduction in left ventricular systolic function which improves gradually after a month; however, close monitoring is required. Larger the PDA size, greater is the reduction in LV function. As such moderate to large PDAs should be followed up more cautiously and immediate timely intervention is needed, if severe deterioration is found.

Outcomes and Determinant Factors of Percutaneous Transcatheter Occlusion among Children with Patent Ductus Arteriosus in the East Coast Malaysia: A 10 Year Experience

Introduction: Transcatheter closure was a well-established procedure in patent ductus arteriosus (PDA). The aim of the study was to determine the outcomes, median time and PDAs closure from diagnosis and the predictive factors which influenced the decision for PDA closure. Material and methods: A 10-year retrospective record review was performed involving patients who had undergone transcatheter closure of PDA from January 2007 to January 2017 at a single centre in the North-eastern of Peninsular Malaysia. Descriptive statistics were used to examine all variables. Kaplan-Meier survival analysis was applied to determine median time for diagnosis and transcatheter closure of PDA. Multiple Cox regression analysis was used to identify predictors for early intervention of PDA closure. Results: A total of 123 patients were recruited with 65.9% of them were predominantly female. The age at the time of diagnosis was between 4-day to 14.5-year-old and median age for undergoing the procedure was 2.6-year-old (range:3-month to 15.8-year-old). The PDA size ranged between 0.2-12mm with 59% of the patients had large size PDA. Successful closure rate was achieved in 96.2 % with 3.8 % having very minimal residual shunt at 2 years post procedure. Complications were noted in 17 patients (4.0% major, 9.8% minor). Overall, the median time to diagnose and to close PDA were 6 months and 16.9 months respectively. Earlier intervention was likely to be performed in younger children (p&lt;0.001) with weight of less than 10 kg (p&lt;0.001). Conclusions: Transcatheter device closure was safe and effective in children with PDA with excellent outcome and minimal complication. Age and weight were the determinant factors for early PDA closure.

Radiation Dose Exposure to Patients During Transcatheter Patent Ductus Arteriosus Closure via the Arterial Route

Objective This study aims to evaluate the radiation dose for transcatheter patent ductus arteriosus (PDA) viathe arterial route and compare it with previously published benchmarks. Background Exposure to radiation in the catheterization lab can cause skin injury and cancer in the long run, especially in pediatric patients with complex heart conditions, which necessitate serial catheterizations. Therefore, measuring the patient radiation dose and establishing a benchmark for each cardiac interventional procedure is essential. Material and methods In this prospective study, 34 patients with transcatheter patent ductus arteriosus closure via an arterial route were included. Patients who had silent PDAs, no left heart dilatation and PDA size of less than 2mm had PDA closed via an arterial route. All the study group patients received an Amplatzer duct occluder II-additional size device (St. Jude Medical Corp, St. Paul, MN) using biplane flat-panel fluoroscopy equipment adjusted in accordance with the pediatric parameters. Patients' dose area product, air kerma and fluoroscopytime were recorded in the catheterization lab and finally compared with internationally published reference data. Results Of 73 patients who had transcatheter patent ductus arteriosus closure between April 2021 to December 2021, 34patients who had a PDA closure via an arterial route were enrolled. The median age and weight were 11.5 (4-168) months and 10.5 (6-31) kg. Twenty-one (61.8%) were males, and 13 (38.2%) were males. The median radiation dose parameters were as follows: air kerma 11 (3-42) milliGray, dose area product 131 (33-443) microGray per m2, median dose area product indexed to weight 12 (1-48) microGray m2 per kg, fluoroscopy time 2 (2-4) min and frame rate 15 (7.5-15) frames per second. Due to many factors, our radiation dose parameters were less than internationally published reference values for transcatheter PDA closure. Conclusion Patient selection, detailed pre-catheterization echocardiography and procedure planning are essential for accomplishing device closure of PDA with a significant reduction in radiation dose. Hemodynamic assessment in the catheterization lab is unnecessary for most PDA patients. Additionally, a next-generation imaging platform equipped with flat-panel detectors and adjusted for pediatric settings and a fluoro recording option can be used to reduce radiation exposure.

Intraventricular hemorrhage prediction in premature neonates in the era of hemodynamics monitoring: a prospective cohort study

Unstable hemodynamics and prematurity are the main players in intraventricular hemorrhage (IVH) development. Our objective was to study 8 the use of superior vena cava flow (SVCF), left ventricular output (LVO), and right ventricular output (RVO), and anterior cerebral artery (ACA) Doppler measures in prediction of IVH in the first week of life in preterm infant ≤ 32 weeks and birth weight ≤ 1500 g. This prospective cohort study was conducted in 55NICU of Alexandria University maternity hospital. Of 147 enrolled patients, 132 infants born ≤ 32 weeks GA and birth weight ≤ 1500 g were eligible for- the study. One hundred twenty-seven infants completed the study. Infants were scanned for ACA-RI using transfontanellar ultrasound, and SVCF, LVO, and RVO using functional echocardiography in the first 24 h after birth. Patients had another two scans on DOL3 and 7 to detect IVH development. Low SVCF and high ACA-RI significantly increased the risk of IVH using logistic regression models with OR, 3.16; 95%CI, 1.19–8.39; P = 0.02 and OR, 1.64; 95%Cl, 1.10–2.44; P = 0.02, respectively. Low SVCF and high ACA-RI significantly increased risk of catastrophic IVH P = 0.025 and 0.023, respectively. Combined use of low SVCF < 55 ml/kg/min and ACA-RI > 0.75 is predictor of IVH with sensitivity 40.8% and 82.1% specificity.Conclusions: There are strong relations between both low SVCF and high ACA-RI, and IVH development in premature neonates ≤ 32 weeks and birth weight ≤ 1500 g, with more significance towards catastrophic IVH. Admission RSS and LVO are the strongest factors affecting SVCF. Maternal anemia, patent ductus arteriosus size (mm/kg), and capillary refill time were significantly associated with high ACA-RI. These findings help in more understanding of pathophysiological factors affecting central perfusion that might affect the longer term neurodeveopmental outcome.Trial registration: This work was registered in clinical trial.gv no NCT05050032.What is Known:•Whether SVCF and RI-ACA can predict IVH in preterm neonates is still debatable.What is New:•Low SVC flow and high ACA-RI significantly increased risk of IVH, confirming the role of hypoperfusion-reperfusion cycle in IVH development. The most striking result that combined metrics using the cut-off value of < 41 ml/kg/min for SVCF and > 0.85 for ACA-RI “in the first day of life” can correctly reject the presence of IVH in 98% of patients “during the first week of life.”

Factors contributing to successful patent ductus arteriosus closure with first pharmacological course

Background Successful closure of patent ductus arteriosus (PDA) with ibuprofen or paracetamol as the first-line treatment has been reported, but little is known about factors affecting the closure rate.&#x0D; Objective To identify the closure success rate and contributing factors affecting a first course of pharmacological treatment in neonates with PDA.&#x0D; Methods A retrospective study was conducted in infants with isolated PDA treated with either ibuprofen or paracetamol and admitted to our neonatal care unit from January 2017 until June 2020. Included infants had PDA on echocardiography and received ibuprofen or paracetamol therapy as the closure treatment. Oral ibuprofen was given at 10 mg/kg on first day, then 5 mg/kg on the 2nd and 3rd days; while paracetamol was given intravenously 15 mg/kg every 6 hours for 3 days. Echocardiographic evaluation was performed 3 days after first course of treatment.&#x0D; Results In total, 20 of 33 (60.6%) infants achieved PDA closure with the first course of treatment. Earlier age at the start of the first course of treatment (PR 7.7; 95%CI 1.2 to 47.7; P=0.035) and normal birth weight (PR 13.3; 95%CI 2.4 to 72.4; P=0.001) were significant factors contributing to PDA closure. However, PDA size did not affect closure rate (PR 2.0; 95%CI 0.4 to 8.5; P=0.46).&#x0D; Conclusion Pharmacological treatment seems to have a good success rate for PDA closure, with significant positive associations with earlier age at start of treatment and normal birth weight.

Immediate and Long-Term Results of Transcatheter Closure of Patent Ductus Arteriosus—Comparison of Two Decades before and after Change in Antibiotic Infective Endocarditis Prophylaxis Guidelines

Objectives: To determine immediate and long-term follow-up of transcatheter closure of patent ductus arteriosus (PDA) in children. Background: National antibiotic prophylaxis (AP) guideline for infective endocarditis changed after 2009, the effect on practice of PDA closure is unknown. Methods: Observational single center study analyzing follow-up of PDA closure comparing two time periods before (2002–2009) and after (2010–2019) changes in AP guideline. Results: 332 patients (68.1% female), median (interquartile range) age 3.0 years (1.5–5.7) and body weight 14.0 kg (10.0–19.3), were enrolled. PDA morphology was conical type A (50.3%), window type B (1.2%), tubular type C (40.1%), complex type D (2.1%), elongated type E (0.9%) and other (5.4%). Minimal PDA diameter and length were 1.9 mm (1.3–2.5) and 8.0 mm (6.2–10.2). PDA was closed using coils (56.3%), Amplatzer Duct Occluders (41.9%) and others (1.8%). Complete closure rate was 61.1% at catheter intervention, 72.3% on day 1, 87.7% after 6 months and 98.4% at last follow-up on echocardiography. Moderate complication rate (severity level 3) was 4.2% and major complication rate (severity level 4) 0.3%, with no catastrophic complications (severity level 5). Annual PDA closure rate declined in the second time period (22.6/year vs. 15.5/ year, p = 0.018), PDA size increased (1.6 mm vs. 2.0 mm, p = 0.002) and proportion of coils decreased (72.4% vs. 37.1%, p < 0.001). Conclusions: Interventional closure of PDA is associated with excellent closure rates during follow-up (>98%) and only a small number of complications leading to reintervention or surgery. Change in AP guidelines changed indication for and practice of PDA closure.

AORTIC FLOW PROPAGATION VELOCITY AND ITS RELATION TO MAGNITUDE OF SHUNT IN PATIENTS WITH ISOLATED PATENT DUCTUS ARTERIOSUS

Background: Patent ductus arteriosus (PDA) is normally associated with hyperdynamic status. Given the presence of a vascular shunt between the aorta and pulmonary artery, intrinsic aortic changes occur (aortic stiffness). Arterial stiffness is currently regarded as an independent predictor of cardiovascular morbidity and mortality. There is a close relationship between arterial stiffness and aortic flow propagation velocity (AFPV). Objective: To assess aortic stiffness in patients with isolated PDA using Doppler-derived AFPV, assess shunt magnitude i.e. pulmonary to systemic blood flow ratio (QP/QS) in patients with isolated PDA by echocardiography, compare AFPV values in patients with isolated PDA and apparently healthy individuals, and to correlate AFPV with PDA size and shunt magnitude. Patients and Methods: Our study was performed at Bab EL-Sha'riya Hospital, Al-Azhar University during the period from September 2019 and August 2020, and consisted of twenty-five patients with isolated PDA, and twenty healthy controls. Detailed history, physical examination was performed and conventional two-dimensional echocardiography was done to all cases then echocardiographic assessment of PDA including magnitude of the shunt by measuring QP/QS ratio. Aortic flow propagation velocity (AFPV) was measured in all cases. Results: Patients with PDA exhibited significantly lower AFPV than the control (p < 0.001). AFPV was significantly correlated with systolic blood pressure (r= -0.29 &p= 0.01). Also, there was significant correlation (r=-0.426) between AFPV and PDA size, mainly pulmonary end (p=0.03), and magnitude of the shunt QP/QS (r= 0.723 & p < 0.001). Conclusion: Transthoracic echocardiographic determination of the color M-mode propagation velocity of the descending aorta is a simple, non-invasive practical surrogate method in identifying arterial stiffness in patients with PDA and is related to effective orifice of PDA and magnitude of the shunt.

Echocardiographic versus Angiographic Measurement of the Patent Ductus Arteriosus in Extremely Low Birth Weight Infants and the Utility of Echo Guidance for Transcatheter Closure

Transthoracic echocardiography (TTE) is increasingly utilized for guiding transcatheter closure of patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objectives of this study were to compare PDA size measurements by TTE with angiographic measurements and to describe TTE techniques used in guiding transcatheter PDA closure (TCPC) in ELBW infants. One hundred twenty-five consecutive ELBW infants (gestational age<27weeks, birth weight<1kg) who underwent TCPC before 8weeks of age under TTE guidance were included. Patent ductus arteriosus sizes were measured from the procedural TTE and angiograms retrospectively by blinded observers. The TTE PDA diameters at the aortic (ED1) and pulmonary end (ED2) were compared with the corresponding angiographic diameters (CD1 and CD2). The TTE PDA lengths, obtained by two techniques (EL1, a straight line between ED1 and ED2; and EL2, a curvilinear line along the PDA), were compared with the PDA length by angiography (CL). Transthoracic echocardiography was used to guide accurate device positioning within the PDA. The procedure weight was 600-1,460g. The TTE and angiographic PDA diameters were comparable (mean ED1 vs CD1=4.5±0.68 vs 4.4±0.85mm, P=.26; and mean ED2 vs CD2=3.1±0.72 vs 3.2±0.94mm, P=.14). The angiographic length was underestimated by EL1 by 2.6±1.6mm(P<.0001), while EL2 estimated it better (mean EL2 vs CL=11.0±1.83 vs 10.8±2.15mm; P=.40). Transcatheter PDA closure was successful in 100% of the cases using TTE guidance. There were no intraprocedural complications. Transthoracic echocardiography guidance during TCPC in ELBW infants eliminates the need for aortograms via femoral arterial access, preventing the complications associated with it. Transthoracic echocardiography PDA measurements are comparable to angiographic measurements, thereby assisting in appropriate device size selection.

How can stretched ductus diameter be predicted from angiographic diameter?

An appropriate size of device for patent ductus arteriosus (PDA) could be chosen by a stretched PDA size. We propose prediction of stretched size from intact PDA size. A total of 361 patients was enrolled. Intact size was measured on angiography before closure, and stretched size was the narrowest diameter immediately after device implantation. The median patient age was 2.8 years. Intact diameter and stretched diameter were 3.6±1.4 mm and 5.1±1.3 mm. The difference and difference ratio were 1.5±0.8 mm and 51.3±38.1% and had negative linear correlations with age (P<0.001). Patients were divided into four groups: <2 years old (159), 2-15 years old (68), 15-40 years old (72), and ≥40 years old (62). Among groups, difference and difference ratio were significantly different. Stretched diameter was inferred by the following formulas: stretched diameter = 0.660 × intact diameter + 2.791 (<2 years old); = 0.971×intact diameter + 0.058 × age + 1.131 (2-15 years old); = 0.790 × intact diameter + 2.263 (15-40 years old); and = 0.837 × intact diameter + 1.353 × BSA - 0.096 (≥40 years old). Stretched PDA diameter can be predicted from intact diameter and might be helpful for safe PDA closure especially in small infants.

Left ventricular systolic dysfunction following percutaneous closure of patent ductus arteriosus

Transcatheter closure has become the standard treatment for patent ductus arteriosus (PDA) with excellent short- and long-term results. Left ventricular systolic dysfunction after closure is a known phenomenon rather than a complication with varied incidence documented in literature. Here, we report our experience of six cases who developed left ventricle (LV) dysfunction following percutaneous closure of PDA. Age, PDA size indexed to body surface area and pulmonary hypertension were the parameters noted to be associated with poorer LV function after closure. The LV dysfunction was transient and asymptomatic in most with delayed recovery noted with increasing age.

The Outcomes of Transcatheter Closure in Patients with Patent Ductus Arteriosus at Haji Adam Malik General Hospital, Indonesia

BACKGROUND: Patent ductus arteriosus (PDA) is one of the most common acyanotic congenital heart diseases. The incidence of PDA is approximately 1 in 500 full-term neonates. The current management of PDA includes pharmacological and surgical treatments. Transcatheter closure is a preferable PDA treatment than pharmacological intervention, for medications have a higher failure rate in premature infants. Several studies have reported the efficacy and safety of transcatheter closure in smaller and lower-weight infants. AIM: This study aims to describe the outcomes of transcatheter closure of PDA, which are complete closure, migrating device, and residuals, while also investigating factors that might affect these outcomes. METHODS: A descriptive cross-sectional study was conducted from January to March 2018 in the pediatric cardiology outpatient clinic of Haji Adam Malik Hospital, Medan, Indonesia. All PDA patients who underwent transcatheter closure were included in this study. We collected patients’ demographic data (age and sex), PDA size (categorize into large, moderate, and small), and PDA closure outcomes from medical records. The collected data were then analyzed with SPSS. RESULTS: One hundred and two children were included in this study, comprised 34 (33.3%) males and 68 (66.7%) females, with a mean age of 4.3 (±4.02) years old and the mean size of the defects 4.4 (±2.25) mm. Transcatheter closure with Lifetech® PDA Occluder was performed in 95 (93.1%) and MFO® in 7 (6.9%) patients. Small residuals were found in three patients, device migration was found in one patient. No relationship was found between the size of PDA and the outcomes measured. CONCLUSION: We concluded that transcatheter closure remains an effective treatment for PDA, with a considerable success rate.

Time period after transcatheter PDA closure with changes in left ventricular function and nutritional status

Background Few studies perform follow ups on patent ductus arteriosus (PDA) patients who undergo transcatheter closure. In addition to side effects from the procedure, it is important to evaluate changes in left ventricular function (LVF) parameters and nutritional status.&#x0D; Objective To compare LVF and nutritional status before and during the one-year period post-transcatheter PDA closure, and evaluate potential associated factors in post-closure PDA transcatheter patients.&#x0D; Methods This retrospective cohort study was done in a single center in patients diagnosed with PDA who had undergone transcatheter closure. Data were obtained from subjects’ medical records. The relationship between the post-closure PDA time span and LVF parameters [ejection fraction (EF) and fractional shortening (FS)] was analyzed by Friedman and repeated ANOVA tests; the post-closure PDA time period and nutritional status was analyzed by Friedman test. The time periods analyzed were 1, 3, 6, and 12 months post-closure. Factors potentially associated with LVF 12 months post-closure were analyzed by linear regression.&#x0D; Results A total of 30 patients who had undergone transcatheter PDA closure were included. The body weight mean of at the time of transcatheter PDA closure was 13.1 kg. We found a significant relationship between time period after PDA closure and nutritional status, before and 1, 3, 6, and at 12 months post-closure. In a comparison of pre-closure to 12 months post-closure, subjects’ mean EF (66.6 vs. 70.9%, respectively; P&lt;0.001) and FS (34.4 vs. 37.8%, respectively; P&lt;0.001) were significantly higher. In addition, significantly more patients had normal nutritional status 12 months post-closure than before closure. Age was not related to LVF parameters (EF: r=0.212; P=0.260; FS: r=0.137; P=0.471).&#x0D; Conclusion Both LVF and nutritional status significantly improve gradually over the 12 months post-closure compared to pre-closure. PDA size is not significantly associated with improved LVF parameters and nutritional status.