Significant Ductus Research Articles

Integrating Clinical and Neuroimaging Markers to Predict the Onset of Posthemorrhagic Ventricular Dilatation in Preterm Neonates

BackgroundPosthemorrhagic ventricular dilatation (PHVD) is a major complication of intraventricular hemorrhage (IVH); it is associated with high risks of cerebral palsy and cognitive deficits compared with infants without PHVD. This study aims to explore the early perinatal risk factors-associated with the risk of progressive PHVD. MethodsNeonates ≤29 weeks gestational age (GA) with Grade II-III IVH and periventricular hemorrhagic infarct (PVHI) between 2015 and 2021 were retrospectively reviewed. All cranial ultrasounds done within 14 days postnatal age (PNA) were assessed for grade of IVH, anterior horn width (AHW), ventricular index (VI), and thalamo-occipital index (TOD). The outcome was defined as death of any cause or VI and/or AHW and/or TOD ≥ moderate-risk zone based on an ultrasound done beyond two weeks PNA. ResultsA total of 146 infants with a mean GA of 26 ± 1.8 weeks, birth weight 900 ± 234 g were included, 46% were females. The primary outcome occurred in 56 (39%) infants; among them 17 (30%) and 11 (20%) needed ventricular reservoir and shunt insertion, respectively. The risk factors present within 14 days PNA that significantly increased the odds of developing PHVD were hemodynamically significant patent ductus arteriosus (odds ratio [OR] 6.1, 95% confidence interval [CI] 1.9 to 22), culture-proven sepsis (OR 5.4, 95% CI 1.8 to 18), Grade III IVH (OR 4.6, 95% CI 1.1 to 22), PVHI (OR 3.0, 95% CI 0.9 to 10), and VI (OR 2.1, 95% CI 1.6 to 2.9). ConclusionsClinical predictors such as significant ductus arteriosus and bacterial septicemia, along with risk levels of AHW and VI measured with early cranial ultrasounds, are potential predictors of subsequent onset of PHVD.

Impact of catheterized ductal closure on renal and cerebral oximetry in premature neonates.

Percutaneous catheter-based closure is increasingly utilized in premature newborns. While near-infrared spectroscopy (NIRS) has been examined for assessment of interventional closure in surgical ligation, its application in percutaneous transcatheter closure remains unexplored. This study aims to assess cerebral and renal hemodynamic changes using NIRS during percutaneous closure compared to surgical closure in preterm infants. A prospective observational study enrolled preterm infants born at 32 weeks of gestation or less and diagnosed with hsPDA between January 2020 and December 2022. These infants received either surgical or catheter-based closure of the PDA. Cerebral and renal oxygen saturation was monitored using the INVOS 5100 device from 12 h before the intervention until 24 h after. Linear mixed-effects models were used to analyze time-dependent variables. Twenty-two patients were enrolled, with catheter-based closure performed in 16 cases and conventional surgery in 6 cases. Following ductal closure, a significant increase in renal and cerebral oximetry was observed alongside a decrease in renal and cerebral tissue oxygen extraction. These changes were particularly pronounced in the renal territory. No differences were detected between catheterization and surgical closure. Conclusion: An improvement in cerebral and renal oximetry following hsPDA closure was observed. However, we did not identify differences in this pattern based on the type of interventional procedure for PDA, whether surgery or catheterization. What is Known: •The presence of a significant ductus is common in premature patients. Studies have shown that it affects cerebral and renal hemodynamics negatively, leading to decreased oximetry values in these areas. It has been reported that closure of the ductus, either pharmacologically or surgically, results in improved oximetry values. What is New: •This study assess the impact of percutaneous closure of ductus, revealing increased oximetry values in cerebral and renal territories without significant differences compared to surgical ligation. Notably, renal oximetry values showed a greater increase, underscoring the importance of multi-location monitoring.

Survival Rate and Short-term Outcomes of Extremely Preterm Infants: A Tertiary Care Center Experience from the Private Sector

Background: Premature birth is one of the leading causes of death in the world. The global incidence of prematurity ranges from 5% to 11% of all births. The aim of this study was to assess the outcome of extremely preterm infants born below 29 weeks in our institution, with regard to survival and major short-term outcomes, and compare our results with national and international centers. This study is the first to be conducted in a private tertiary care hospital in Saudi Arabia. Materials and Methods: This was a retrospective descriptive cohort study that reviewed the medical records of preterm infants admitted to the neonatal intensive care unit at the International Medical Center, Jeddah, Kingdom of Saudi Arabia, between January 2014 and January 2020. We compared our results to the national data from King Faisal Specialist Hospital and Research Center-Riyadh, King Abdulaziz Medical City (KAMC)-Jeddah and KAMC Riyadh, King Abdulaziz Medical City-Alhasa, the National Institute of Child Health and Human Development Neonatal Research Network, and the Canadian Neonatal Network. Results: A total of 92 preterm infants were included: 3, 8, 17, 17, 29, and 18 infants with a gestational age of 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, and 28 weeks, respectively. The mean gestational age was 25 weeks and 5 days. Fifty-four infants (58.7%) survived to hospital discharge. In terms of short-term outcomes, 13% had bronchopulmonary dysplasia, hemodynamically significant ductus arteriosus was present in 27%, and retinopathy of prematurity was found in 13%, necrotizing enterocolitis was diagnosed in 5.4%, while late-onset sepsis was reported in 23.9% of infants. Conclusion: Our study represents outcomes of Extremely Preterm Infants in a single Private tertiary Care Center from Saudi Arabia with a comparison to national and international data. Though it cannot be generalized our data can be used as an add-value cohort toward establishing countrywide neonatal network to better plan regional resource allocation and utilization and facilitate ongoing audit, benchmarking, and overall quality improvement initiatives.

The left ventricle in well newborns versus those with perinatal asphyxia, haemodynamically significant ductus arteriosus or fetal growth restriction.

Hemodynamic changes accompanying the initial breaths at the time of birth are especially important for a smooth transition of fetal to neonatal circulation. Understanding the normal transitional physiology and the clinical impact of adverse adaptation is important for delineating pathology so as to guide physiologically relevant therapies. Disorders such as severe perinatal asphyxia, hemodynamically significant patent ductus arteriosus (and its surgical ligation) and utero-placental insufficiency underlying fetal growth restriction, can adversely affect left ventricular (LV) function. The left ventricle is the predominant chamber involved in systemic perfusion during postnatal life. Cardiac output is closely linked to afterload; the latter is determined by arterial properties such as stiffness and compliance. This article outlines normal transition in term and preterm infants. It also highlights the adverse impact of three not uncommon neonatal disorders on LV function. Perinatal asphyxia leads to a reduced LV output, superior vena cava and coronary artery blood flow and an increase in the troponin level. Multiple haemodynamic changes are observed in the premature infant with a large patent ductus arteriosus. They need careful analysis to determine when ligation should proceed. Ligation itself generally results in a dramatic increase in afterload which may lead to a reduction in LV contractility and the need for ionotropic support. Fetal growth restricted infants have a higher systolic pressure, a somewhat hypertrophied heart arising from an increased arterial wall thickness/stiffness and systemic peripheral resistance. Point of care ultrasound (POCUS) helps differentiate normal transition and that resulting from neonatal disorders. It may be increasingly utilized in guiding management.

Combination therapy for patent ductus arteriosus in preterm infants: Echocardiographic changes and clinical use

BackgroundSearching for the optimal therapeutic strategy for hemodynamically significant Patent Ductus Arteriosus in preterm infants is ongoing. A novel approach utilizing a combination of ibuprofen and acetaminophen has generated interest, with speculations that this approach may be more effective than standard single-agent therapy. ObjectivesOur objectives were to compare the echocardiographic parameters before and after the combination therapy and to describe its use (primary vs. rescue), effectiveness, and side effects. MethodsThis was a retrospective cohort review of preterm infants born <33 weeks gestation who were admitted to a tertiary-level neonatal intensive care unit between January 1, 2012, and December 31, 2020. Included infants received combination pharmacotherapy with ibuprofen and acetaminophen for ductal closure, either as a primary course (1st line use) or as a rescue (2nd or 3rd course), and had echocardiographic measurements pre-and post-therapy. Baseline characteristics, echocardiographic parameters of ductus arteriosus hemodynamics before and after combination therapy, the effectiveness of treatment, and adverse effects were examined. ResultsDuring the study period, 32 infants received combination therapy, with 17 (53 %) receiving it as a primary course and 16 (47 %) receiving it as a rescue course after trying another pharmacological agent. Complete echocardiographic data were available for 17 infants included in the study (11 primary and 6 rescues). The overall treatment success rate was 41 %. The primary course had a better treatment success rate (55 %) than the rescue course (17 %). Echocardiographic analysis showed that the primary course treatment resulted in significantly lower ductal diameter (p = 0.013), higher ductal flow Doppler velocities (p = 0.037), more restrictive shunt pattern (p = 0.005), and decreasing ductus arteriosus significance score (p = 0.016). Such improvement in hemodynamic significance was not noted when combination therapy was used as rescue therapy. ConclusionPrimary combination therapy with ibuprofen and acetaminophen resulted in considerable improvements in echocardiographic markers of hemodynamically significant ductus arteriosus. Future trials exploring the safety and efficacy of this treatment as a first-line option are required.

Взаимосвязь динамики роста окружности головы в первый месяц жизни и психомоторного развития крайне недоношенных детей в возрасте 3 лет

Aim: to study the association of the head circumference (HC) growth trajectory in extremely preterm neonates (1 month) with the outcomes of psychomotor development by the age of 3 years. Patients and Methods: a retrospective cohort study included 140 children with extremely low birth weight in the Yaroslavl region in the period from 2012 to 2018 and observed up to the age of 3 in the outpatient department for infants of the Regional Perinatal Center. The HC growth trajectory was determined based on the tendency of indicators from the birth to the age of 1 month, expressed as a percentage. The Clinical Adaptive Test / Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) was used to assess psychomotor development. The outcomes of psychomotor development were defined as the norm, development dissociation (differences in indicators of the CAT/CLAMS and motor skills) and delayed development. Results: the tendency of the HC growth in neonates (1 month) was characterized by three trajectories: slow growth (n=37; 26.4%), catch-up growth (n=69; 49.3%) and rapid catch-up growth (n=34; 24.3%) with significant differences in indicators of psychomotor development at the age of 3 years (p&lt;0.001). More than half (52.9%) of extremely preterm infants with rapid catch-up growth of HC had normal psychomotor development, while in the group with HC delayed growth — only 24.3%. The HC growth trajectory in neonates (1 month) and the outcomes of psychomotor development of children by the age of 3 were influenced by the following: gestational age, birth weight, HC at birth, ventilator length of stay, the presence of bronchopulmonary dysplasia, hemodynamically significant persistent ductus arteriosus, postnatal growth retardation and the method of feeding. Conclusion: extremely preterm neonates (1 month) with HC slow growth are subject to a delay in psychomotor development by the age of 3 years. KEYWORDS: children, preterm infants, head circumference, head circumference growth trajectory, psychomotor development, CAT/CLAMS. FOR CITATION: Shcherbakova V.P., Mozzhukhina L.I., Stroyeva L.E. et al. The association between the tendency of the head circumference growth trajectory in neonates (1 month) and the psychomotor development of extremely preterm infants at the age of 3 years. Russian Journal of Woman and Child Health. 2023;6(2):157–163 (in Russ.). DOI: 10.32364/2618-8430-2023-6-2-157-163.

The perinatal factors that influence the excretion of fecal calprotectin in premature-born children.

This study aimed to provide additional information on the influence of perinatal factors on fecal (f)-calprotectin values in preterm infants. Calprotectin was determined from the first spontaneous stool (analyzed on the Alegria device by using the enzyme-linked immunosorbent assay [ELISA] method) obtained from neonates at a mean age of 3.41 ± 2.44 days of life. We analyzed 114 subjects who had a body weight of 1847.67 ± 418.6 g and were born at a gestational age of 32.6 ± 2.43 weeks, without intestinal and other congenital anomalies or any diseases other than those related to premature birth. The values of f-calprotectin are in a positive correlation with female subjects, intrauterine growth restriction, significant ductus arteriosus, enteral feeding intolerance, postnatal prolonged use of broad-spectrum antibiotics, and values ​​of bicarbonates (analyzed in a sample of capillary arterial blood). Measurement of f-calprotectin in the first 7 days after birth can help to early detect the intestinal distress or early staging of necrotizing enterocolitis in premature infants.

Assessment of diastolic myocardial function in neonates with patent ductus arteriosus using tissue Doppler imaging

Background: The present study was an analytic case control study was done and included full and preterm neonates with PDA and respiratory distress. Neonates with no PDA were also included as a control. Aim of the study: This study aimed to assess diastolic myocardial functions in neonates with different degrees of ductal patency in 1st week of life using tissue Doppler imaging. Methods: The study was conducted at neonatal intensive care unit (NICU) in Bab-Sheria hospital, pediatric department, faculty of medicine, Al Azhar University in the period from June 2018 to June 2021. The present work was conducted on fifty Neonates categorized into 3 groups as follow: Haemodynamically significant dusctus arteriosus cases: ductal diameter more than 2.5 mm and left atrium to aorta (LA: AO) ratio more than 1.5. Non haemodynamically significant ductus arteiosus cases: ductal diameter less than 2.5 mm or (LA: AO) ratio less than 1.5 and Non patent dusctus arteriosus ( Control group). Results: Amount of left-to-right shunt will increase according to the size of the systemic-to-pulmonary communication, and it results in an increased pulmonary blood flow which agrees with our study.

Brain and renal oxygenation measured by NIRS related to patent ductus arteriosus in preterm infants: a prospective observational study

BackgroundPatent ductus arteriosus (PDA) is common among preterm neonates. Haemodynamically significant ductus arteriosus (hsPDA) can cause ductal steal and contribute to poor outcomes. Our aim was to evaluate ductus arteriosus patency and significance using two-site near-infrared spectroscopy (NIRS) measurements in preterm infants older than 72 h as a supplemental tool to echocardiography.MethodsIn this prospective observational study, 123 preterm infants (gestational age (GA) < 32 weeks, birth weight < 1500 g) were enrolled. Sixty-four newborns had closed ductus arteriosus (noPDA), and 41 and 18 patients were assigned to the PDA and hsPDA groups, respectively, per predefined echocardiographic criteria. Cerebral and renal oxygenation were assessed during NIRS monitoring.ResultsA higher renal mean (±SD) regional tissue oxygen saturation (rSpO2) (76.7 (±7.64)) was detected in the noPDA group than in the PDA (71.7 (±9.02)) and hsPDA (67.4 (±13.48)) groups (p < 0.001). Renal fractional tissue oxygen extraction (FTOE) (0.18 (±0.079)) was lower in the noPDA group than in the PDA (0.23 (±0.092)) and hsPDA (0.24 (±0.117))0.117 groups (p = 0.002). Cerebral oxygenation was significantly lower in the hsPDA group (77.0 (±5.16)) than in the noPDA (79.3 (±2.45)) and PDA (79.7 (±2.27)) groups (p = 0.004). There was no significant difference in cerebral fractional tissue oxygen extraction (FTOE) between any of the groups.ConclusionsOur results suggest that renal oxygenation is affected by ductus patency in preterm infants older than 72 h. Significant differences in cerebral oxygenation were observed between the hsPDA group and the PDA and noPDA groups.Trial registrationClinicalTrials.gov Identifier: NCT04295395. Registration date: 4 March 2020. This study was retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04295395.

46 Impact of early versus late medical treatment of a hemodynamically significant patent ductus arteriosus on time to reach full feeds in preterm neonates

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Prolonged exposure to a hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants has been associated with an increase in neonatal morbidities. Objectives To examine the effect of timing of medical treatment (within first 7 days of life versus after 7 days of life) for a hsPDA on the duration to achieve full feeds in infants born at &amp;lt;30 weeks of gestation. Design/Methods This was a retrospective cohort study in a quaternary neonatal intensive care unit (NICU) with a targeted neonatal echocardiography service. Infants admitted between July 2015 – June 2019 who received medical treatment for an hsPDA were included and grouped based on those who received first medical therapy within 7 days of life (early treatment) and after 7 days of life (late treatment). An hsPDA was defined using both clinical (worsening ventilation, pulmonary hemorrhage/edema, or hypotension requiring inotrope or hydrocortisone) and echocardiographic findings (LA/Ao ratio &amp;gt;1.4; LVO &amp;gt;350 mL/kg/min, PDA &amp;gt;1.4 mm, IVRT &amp;lt; 35 ms). Duration to reach full feeds was calculated based on number of days to reach a total enteral feed ≥ 120 mL/kg/day with no parenteral source of nutrition. Results Forty-six infants met the inclusion criteria. Of the 46 infants, 24 were identified as receiving early treatment and 22 received late treatment. Infants in the early treatment group had lower median birth weight than the late treatment group (802 g vs. 1016 g, p=0.022). All other clinical characteristics were not significantly different. No significant difference was found in the use of indomethacin, ibuprofen, or acetaminophen as the initial medical treatment (Table 1). The late treatment group had elevated left ventricular output (median: 286 vs. 369 mL/kg/min, p=0.013) and tricuspid annular plane systolic excursion (median: 6 vs. 8 mm, p=0.002) (Table 2). Infants in the early treatment group reached full feeds earlier than those in the late treatment group (19 vs. 30 days, p=0.042) (Table 1). Conclusion Early medical treatment of hsPDA was associated with shorter duration to reach full feeds in our cohort of preterm infants. Further larger scale study is needed to understand the association between the timing of medical therapy and prolonged exposure of splanchnic circulation to hemodynamically significant ductus.

Prediction of persistence of hemodynamically significant open arterial duct in profoundlypreterm infants

Objective. To develop a method for predicting the persistence of hemodynamically significant ductus arteriosus in profoundly premature newborns based on the evaluation of clinical data and the results of additional studies.&#x0D; Material and methods. Sixty-nine profoundly preterm newborns were examined including 37 with very low and 32 with extremely low body weight. Clinical and anamnestic data, the results of laboratory radiographic and instrumental examinations were evaluated. The state of the arterial duct, as well as the parameters of central and intracardiac hemodynamics were determined by echocardiography. The criteria for hemodynamically significant open arterial duct (OAD) were the following: duct size greater than 1.5 mm, left-right blood bypass, the presence of retrograde blood flow in the aorta greater than 50 % of the antegrade value. There were 2 groups: comparison (n = 41) children with hemodynamically insignificant ductus arteriosus, main (n = 28) children with hemodynamically significant ductus arteriosus after 72 hours of postnatal life.&#x0D; Results. After 72 hours of the postnatal life, a hemodynamically significant ductus arteriosus is detected in 40.6 % of profoundly premature newborns. The factors of a long-term persistence of ductus arteriosus are as follows: birth at term of gestation less than 27 weeks with a low Apgar score within the first minute of life ( 4 points), a patient has a sharp weakening or absence of reflexes of the newborn, severe muscular hypotonia, signs of peripheral circulation, moist fine wheezing and crepitation in the lungs, strengthening of their images on the radiograph due to the interstitial and vascular components, dilation of the left and right ventricles and the left atrium. The method for predicting the dynamics of the open ductus arteriosus in profoundly premature newborns has been developed.&#x0D; Conclusion. The use of the developed prognostic table makes it possible to identify with an accuracy of 85.7 % profoundly premature newborns with a high risk of persistence of a hemodynamically significant ductus arteriosus after 72 hours of postnatal life.

Acetaminophen and the Developing Lung: Could There Be Lifelong Consequences?

Acetaminophen and the Developing Lung: Could There Be Lifelong Consequences?

Перинатальная патология и ее исходы к трехлетнему возрасту у глубоконедоношенных детей с дыхательными нарушениями

Objective. A single-center prospective study of late preterm children’s health condition in the neo-natal period and at the age of 3 was conducted. Patients and methods. 115 late preterm children with respiratory disorders were examined. Two observation groups were formed: group 1 – 62 children with congenital pneumonia, group 2 – 53 children with respiratory distress syndrome (RDS). Results. Children with congenital pneumonia, unlike those with RDS, are born at earlier periods of gestation reliably more often: they are born in extremely critical condition, have a low Apgar score at 5 minutes after birth, require surfactant re-administration. In addition, they are significantly more often diagnosed with brain ischemia (grade III) and intraventricular hemorrhages (grade II–III), acute anemia, hemodynamically significant ductus arteriosus, retinopathy of prematurity and bron-chopulmonary dysplasia. By the age of 3, 59.7% of children from group 1 and 83.0% of children from group 2 are practically healthy. However, transferred congenital pneumonia worsens health indicators at the age of 3: these children more frequently have health group III, a low level of body resistance to external influences and higher disability rates. Conclusion. The presence of congenital pneumonia is an aggravating factor of late preterm chil-dren’s health condition not only in the neonatal period, but also by the age of 3. Keywords: congenital pneumonia, late preterm infant, health groups, catamnesis, neonatal period, perinatal pathology, respiratory distress syndrome

Early Urinary Metabolomics in Patent Ductus Arteriosus Anticipates the Fate: Preliminary Data.

Introduction: In premature neonates, the persistence of hemodynamically significant ductus arteriosus (hsPDA) can be associated with short- and long-term consequences, impairing their outcome. The correct strategy of management for such condition is under debate, especially regarding contraindications and/or side effects. In recent years, metabolomics was applied to several perinatal, pediatric, and adult conditions to investigate potential biomarkers of disease, which have become useful for early diagnosis and/or therapeutic management.Aim of the Study: The main purpose of our exploratory study was to asses, through 1H-NMR metabolomics analysis of urinary samples at birth, possible metabolic pathways differentiating, with a significant predictive power, those preterm neonates who will subsequently develop hsPDA and neonates of comparable gestational age (GA) who will undergo spontaneous ductal closure or the persistence of an irrelevant PDA (no-hsPDA). Moreover, we investigated potential prenatal or perinatal clinical factors potentially influencing the development of hsPDA.Materials and Methods: We enrolled n = 35 preterm neonates with GA between 24 and 32 weeks; urinary samples were collected within the first 12 h of life. Patients were closely monitored regarding intensive care, respiratory support, fluid balance and administered drugs; an echocardiogram was performed at 48–72 h.Results: Our results reported a significant correlation between lower GA at birth and the development of hsPDA. Moreover, neonates with GA ≤ 30w developing hsPDA were characterized by lower Apgar scores at 1′ and 5′, higher rates of perinatal asphyxia, higher need of delivery room resuscitation and subsequent surfactant administration. Interestingly, metabolomics analysis at birth detected a clear separation between the 1H-NMR urinary spectra of subjects GA ≤ 30w not developing hsPDA (n = 19) and those of subjects born at GA ≤ 30w in which hsPDA was confirmed at 48–72 h of life (n = 5).Conclusions: This is the first study applying metabolomics to investigate the PDA condition. Although preliminary and conducted on a limited sample, our results reveal that metabolomics could be a promising tool in the early identification of hsPDA, potentially superior to the clinical or laboratory predictive tools explored to date and even to the clinical observations and correlations in our sample, through the detection of specific urinary metabolites.

Mature and immature platelets during the first week after birth and incidence of patent ductus arteriosus.

Thrombocytopenia is a risk factor for patent ductus arteriosus. Immature and mature platelets exhibit distinct haemostatic properties; however, whether platelet maturity plays a role in postnatal, ductus arteriosus closure is unknown. In this observational study, counts of immature and mature platelets (=total platelet count - immature platelet count) were assessed on days 1, 3, and 7 of life in very low birth weight infants (<1500 g birth weight). We performed echocardiographic screening for haemodynamically significant patent ductus arteriosus on day 7. Counts of mature platelets did not differ on day 1 in infants with (n = 24) and without (n = 45) haemodynamically significant patent ductus arteriosus, while infants with significant patent ductus arteriosus exhibited lower counts of mature platelet on postnatal days 3 and 7. Relative counts of immature platelets (fraction, in %) were higher in infants with patent ductus arteriosus on day 7 but not on days 1 and 3. Receiver operating characteristic curve analysis unraveled associations between both lower mature platelet counts and higher immature platelet fraction (percentage) values on days 3 and 7, with haemodynamically significant ductus arteriosus. Logistic regression analysis revealed that mature platelet counts, but not immature platelet fraction values, were independent predictors of haemodynamically significant patent ductus arteriosus. During the first week of postnatal life, lower counts of mature platelets and higher immature platelet fraction values are associated with haemodynamically significant patent ductus arteriosus. Lower counts of mature platelet were found to be independent predictors of haemodynamically significant patent ductus arteriosus.

Risk Factors and Neonatal Outcomes of Patent Ductus Arteriosus Ligation in Preterm Infants in a Single Center over 6 Years

Objective: To determine the effects of patent ductus arteriosus (PDA) ligation, clinical characteristics of infants who need surgical ligation of PDA and risk factors of PDA ligation were evaluated. Methods: Preterm infants with gestational age (GA) <30 weeks presenting with hemodynamically significant ductus arteriosus (HSDA) were enrolled. HSDA was closed with ibuprofen (medical group, n=55) or surgical ligation (surgical group, n=57). Results: GA and birth weight were smaller in the surgical group (27.8±1.4 weeks in the medical group vs. 26.1±1.6 weeks in the surgical group, P<0.001; 959±241 g in the medical group vs. 815±193 g in the surgical group, P=0.001, respectively). There were no significant differences in gender, Apgar scores, antenatal steroids therapy, maternal gestational diabetes mellitus, pregnancy-induced hypertension, or chorioamnionitis between the two groups. In the surgical group, total duration of mechanical ventilation and duration of invasive ventilation were longer, although postnatal day of ductal closure was not delayed. Moderate to severe bronchopulmonary dysplasia, high-grade intraventricular hemorrhage (≥grade 3), retinopathy of prematurity (≥stage 2), necrotizing enterocolitis (≥stage 2), and mortality rate were also similar between the two groups. Low GA was a significant risk factor associated with surgical ligation of PDA (adjusted odds ratio 0.493, 95% confidence interval 0.366-0.666; P<0.001). Conclusion: Although surgical ligation of PDA is inevitable in certain cases with large shunt and severe respiratory failure, clinicians should weigh the benefit of ductal closure and complications associated with surgery.

Ductal size indexed to weight and body surface area correlates with morbidities in preterm infants ≤32 weeks

Objectives To assess ductal size correlated to spontaneous closure, pharmacological or surgical treatment; to index ductal diameter to body weight and body surface area; to evaluate the morbidities. Study design Retrospective study on preterms ≤32 weeks, birth weight ≤1500 g, extremely low birth weight (ELBW) and very low birth weight (VLBW). Inclusion criteria: patent ductus arteriosus (PDA) with a diameter ≥1 millimeter (mm) at 72 h from birth; need for ibuprofen treatment on the basis of a hemodynamically significant ductus arteriosus (HsPDA). Results One hundred infants with the diagnosis of PDA have been included. We observed a prevalence of spontaneous closure in 34% of newborns (41.3% VLBW versus 26.7% ELBW). The percentage of response to a single course of ibuprofen was of 62% (68.5% ELBW versus 54.3% VLBW). The mean of absolute ductal diameter was of 2.26 ± 0.62 mm in ELBW and 2.18 ± 0.42 mm in VLBW. The indexing of ductus size to body weight demonstrated a higher value in ELBW than VLBW (2.76 ± 0.97 mm/kg versus 1.84 ± 0.40 mm/kg). Conclusions Our results confirmed that HsPDA can develop in presence of a ductus >1.5 mm as absolute value or >1.4 mm/kg as indexed to body weight. In ELBW infants the ductal size indexed for body weight and body surface area could be more predictive of spontaneous closure or need for pharmacological treatment compared to the absolute value of ductal size. A strong association between HsPDA and short- or long-term morbidities was confirmed particularly in ELBW

Anticipatory perioperative management for patent ductus arteriosus surgery: Understanding postligation cardiac syndrome.

Ligation of a hemodynamically significant ductus arteriosus results in significant changes in loading conditions which have predictable consequences. Postligation cardiac syndrome, defined as hypotension requiring inotropic support and failure of oxygenation and ventilation, may occur 6-12hours following ligation due to left ventricular systolic and diastolic failure, respectively. Afterload is the primary driver of this decompensation. In this review, we describe the pathophysiological changes in loading conditions associated with postligation cardiac syndrome and other contributors to cardiovascular dysfunction following ductal ligation. We present strategies for perioperative optimization and a physiology-based algorithm for postoperative management guided by targeted neonatal echocardiography. The use of these strategies to reduce the frequency of postligation deterioration may be an avenue to improve outcomes for neonates in this vulnerable patient population.

Correction: Monitoring cerebral oxygenation of the immature brain: a neuroprotective strategy?

The original version of this article contained an error in the legend of Fig.3, which incorrectly read:Figure3. a The patterns of arterial saturation (SaO2; orange), and rScO2 (blue) and mean arterial blood pressure (MABP; red) of an extremely preterm infant on postnatal day 1. The initial rScO2 values were very low (red box). These low values seemed to be associated with PaCO2 values below 30 mmHg (brown squares; starting at 24 mmHg. SaO2 and MABPs values were always normal. When PaCO2 values increased above values of 30 mmHg (brown arrow) the rScO2 increased and eventually normalized. b The patterns of rScO2 (blue) and mean arterial blood pressure (MABP; red) of a very preterm girl, starting on postnatal day 1, was especially marked by a steep decrease in cerebral oxygenation (rScO2;red box) to very low values (<40%). Echocardiographic investigation early on postnatal day 2 revealed a hemodynamically significant ductus arteriosus. Subsequent ductal closure with indomethacin (2 courses) was followed by normalization of cerebral oxygenation. c The patterns of heart rate (HR), arterial saturation (SaO2) and rScO2 (red box) in a preterm neonate.with severe anemia. The rather low rScO2 recovered following packed red blood cell transfusion (courtesy Prof. Gunnar Naulaers, UZ Leuven).This has been corrected in both the PDF and HTML versions of the article.

Development of a Diagnostic Clinical Score for Hemodynamically Significant Patent Ductus Arteriosus.

There is no consensus about the hemodynamic significance and, therefore, the need to treat a persistent ductus arteriosus in preterm newborns. Since the diagnosis of a hemodynamically significant persistent ductus arteriosus (hsPDA) is made by a summary of non-uniform echo-criteria in combination with the clinical deterioration of the preterm neonate, standardized clinical and ultrasound scoring systems are needed. The objective of this study was the development of a clinical score for the detection and follow-up of hsPDA. In this observational cohort study of 154 preterm neonates (mean gestational age 28.1 weeks), clinical signs for the development of hsPDA were recorded in a standardized score and compared to echocardiography. Analyzing the significance of single score parameters compared to the diagnosis by echocardiography, we developed a short clinical score (calculated sensitivity 84% and specificity 80%). In conclusion, this clinical diagnostic PDA score is non-invasive and quickly to implement. The continuous assessment of defined clinical parameters allows for a more precise diagnosis of hemodynamic significance of PDA and, therefore, should help to detect preterm neonates needing PDA-treatment. The score, therefore, allows a more targeted use of echocardiography in these very fragile preterm neonates.