Early Surgical Ligation Versus a Conservative Approach for Management of Patent Ductus Arteriosus That Fails to Close after Indomethacin Treatment

Department of Pediatrics, University of California, San Francisco, CA 94143-0544, USA.
The Journal of pediatrics (Impact Factor: 3.79). 04/2010; 157(3):381-7, 387.e1. DOI: 10.1016/j.jpeds.2010.02.062
Source: PubMed


To examine whether a more conservative approach to treating patent ductus arteriosus (PDA) is associated with an increase or decrease in morbidity compared with an approach involving early PDA ligation.
In January 2005, we changed our approach to infants born at age<or=27 weeks gestation who failed indomethacin treatment. We changed from an early surgical approach, in which feedings were stopped and all PDAs were ligated (period 1: January 1999 to December 2004; n=216) to a more conservative approach in which feedings continued and PDAs were ligated only if cardiopulmonary compromise developed (period 2: January 2005 to August 2009; n=180). All infants in both periods received prophylactic indomethacin therapy.
The 2 periods had similar rates of perinatal/neonatal risk factors and indomethacin failure (24%), as well as ventilator management and feeding advance protocols. The conservative approach (period 2) was associated with decreased rates of duct ligation (72% vs 100%; P<.05). Even though infants subjected to this approach were exposed to larger PDA shunts for longer durations, the rates of bronchopulmonary dysplasia, sepsis, retinopathy of prematurity, neurologic injury, and death were similar to those in period 1. The overall rate of necrotizing enterocolitis was significantly lower in period 2 compared with period 1.
These findings support the need for new controlled, randomized trials to reexamine the benefits and risks of different approaches to PDA treatment.

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Available from: Anita J Moon-Grady, Apr 18, 2014
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    • "However, controversy regarding the treatment of PDA still exists. Of greatest concern is the treatment of PDA in extremely preterm infants "born at the limits of viability" because 1) the rate of spontaneous ductal closure is extremely low (1); 2) the response rate to pharmacologic treatment is very low as well (1, 2); and 3) they are prone to develop hemodynamically significant PDA with cardiopulmonary compromise (3). For these reasons, surgical ligation is frequently performed despite the surgical risk and complications. "
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    ABSTRACT: The purpose of this study was to evaluate prognostic factors associated with surgical ligation for patent ductus arteriosus (PDA) in extremely preterm infants born at the limits of viability. Ninety infants who were born at 23-25 weeks of gestation and who received surgical ligation were included and their cases were retrospectively reviewed. Infants were classified into two different groups: survivors with no major morbidity (N), and non-survivors or survivors with any major morbidity (M). Clinical characteristics were compared between the groups. Possible prognostic factors were derived from this comparison and further tested by logistic regression analysis. The mean gestational age and the mean birth weight of M were significantly lower than those of N. Notably, the mean postnatal age at time of ligation in N was significantly later than that of the other group (17±12 vs 11±8 days in N and M, respectively). An adjusted analysis showed that delayed ligation (>2 weeks) was uniquely associated with a significantly decreased risk for mortality or composite morbidity after surgical ligation (OR, 0.105; 95% CI, 0.012-0.928). In conclusion, delayed surgical ligation for PDA (>2 weeks) is associated with decreased mortality or morbidities in extremely preterm infants born at 23-25 weeks of gestation. Graphical Abstract
    Full-text · Article · Apr 2014 · Journal of Korean medical science
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    • "Studies have reported that strategies avoiding or more selectively administering ductal closure treatments resulted in outcomes that are no worse (and perhaps better) than outcomes where infants were more aggressively treated with medication or surgery.[89909192] Jhaveri et al. reported similar neonatal outcomes with a late, selective ligation strategy compared with an early ligation approach for infants with a persistent PDA after medical therapy failure.[91] "
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    ABSTRACT: Observational studies have associated patent ductus arteriosus (PDA) ligation in preterm infants with increased chronic lung disease (CLD), retinopathy of prematurity, and neurodevelopmental impairment at long-term follow-up. Although the biological rationale for this association is incompletely understood, there is an emerging secular trend toward a permissive approach to the PDA. However, insufficient adjustment for postnatal, pre-ligation confounders, such as intraventricular hemorrhage and the duration and intensity of mechanical ventilation, suggests the presence of residual bias due to confounding by indication, and obliges caution in interpreting the ligation-morbidity relationship. A period of conservative management after failure of medical PDA closure may be considered to reduce the number of infants treated with surgery. Increased mortality and CLD in infants with persistent symptomatic PDA suggests that surgical ligation remains an important treatment modality for preterm infants.
    Full-text · Article · Apr 2014
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    • "In the contrary, the overall rate of NEC was significantly lower in patients treated with selective ligation compared with those treated with early ligation (OR, 0.26; 95% CI, 0.07–0.95) [32]. Neurodevelopmental followup was conducted for 224 of those infants up to 18–36 months of age. "
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    ABSTRACT: Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.
    Full-text · Article · Dec 2013
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