Enhanced intensive care for the neonatal ductus arteriosus

Abstract

Failure of ductal closure is common in extremely low birth weight infants with significant postnatal morbidities from both pulmonary overcirculation (i.e. chronic lung disease) and/or systemic hypoperfusion (i.e. necrotizing enterocolitis). Early clinical signs of a hemodymanically significant ductus may be non-specific (i.e. hypotension, increasing ventilator requirements, metabolic acidosis) necessitating early screening by echocardiography. Cyclooxygenase inhibitors remain the first-line treatment option. Indomethacin remains the most commonly used agent, despite comparable efficacy and reduced risk of adverse events with ibuprofen. Surgical intervention is recommended after failure of medical therapy, contraindications to medical treatment or fulminating duct-related cardiorespiratory deterioration. Wherever possible, surgical intervention in ELBW infants should be avoided in the first week of life due to the potential risks of ischemia-reperfusion cerebral hemorrhage. The postoperative course is often complicated by left ventricular failure, pulmonary edema, and/or hemodynamic instability requiring close monitoring and physiologically relevant therapeutic interventions.

Carina Angle Measurements for Diagnosis of Patent Ductus Arteriosus in Preterm Infants

“…Clinical signs of PDA should be sought during the first 2-3 days of life, and this is a routine procedure for neonatologists. Early detection of hemodynamically significant PDA and targeted intervention may potentially improve neonatal outcomes and reduce associated morbidities [6] . Nevertheless, there is still no consensus on the clinical definition and criteria for a hemodynamically significant PDA.…”

“…Preterm infants (i.e., born before 32 weeks of gestation) and very-low-birth-weight infants may have delayed ductal closure [1][2][3][4][5][6] . Persistent DA causes a left-toright shunt which may create left-side volume overload leading to enlargement of the left heart and the left atrium (LA) [7,8] .…”

“…These changes include pulmonary congestion and cardiomegaly, which are, however, nonspecific for PDA [6,14,16] . More specific findings on posteroanterior CXR of patients with PDA are left ventricle and LA enlargement, which produces a definite downward dipping of the cardiac apex.…”

Does echocardiography facilitate determination of hemodynamic significance attributable to the ductus arteriosus?

“…The nature of clinical compromise is secondary to pulmonary overcirculation/ edema, which in turn may lead to reduced lung compliance and/or leakage of plasma proteins causing increased need for oxygen and ventilation (e.g., chronic lung disease), and/or systemic hypoperfusion (e.g., necrotizing enterocolitis, acute renal impairment, or low cardiac output state) [38]. A more informed evaluation should consider echocardiography markers of pulmonary overcirculation and/or systemic hypoperfusion.…”

Postoperative cardiorespiratory instability following ligation of the preterm ductus arteriosus is related to early need for intervention

“…[1][2][3] Failure of medical intervention occurs in 40 to 50% of extremely low birth weight infants necessitating surgical intervention. 4 In patients with a bleeding diathesis, necrotizing enterocolitis (NEC) or where nonsteroidal anti-inflammatory drugs (NSADs) are contraindicated surgical intervention is the only available option.…”