Management of Patent Ductus Arteriosus in Preterm Infants-Where Do We Stand?

Abstract

Patent ductus arteriosus (PDA) in preterm infants is a controversial topic in the management of preterm neonates. There are no generally accepted guidelines for diagnosis, treatment, and follow-up of PDA, and few publications have covered the whole topic or have been conclusively summarized to give a proper direction for the treating physician. Major issues remain to be clarified, both with respect to diagnosis and treatment. The definition of hemodynamic significance varies because of different use of echocardiographic criteria and uncertainty about the role of biomarkers. The detailed risks and benefits of available treatment alternatives are still under investigation. There has been a general shift in the management of PDA in preterm neonates from the "aggressive approach" to a more "conservative approach," but the effects of this strategy on morbidity in a longer time perspective are not fully known. An individualized therapeutic strategy with special emphasis on identification of hemodynamically significance seems to be the way forward. In this review we put forward the scientific background in favor of a seemingly growing body of evidence against active treatment, but we raise caution against shying away from all forms of treatment or instituting them too late. Finally, we try to integrate the current knowledge into suggestions for the management of PDA in premature infants.

Cardiac remodeling in preterm infants with prolonged exposure to a patent ductus arteriosus

“…This PDA profile is associated with echocardiographic and clinical volume overload in preterm infants. 2,5 The control group consisted of preterm infants less than 30 weeks gestation that were not treated with mechanical ventilation or inotropic support, received an echocardiogram during the study period and did not have a significant PDA. Most control infants were investigated for a murmur or were unable to tolerate a trial off positive airway pressure support.…”

“…3,4 For remaining cases, awaiting spontaneous closure is an alternative approach to management. 5 Although PDA pathophysiology has been extensively studied during the first few days of life, little is known in terms of how the preterm heart remodels with sustained changes in volume loading conditions during a period of rapid organ development in the neonatal intensive care setting. Ventricular remodeling refers to the structural changes of the heart in response to biomechanical stress from ischaemic or inflammatory events, or from pressure or volume overload conditions.…”

Management of Patent Ductus Arteriosus in Preterm Infants-Where Do We Stand? A UK National Perspective

“…published in the journal of Congenital Heart Disease December 2013 issue. 1 The authors have very elegantly reviewed and summarized the evidence supporting and refuting the treatment of patent ductus arteriosus (PDA) in preterm infants. We strongly agree with the main recommendations made in this review article that individualized "targeted" treatment of PDA in preterm infants using pharmacotherapy seems to be the most reasonable approach.…”

Which Criteria are More Valuable in Defining Hemodynamic Significance of Patent Ductus Arteriosus in Premature Infants? Respiratory or Echocardiographic?

“…Therefore, PDA treatment strategies differ between centers. The decision whether, when, or how to administer therapies to close PDA in premature infants remains challenging (9). Treatment is commonly prescribed for hsPDA (10).…”