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

Abstract

Objective: To investigate the effect of postnatal age at patent ductus arteriosus (PDA) ligation on postoperative need for cardiotropic support.Study Design: A significant proportion of premature infants with a hemodynamically significant ductus arteriosus (HSDA) require surgical intervention. The relationship of postnatal maturation to postoperative cardiorespiratory stability is poorly understood. All preterm neonates who underwent PDA ligation between October 2002 and September 2004 were identified and divided according to postnatal age at ductal ligation, into early (p4 weeks, n ¼ 29) and late (>4 weeks, n ¼ 36) groups. Neonatal birth demographics and morbidities, characteristics of the HSDA and reason for ligation were reviewed. Indices of cardiorespiratory stability (for example heart rate, mean arterial pressure) were recorded before and 1, 4, 8, 12 and 24 h following ligation. Details of perioperative cardiovascular interventions (for example crystalloid boluses, cardiotropic agents) were recorded.Result: There were no differences in baseline neonatal demographics between the groups although a greater number of babies requiring early ligation had contraindication to indomethacin as the main reason for ligation. Early PDA ligation was associated with increased postoperative cardiotrope requirement (27.6 vs 5.6%, P ¼ 0.02) and decreased systolic blood pressure 8 h after intervention (P<0.05). Although increased oxygenation index was observed in both groups during the first 12 h it was only sustained to 24 h in the early group (P<0.05). Age at ligation remained a significant risk factor for postoperative cardiotrope requirement on multiple logistic regression analysis.Conclusion: Surgical ligation of the ductus arteriosus in preterm infants less than 28 days old is associated with oxygenation difficulties, decreased systolic arterial pressure and an increased need for cardiotropic support in the initial 24 postoperative hours. These data suggest the need to prospectively characterize perioperative cardiovascular physiology and identify predictive factors of clinical deterioration.

Cardiovascular instability after patent ductus arteriosus ligation in preterm infants: the role of hydrocortisone

“…Left ventricular failure could lead to pulmonary edema and result in difficulty with oxygenation. 4,13 A study in the preterm baboon showed ligated animals had more severe left ventricular dysfunction, required more cardiovascular support and higher mean airway pressures at 24 h of age compared with animals with persistent PDA that is consistent with what we often see in this population. 14 This acute decompensation experienced by infants post ligation is important because it may place them at higher likelihood for poor long-term outcomes.…”

“…3 Prostaglandin inhibitors, such as indomethacin or ibuprofen, are used to close the PDA, but if pharmacological closure is contraindicated or unsuccessful, surgical ligation is usually performed in most neonatal intensive care units (NICU) according to present clinical practice. 4 Surgery is well tolerated in most infants, but B30% develop severe systemic hypotension and respiratory decline requiring maximum levels of cardiopulmonary support in the postoperative period. 5 It has been suggested that this postoperative cardiorespiratory instability is the reason why the infants that have PDA ligations are at higher risk for bronchopulmonary dysplasia, severe retinopathy of prematurity and neurosensory impairment.…”

Percutaneous Patent Ductus Arteriosus (PDA) Closure in Very Preterm Infants: Feasibility and Complications

“…Evidence on the risks of drug therapy or surgical PDA ligation26, 27 has led to growing interest in the use of percutaneous closure in premature infants 10, 15, 16, 28, 29, 30. The main finding of our 10‐year study is that, among a large cohort of infants born very premature and referred for percutaneous closure at weights <4 kg, the majority are successfully closed in the catheterization suite with evidence of improved pulmonary status following closure, but risk of arterial injury in these infants is noteworthy.…”

Patent ductus arteriosus in the preterm infant: to treat or not to treat?

“…In about 30% of preterm infants undergoing PDA ligation, there is some degree of cardiovascular compromise as evidenced by the need for initiation or escalation of vasopressorinotrope or inotrope treatment. [52][53][54] The reason for this deterioration is not known. In one study, lower gestational age, and higher respiratory support and, interestingly, exposure to antenatal steroids were associated with post-ligation hypotension.…”