Survey highlighting the lack of consensus on diagnosis and treatment of patent ductus arteriosus in prematurity

Abstract

To gain insight in the availability of guidelines, diagnostic criteria, and treatment strategies and whether clinical equipoise regarding optimal treatment for patent ductus arteriosus (PDA) in prematurity is present. We hypothesized that (co-)authors of PDA-related papers were more likely to screen for a PDA and would treat earlier and more aggressively. An international internet-based survey between September 2019 and March 2020 in which we collected (1) baseline characteristics; (2) availability of guidelines; (3) screening strategy for PDA; (4) diagnostic criteria for hemodynamic significance; (5) treatment strategy; and (6) metrics of treatment efficacy. Finally, ten clinical equipoise statements were posed on a Likert scale. In total, 144 surveys were sent, of which 71/144 (49%) surveys could be analyzed with 56/71 (79%) fully completed surveys. The respondents, mainly neonatologists in a level III neonatal intensive care unit, of whom 36/71 (51%) had (co-)authored a publication on the PDA, highlighted a lack of national guidelines, heterogeneous approach to screening strategies, and marked variability in diagnostic criteria to assess hemodynamic significance, treatment strategies and effect measurement. No major significant differences were observed between respondents who did or did not (co-)author a publication on the PDA. Respondents who screened for PDA scored significantly higher on the need for screening, early and aggressive treatment. Remarkably, the scores of all statements regarding clinical equipoise varied widely. Conclusions: Our survey highlights the lack of guidelines and enormous heterogeneity in current practice. Current evidence is not robust enough to harmonize current treatment strategies into (inter)national guidelines. What is Known:• Patent ductus arteriosus (PDA) incidence is inversely related to gestational age.• Although early pharmacological treatment induces PDA closure, optimal treatment is debated due to the lack of beneficial effects on outcome. What is New:• In the absence of (inter)national guidelines, diagnostic and treatment strategies are heterogeneous and contradictory, even in a selected hemodynamically- interested group.• Different PDA screening strategies did, while PDA publication status did not, show significant differences in treatment strategy and responses to equipoise statements.

Patent Ductus Arteriosus and Bronchopulmonary Dysplasia–Associated Pulmonary Hypertension

“…For some clinicians, PDA has acquired the status of a benign event, with treatment resulting in more complications than benefits. In the absence of a consensus on how, when, and which infants to treat for PDA, a growing number of neonatologists are adopting a less interventional approach to management of PDA . As a result, an increasing number of preterm infants are and will be potentially exposed to a prolonged ductal shunt .…”

“…With regard to exposure, a majority of the included studies were retrospective and did not report the time of diagnosis or treatment of PDA or the rate of response to treatment. In addition, the diagnostic criteria for hsPDA or the time limit defining prolonged exposure to PDA are the subject of ongoing and far from settled debate . It is important to note that the hemodynamic meaning of PDA is affected by factors such as the transductal diameter, the balance between pulmonary and systemic vascular resistance, and the compensatory capacity of the immature myocardium .…”

“…In the absence of a consensus on how, when, and which infants to treat for PDA, a growing number of neonatologists are adopting a less interventional approach to management of PDA. 55 , 56 , 57 As a result, an increasing number of preterm infants are and will be potentially exposed to a prolonged ductal shunt. 58 , 59 As pointed out by El-Khuffash et al, 60 it is unlikely that a true hsPDA with chronic left-to-right shunting does not play a role in pulmonary vascular remodeling during the first few weeks of life.…”

Transcatheter closure of patent ductus arteriosus in preterm infants: results from a single-center cohort

“…In this regards, interventional catheterization offers an interesting alternative in the PDA treatment strategy. Further studies are needed to define clinical and hemodynamic criteria of closure as well as its adequate timing ( 4 ). They should also evaluate the benefits on neonatal comorbidities such as BPD.…”

“…Consequently, the shared takeaway from the vast literature about PDA is that preterm infants would benefit from ductal closure. Despite numerous studies about indication, timing and modalities of ductal closure, management of PDA remains controversial without any consensus ( 4 ). Pharmacological treatment, including intravenous administration of cyclooxygenase inhibitors or acetaminophen, is effective in only 50%–70% of infants and efficiency decreases for those born before 32 weeks of GA.…”