The effect of patent ductus arteriosus on flow velocity in the anterior cerebral arteries: Ductal steal in the premature newborn infant

Perlman, Jeffrey M.; Hill, Alan; Volpe, Joseph J.

doi:10.1016/s0022-3476(81)80408-8

Cited by 223 publications

(81 citation statements)

References 9 publications

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“…This is because there was insufficient time for PVR to decrease enough to allow blood to flow predominantly from left to right through the DA. Retrograde blood flow during diastole in the carotid, cerebral, mesenteric, and renal arteries is commonly observed in preterm infants with a large patent DA (24)(25)(26). However, this can only occur when PVR is lower than downstream resistance in these peripheral vascular beds.…”

Section: Discussionmentioning

confidence: 99%

Effects of chest compressions on cardiovascular and cerebral hemodynamics in asphyxiated near-term lambs

et al. 2015

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Background: Chest compressions (CC) and adrenaline administration are recommended in asphyxiated newborns with persistent bradycardia despite effective ventilation. The effects of CC on cerebral blood flow in newborns at birth are unknown. Our aim was to determine the effects of CC, with or without adrenaline administration, on the return of spontaneous circulation, carotid blood flow (CBF), and carotid arterial pressure (CAP) in asphyxiated near-term lambs. Methods: Asphyxia was induced in near-term lambs by clamping the umbilical cord and delaying ventilation onset until spontaneous circulation ceased. Lambs were then resuscitated by positive pressure ventilation along with CC followed by adrenaline administration. CAP and CBF were continuously recorded. results: Mean CAP did not increase significantly during CC and only increased following adrenaline administration. CC did not increase mean CBF but increased CBF amplitude due to increased peak flow and the onset of retrograde flow during diastole. Adrenaline increased mean CBF from 1 ± 2 to 15 ± 5 ml/kg/min and abolished retrograde diastolic CBF, leading to the return in spontaneous circulation. conclusion: We conclude that CC with adrenaline administration was required to increase CBF and restore spontaneous circulation in asphyxiated lambs. Low CBF and retrograde diastolic CBF during CC indicate hypoperfusion to the brain. a pproximately 5% of all newborns worldwide will require some form of assisted ventilation at birth and about 0.03% of newborns will require more advanced resuscitation such as intubation, chest compressions (CCs), and drug administration (1,2). Severely asphyxiated newborn infants are born bradycardic and apneic and require resuscitation to establish pulmonary gas exchange and restore cardiac function after birth. As the initiation of ventilation and the establishment of a functional capacity also trigger the increase in pulmonary blood flow at birth, it plays a dual role in severely asphyxiated newborn infants (3). That is, it is responsible for both increasing oxygenation and for facilitating the increase in cardiac output by providing preload for the left ventricle (3,4). If low cardiac output persists despite effective positive pressure ventilation, the newborn is likely to suffer increasingly severe hypoxia and acidemia, leading to hypoxic/ischemic injury. Continued asphyxia further depresses myocardial function, leading to low systolic and diastolic blood pressures despite a chemoreceptor-mediated peripheral vasoconstriction (5,6). Current international neonatal resuscitation guidelines recommend that if heart rate is less than 60 BPM despite effective positive pressure ventilation, CCs should be applied (7,8). CC will assist to mechanically pump blood until the myocardium is sufficiently oxygenated to recover spontaneous function (9). If heart rate remains below 60 BPM despite effective CC, then adrenaline should be administered (7,8).Given the infrequent use of CC and adrenaline, rigorous clinical studies to optimize CC and adren...

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Section: Discussionmentioning

confidence: 99%

Effects of chest compressions on cardiovascular and cerebral hemodynamics in asphyxiated near-term lambs

et al. 2015

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“…13 With regard to the central nervous system, although some investigators have reported no change in cerebral blood flow (CBF) as a result of compensatory increase in cardiac output, 14 most studies have found CBF to be impaired in preterm infants with a PDA. [15][16][17][18][19] Doppler studies have shown that the negative effect of PDA on CBF mainly affects the blood flow during diastole, as evidenced by a decrease in flow velocity and increase in pulsatility or resistance index. Similarly, near-infrared spectroscopy and superior vena cava flow studies have demonstrated and suggested, respectively, a reduced CBF in the presence of a hemodynamically significant PDA.…”

Section: Introductionmentioning

confidence: 99%

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

Noori

2010

J Perinatol

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Pharmacological and/or surgical closure of a hemodynamically significant patent ductus arteriosus (PDA) in the very preterm infant has been the standard of care over the past few decades. However, the rationale for closure of PDA has recently been challenged. In this article, the factors that have fueled the controversy of the approach to the management of PDA and the gap in our knowledge are reviewed in detail. In addition, the pros and cons of the different treatment strategies applied in clinical care are evaluated with a focus on discussing the available evidence in the literature.

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“…After this time, pulmonary pressure continues to fall and ductal shunting has increased impact on blood pressure (4,33) and patterns of cerebral perfusion (34,35). In addition, it should be noted that the finding that upper body perfusion is maintained in the presence of ductal shunt is drawn from mean values seen across a large cohort of preterm infants, and it is clear that the transitional circulation varies greatly between individuals (17,36).…”

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confidence: 99%

Does Retrograde Diastolic Flow in the Descending Aorta Signify Impaired Systemic Perfusion in Preterm Infants?

et al. 2008

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High-volume systemic-to-pulmonary ductal shunting occurs frequently in preterm infants and is indicated by diastolic flow reversal in the descending aorta (DAo). We studied the relationship between ductal diameter, diastolic DAo reversal, and left ventricular output (LVO); and superior vena caval (SVC) flow (upper body perfusion) and DAo flow (lower body perfusion) in preterm (Ͻ31 wk) infants. Echocardiographic assessments were performed at 5, 12, 24, and 48 h postnatal age (80 infants, median gestation 28 wk, 1060 g). Incidence of ductal patency fell from 100% at 5 h to 72% at 48 h; incidence of pure systemic-to-pulmonary shunting increased from 66% to 95% of infants with patent ducts. In infants with duct diameter greater than the median, 35-48% of infants had DAo flow reversal. In infants with duct diameter greater than median, DAo reversal was associated with 23-29% increases in LVO at 5-48 h, and 35% decreases in DAo flow volume at 24 -48 h, but no differences in SVC flow. In conclusion, a large duct with left-to-right shunting is common in preterm infants. Retrograde DAo flow is a marker of high-volume shunt, evidenced by increased LVO. Preterm infants with high-volume ductal shunt may have preserved upper body perfusion but reduced lower body perfusion. T he clinical significance of shunting through the patent ductus arteriosus in the premature newborn infant remains uncertain (1-4). It is clear that prolonged patency of the ductus arteriosus is seen in preterm infants with respiratory distress (5), and can be associated with significant volume of systemic-to-pulmonary shunting (6). In addition, prolonged ductal patency is associated with a variety of adverse outcomes in preterm infants (7). However, a causative association between ductal shunting and adverse outcome has not been established (8,9), and clinical trials of therapeutic intervention have not demonstrated reductions in morbidity (1). There is increasing awareness that ductal patency may not be a primary pathologic entity but rather an epiphenomenon of prematurity itself (10).Circulatory impact of ductal shunt depends on the volume of shunt and the ability of the myocardium to produce a compensatory increase in left ventricular output (LVO). It has previously been suggested that in the first postnatal days shunt volume through the ductus would be low due to the relatively balanced pulmonary and systemic arterial pressures at this time (11). However, there is now substantial evidence that pulmonary pressure in surfactant treated infants falls rapidly after birth (12,13). High-volume ductal shunt, as evidenced by reversal of blood flow during diastole in the descending aorta (DAo), has been seen as early as 7 h after birth (8), and may occur days before clinical signs appear (5).LVO has been shown to increase with increased ductal shunting in many preterm infants (14). However, it is possible that the immature myocardium has a limited ability to increase output in the first postnatal day (15). The combination of high-volume ductal shunt...

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The effect of patent ductus arteriosus on flow velocity in the anterior cerebral arteries: Ductal steal in the premature newborn infant

Cited by 223 publications

References 9 publications

Effects of chest compressions on cardiovascular and cerebral hemodynamics in asphyxiated near-term lambs

Effects of chest compressions on cardiovascular and cerebral hemodynamics in asphyxiated near-term lambs

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

Does Retrograde Diastolic Flow in the Descending Aorta Signify Impaired Systemic Perfusion in Preterm Infants?

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