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Coronary artery perfusion and myocardial performance after patent ductus arteriosus ligation
Arvind Sehgal1, Patrick J McNamara
1Monash Newborn, Monash Medical Centre, Victoria, Australia; Monash University, Victoria, Australia.
Insights
Patent ductus arteriosus (PDA) ligation in premature infants can alter coronary artery (CA) perfusion. Monitoring CA perfusion perioperatively helps identify neonates at risk for impaired myocardial function and hypotension.
Area of Science:
- Neonatal cardiology
- Pediatric cardiovascular surgery
- Echocardiography
Background:
- Surgical ligation of patent ductus arteriosus (PDA) in premature infants often leads to cardiorespiratory instability.
- This instability is frequently linked to impaired left ventricular performance post-surgery.
Purpose of the Study:
- To investigate changes in coronary artery (CA) perfusion and myocardial performance following PDA ligation.
- To identify potential echocardiographic markers for predicting postoperative complications.
Main Methods:
- Serial echocardiography was used to assess myocardial performance (left ventricular output, diastolic function) and CA diastolic flow before and after PDA ligation.
- The ratio of CA flow to left ventricular output was calculated as a surrogate for coronary blood flow.
Main Results:
- A postoperative increase in the CA flow/left ventricular output ratio was observed.
- Early decreases in diastolic function parameters (E and A wave peak velocity) and increased isovolumic relaxation time were noted one hour post-ligation.
- Low baseline CA flow was associated with impaired diastolic function, lower systolic blood pressure, and increased need for inotropes and oxygen postoperatively.
Conclusions:
- PDA ligation is associated with significant alterations in coronary artery perfusion.
- Perioperative echocardiographic assessment of CA perfusion can identify neonates at risk for adverse outcomes such as impaired myocardial performance, hypotension, and need for inotropic support.
Objectives:
To study coronary artery (CA) perfusion and myocardial performance after patent ductus arteriosus (PDA) ligation. The postoperative course in premature infants undergoing surgical ligation of PDA is often complicated by cardiorespiratory instability secondary to impaired left ventricular performance.
Methods:
Serial echocardiography was performed before and after (1, 8, and 24 hours) PDA ligation to assess systolic (left ventricular output [LVO]) and diastolic (isovolumic relaxation time, E and A wave peak velocity) myocardial performance, and CA diastolic flow (CA velocity time integral and flow). The ratio of CA flow to LVO was calculated as a surrogate of coronary flow.
Results:
A total of 20 infants (gestational age at birth, 26.3 ± 0.7 weeks) requiring PDA ligation at a median of 28.5 days (range, 9-40) after birth and weight of 780 g (range, 570-2840) were studied. A postoperative increase in the CA flow/LVO ratio was demonstrated. An early decrease in E and A wave peak velocity (P < .05) and increase in isovolumic relaxation time (P < .05) were demonstrated at 1 hour, before any clinical deterioration. A low baseline CA velocity time integral was associated with a low E/A ratio (r = 0.63, P = .01) at 1 hour and lower systolic blood pressure at 8 hours (r = 0.5, P = .05). The postoperative need for inotropes (n = 8) was associated with a low baseline CA velocity time integral at 1 hour (r = 0.52, P < .05), low LVO at 1 and 8 hours (P < .05), and increased oxygen requirement at 24 hours (P < .05).
Conclusions:
PDA ligation is followed by altered CA perfusion. Perioperative evaluation of the CA perfusion can help identify neonates at risk of impaired myocardial performance, systolic hypotension, and the need for inotropes.
