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PDA: To treat or not to treat
Meera N Sankar1, Shazia Bhombal1, William E Benitz1
1Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California.
Insights
Management of patent ductus arteriosus in extremely preterm infants is debated. While treatments close the ductus, evidence for reduced mortality is lacking; conservative approaches may improve outcomes.
Area of Science:
- Neonatal Medicine
- Pediatric Cardiology
- Perinatal Research
Background:
- Patent ductus arteriosus (PDA) management in extremely preterm infants is controversial.
- Previous treatments, including nonsteroidal anti-inflammatory drugs and surgical ligation, lack proven benefits for mortality and carry risks.
- Conservative approaches are emerging as a potential alternative.
Purpose of the Study:
- To review the current evidence and debates surrounding PDA management in extremely preterm infants.
- To evaluate the effectiveness and risks of different PDA treatment strategies.
- To highlight the need for better identification of infants who would benefit from intervention.
Main Methods:
- Review of meta-analyses of nonsteroidal anti-inflammatory drug trials.
- Analysis of outcomes associated with surgical ligation.
- Evaluation of recent data on conservative management strategies.
- Discussion of potential long-term adverse effects of untreated PDA.
Main Results:
- Nonsteroidal anti-inflammatory drugs accelerate ductal closure but do not reduce neonatal morbidities.
- Surgical ligation closes the ductus but is linked to adverse effects.
- Conservative management shows promise for improved neonatal outcomes and spontaneous closure.
- Long-standing aortopulmonary shunts may necessitate later interventions.
Conclusions:
- The optimal management strategy for PDA in extremely preterm infants requires further investigation.
- Conservative approaches may offer improved outcomes, but careful follow-up is essential.
- Identifying high-risk infants for targeted treatment is a critical unmet need.
Abstract:
Management of patent ductus arteriosus in extremely preterm infants remains a topic of debate. Treatment to produce ductal closure was widely practiced until the past decade, despite lack of evidence that it decreases morbidities or mortality. Meta-analyses of trials using nonsteroidal anti-inflammatory drugs have shown effectiveness in accelerating ductal closure, but no reduction in neonatal morbidities, regardless of agent used, indication, timing, gestational age, or route of administration. Surgical ligation closes the ductus but is associated with adverse effects. Recent experience with conservative approaches to treatment suggest improved neonatal outcomes and a high rate of spontaneous ductal closure after discharge. Careful postdischarge follow-up is important, however, because potential adverse effects of long-standing aortopulmonary shunts may be an indication for catheter-based ductal closure. Identification of extremely preterm infants at greatest risk of potential harm from a persistently patent ductus, who may benefit most from treatment are urgently needed.
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