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Published on: January 27, 2023
Patent Ductus Arteriosus in Preterm Infants
Namasivayam Ambalavanan1, Susan W Aucott2, Arash Salavitabar3
1University of Alabama at Birmingham, Birmingham, Alabama.
Insights
Uncertainty persists regarding patent ductus arteriosus (PDA) in preterm infants. Current evidence does not support early medical closure, and long-term outcomes for later interventions remain undefined.
Area of Science:
- Neonatal Medicine
- Pediatric Cardiology
- Clinical Evidence Synthesis
Background:
- Patent ductus arteriosus (PDA) remains a controversial topic in preterm infants, despite extensive research.
- Delayed ductal closure is common, especially in extremely premature infants, leading to varied clinical practices.
Purpose of the Study:
- To review evidence guiding the evaluation and treatment of preterm infants with prolonged ductal patency.
- To address the persistent uncertainty surrounding the significance, assessment, and management of PDA in this population.
Main Methods:
- Systematic review of existing clinical evidence and trial data.
- Echocardiography is highlighted as essential for PDA diagnosis and hemodynamic assessment.
Main Results:
- Prophylactic or early (<2 weeks) medical closure of PDA shows no benefit over expectant management and is not recommended.
- Evidence is insufficient for guiding management of hemodynamically significant PDA (hsPDA) beyond 2 weeks of age.
Conclusions:
- Management of hsPDA beyond 2 weeks requires further research, with equipoise regarding expectant management, pharmacologic closure, or procedural intervention.
- Transcatheter closure is becoming more common than surgical ligation for persistent hsPDA.
- More trials are needed to define optimal timing and long-term outcomes of PDA interventions.
Abstract:
Despite extensive research in basic science and in clinical settings with thousands of infants over decades, uncertainty and controversy persist regarding the significance, assessment, and management of the patent ductus arteriosus (PDA) in preterm infants, resulting in substantial variability in clinical approach. This clinical report aims to succinctly review the available evidence to guide evaluation and treatment of preterm infants with prolonged ductal patency. Delayed closure of the PDA is common in preterm infants, particularly at more extreme immaturity. Echocardiography is essential for confirming the presence of a PDA and assessing hemodynamic significance. Medical closure of a PDA using ibuprofen or acetaminophen is an option for a hemodynamically significant PDA (hsPDA). Recent data from multiple clinical trials indicate the lack of benefits of prophylactic or early (<2 weeks of age) medical closure of PDA as compared with expectant management, and they are, therefore, not recommended. There are insufficient data to support firm recommendations on management of infants with an hsPDA beyond 2 weeks of age as relative benefits and risks of expectant management with close monitoring, attempted pharmacologic closure, or procedural (transcatheter/surgical) closure have not been adequately defined. Many clinicians attempt medical closure of an hsPDA beyond 2 weeks of age. If the hsPDA persists despite medical therapy (or if medical therapy is contraindicated), such infants may be considered for either transcatheter closure or surgical ligation. In recent years, surgical closure of the PDA has become less frequent, and transcatheter closure is more common in many centers. Although there are known adverse effects of an hsPDA, there is a lack of evidence to guide management, necessitating equipoise regarding treatment options and timing and a need for trials that can expand the available body of evidence, especially regarding long-term cardiopulmonary and neurodevelopmental outcomes.
