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Surgical and medical experience with 734 premature infants with patient ductus arteriosus
Insights
Surgical ligation of patent ductus arteriosus (PDA) in preterm infants reduces necrotizing enterocolitis and improves survival. Early surgical intervention for PDA leads to shorter intubation times and better long-term outcomes.
Area of Science:
- Neonatalogy
- Pediatric Cardiology
- Surgical Neonatology
Background:
- Patent ductus arteriosus (PDA) is common in preterm infants, often leading to complications like congestive heart failure.
- Medical management of PDA includes fluid restriction, diuretics, and respiratory support, with surgery reserved for refractory cases.
Purpose of the Study:
- To evaluate the outcomes of surgical ligation versus medical management for patent ductus arteriosus (PDA) in preterm infants.
- To compare the incidence of complications and long-term survival rates between surgical and medical treatment groups.
Main Methods:
- Retrospective analysis of 734 preterm infants with PDA over 5 years.
- Comparison of outcomes between infants treated medically and those undergoing surgical ligation, with subgroup analysis for infants weighing less than 1.5 kg.
Main Results:
- Surgical ligation was associated with a reduced incidence of necrotizing enterocolitis (NEC) (0.3% vs 11%) and improved long-term survival (89% vs 77%) in infants <1.5 kg.
- Surgical patients had a shorter average duration of intubation (8.9 days vs 13.6 days) compared to medical patients in the subgroup <1.5 kg.
- Left atrial enlargement was more common in surgical patients (58% vs 32%), but early ligation correlated with reduced intubation duration.
Conclusions:
- Surgical ligation of significant PDA in preterm infants offers zero surgical risk and is associated with reduced NEC and improved survival.
- Early surgical intervention for PDA is recommended to decrease duration of intubation and enhance long-term outcomes.
- The surgical approach is the preferred treatment for refractory PDA due to its associated benefits.
Abstract:
During the past 5 years, patent ductus arteriosus (PDA) presented in 734 preterm infants (less than 2.5 kg and 37 weeks gestation) of 2,532 admissions (29%). The ductus presented with murmur, bounding pulses, and often congestive heart failure. Medical treatment consisted of the following: fluid restriction, furosemide, respiratory support, and rarely digoxin. The patients who were unresponsive to medical treatment had surgical ligation (306 of 734 or 42%). The patients who had ductal ligation were smaller, i .e., 82% of the surgical patients weighed less than 1.5 kg as compared to 38% of the medical patients. Of those patients weighing less than 1.5 kg, the surgical and medical groups were compared and the following observations made: The incidence of respiratory distress syndrome was greater in the surgical group (86% or 216 of 252 patients versus 69% or 111 of 161 medical patients, p less than 0.001) and the long-term survival was better (89% or 224 of 252 surgical patients versus 77% or 124 of 161 medical patients, p less than 0.005). In addition, the average duration of intubation was shorter in this surgical subgroup (8.9 versus 13.6 days). Significant left atrial enlargement and echocardiographic left atrial/aortic (LA/Ao) ratios of greater than 1.5:1 occurred in 58% or 171 of 290 surgical patients versus 32% or 59 of 190 medical patients (p less than 0.001). During the first 3 years of this study (medical treatment averaged 5 days), the duration of intubation in the surgical patients averaged 15.2 days; by comparison, in the last 2 years of this study (medical treatment averaged 1 to 2 days), the duration of intubation was 6.5 days (p less than 0.001). Necrotizing enterocolitis (NEC) occurred in 11% or 46 of 428 medical patients versus 0.3% (one of 305 patients) in the ligated group postoperatively (p less than 0.001). Late deaths were related to lung disease, central nervous system problems, NEC, and so on. From this study, it was determined that ligation of a significant PDA is associated with (1) zero surgical risk, (2) a reduced incidence of NEC, (3) reduced duration of intubation, especially with early ligation, and (4) improvement in late survival. Thus the surgical approach is our treatment of choice for a refractory PDA.