Patent ductus arteriosus in micropreemies and full-term infants: The relative merits of surgical ligation versus indomethacin treatment

Presented at the 33rd Annual Meeting of the American Pediatric Surgical Association, Phoenix, Arizona, May 19-23, 2002.
https://doi.org/10.1053/jpsu.2003.50086Get rights and content

Abstract

Background/Purpose: Treatment of ductus arteriosus is controversial. The merits and timing of ductus ligation versus indomethacin treatment were compared. Methods: Study parameters for infants with PDA (June 1988 through March 2001) included age, weight, physical findings, echocardiograph, success/complications of treatment, and length of stay (LOS). Statistical analysis was by descriptive univariate analysis. Results: Two hundred twelve infants were included. Median gestational age was 26 weeks (range, 22-38); weight, 836 g (447 to 2,863). Findings included murmur (94%), congestion (20%), cardiomegaly (15%), bounding pulses (6%), hyperdynamic precordium (4%), and CHF (2%). Echocardiographic measurements were left atrial diameter, 0.92 cm; posterior wall thickness, 0.26 cm; PDA diameter, 2.5 mm; septal thickness, 0.27 cm; aortic root diameter, 0.64 cm; ejection fraction, 39%; left ventricular internal diameter–diastole, 1.3 cm; left ventricular internal diameter–systole, 0.82 cm; right ventricular internal diameter–diastole, 0.51 cm. No measurement, except PDA diameter, was predictive of medical failure or need for reoperation. However, weight less than 1,000 g was highly predictive of medical failure. Additional cardiac anomalies included ASD (69%), VSD (3%), and aortic coarctation (1%). One hundred sixty-seven babies (79%) received indomethacin, closing the PDA in 88 cases (53%, recurrence = 47%). Indomethacin complications (73%) included thrombocytopenia (36%), BUN increase (31%), sepsis (30%), oliguria (25%), hyponatremia (25%), IVH (16%), pulmonary interstitial emphysema (11%), NEC (8%), intestinal perforation (4%), and bleeding (3%). Seventy-seven babies (36%) required operations (92% in the NICU) performed by pediatric surgeons. Ligation criteria included hypoxia, hypercapnia, decreasing compliance, CHF, and contraindications/failure of indomethacin. Complications included pneumothorax (4%), IVH (4%), bleeding (4%), NEC (1%), and wound infection (1%). LOS averaged 82 days. Conclusions: Although indomethacin therapy is a reasonable treatment alternative, it is associated with significant complications. Ductus ligation may be preferable, especially in very low birth weight babies, because it is associated with low morbidity and almost certain degree of success. J Pediatr Surg 38:492-496. Copyright 2003, Elsevier Science (USA). All rights reserved.

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Materials and methods

The medical records, X-rays, and echocardiograph reports of all newborns admitted to the neonatal intensive care unit with diagnosis of patent ductus arteriosus from June 1988 through March 2001 (154 months) were reviewed. No infants were excluded. Previous approval from the Texas A&M Institutional Review Board (IRB) had been obtained. Demographic as well as clinical data from these infants were collected and tabulated. A PDA was suspected based on a heart murmur, congestive heart failure,

General

Two hundred twelve newborns (101 boys and 111 girls) had patent ductus arteriosus diagnosed during the 154-month study period. Mean gestational age and birth weight were 26.5 weeks (22.0 to 38.0 weeks) and 836.0 g (447 to 2,863 g), respectively. One hundred forty-six infants (69%) were born with extremely low birth weight, defined as birth weight less than 1,000 g. Eighty-four percent of neonates received surfactant. Patent ductus arteriosus was suspected by new heart murmur (94%), pulmonary

Discussion

During intrauterine life, only 10% of the cardiac output passes through the lungs; the remaining 90% is shunted via the ductus to the aorta and systemic circulation. Shortly after birth, increased oxygen tension in the pulmonary artery and decreased responsiveness to prostaglandin type E provide a stimulus for the ductus to close. Failure of ductal closure leads to a persistent left to right shunt predisposing the newborn to decreasing cardiac performance, prolonged ventilatory support, and

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Address reprint requests to Danny C. Little, MD, Scott and White Hospital, 2401 South 31st St, Temple, TX 76508.

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