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Patent Ductus Arteriosus in Premature Babies

Dominic C. Sia, M.D. Patent Ductus Arteriosus in Premature Babies. Right to left flow Systemic resistance Pulmonary Resistance. Neonatal Circulation. Postnatally. PGE2. O 2. PGE2. Nitric Oxide. O 2. Prenatal Cortisol. PDA remains patent. Closure of PDA. 24 hrs - 50% 48 hrs - 90%

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Patent Ductus Arteriosus in Premature Babies

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  1. Dominic C. Sia, M.D. Patent Ductus Arteriosusin Premature Babies

  2. Right to left flow Systemic resistance Pulmonary Resistance Neonatal Circulation

  3. Postnatally PGE2 O2 PGE2 Nitric Oxide O2 Prenatal Cortisol PDA remains patent Closure of PDA

  4. 24 hrs - 50% 48 hrs - 90% 72 hrs - 99.9% PDA Closure • ligamentum arteriosum • 1-3 months

  5. PDA Obliteration

  6. PDA Obliteration

  7. When the DA has not closed by 72 hrs Preterm infants, especially those <30 weeks or <1000 gms (50%)‏ increased sensitivity to PGE2 and NO delayed ductal obliteration PDA

  8. Pulmonary Edema Pulmonary Hemorrhage Bronchopulmonary Dysplasia incidence of Necrotizing Enterocolitis incidence of Intraventricular Hemorrhage PDA Consequences

  9. 2-3 days after birth up to 1 week of life later in those treated with surfactant prominent left ventricular impulse bounding pulses widened pulse pressure (>25 mmHg)‏ murmur can be initially silent initially systolic becoming continuous machinery like Signs and Symptoms

  10. deterioration of respiratory status circulatory instability cardiac enlargement tachypnea/apnea increased CO2 retention increased requirements for mechanical ventilation diagnosis confirmed by echocardiography Signs and Symptoms

  11. Echocardiography

  12. Transductal diameter > 1.5mm (@7-31 hrs of life)‏ Left atrial to aortic root ratio (LA/AO ratio) >1.4 or >1.5 Left ventricular output to superior vena cava ratio (LVO/SVC ratio) >4 B-type Natriuretic Peptide Chest radiography cardiomegaly or pulmonary congestion Grading System oxygenation index - chest radiography degree of respiratory support - end-organ function Significant PDA

  13. Conservative Prophylactic Indomethacin/Ibuprofen Medical Treatment Indomethacin Ibuprofen Surgical Treatment Management

  14. Neutral Thermal Environment Adequate Oxygenation PEEP Hct at 35-40 Avoid exacerbating factors furosemide excessive fluids (>170 cc/kg/day)‏ no evidence that fluid restriction reduces PDA ManagementConservative

  15. Indomethacin 3 doses at 12 or 24 hr intervals (0.2 mg/kg)‏ increased risk for NEC, Renal failure, Platelet dysfunction and BPD Dopamine may prevent Renal tubular dysfunction Regular measurement of creatinine and platelets Ibuprofen 10 mg/kg 1st dose then 5 mg/kg 2 doses daily less oliguria increased risk for NEC and platelet dysfunction increased risk for kernicterus ManagementMedical

  16. complications blood pressure fluctuations respiratory compromise infection intraventricular hemorrhage chylothorax recurrent laryngeal nerve paralysis BPD death neurosensory impairment ROP ManagementSurgical

  17. Conservative Management high rate of spontaneous closure established adverse effects of intervention lack of evidence that treatment results in a decrease in neonatal morbidity and mortality Prophylactic Indomethacin 0.1 mg/kg/day q24 hrs after birth x 3 days no effect on mortality, pulmonary outcome or reducing the risk of NEC early treatment more likely to be successful Controversies

  18. Medical vs Surgical Treatment no difference in mortality higher adverse events with surgery Controversies

  19. Clyman, RI. Ibuprofen and patent ductus arteriosus. N Engl J Med 2000; 343:728. Clyman, R, Cassady, G, Kirklin, JK, et al. The role of patent ductus arteriosus ligation in bronchopulmonary dysplasia: reexamining a randomized controlled trial. J Pediatr 2009; 154:873. Bose, CL, Laughon, MM. Patent ductus arteriosus: lack of evidence for common treatments. Arch Dis Child Fetal Neonatal Ed 2007; 92:F498. Brooks, JM, Travadi, JN, Patole, SK, et al. Is surgical ligation of patent ductus arteriosus necessary? The Western Australian experience of conservative management. Arch Dis Child Fetal Neonatal Ed 2005; 90:F235. Noori, S, McCoy, M, Friedlich, P, et al. Failure of ductus arteriosus closure is associated with increased mortality in preterm infants. Pediatrics 2009; 123:e138. Kabra, NS, Schmidt, B, Roberts, RS, et al. Neurosensory impairment after surgical closure of patent ductus arteriosus in extremely low birth weight infants: results from the Trial of Indomethacin Prophylaxis in Preterms. J Pediatr 2007; 150:229. Chorne, N, Leonard, C, Piecuch, R, Clyman, RI. Patent ductus arteriosus and its treatment as risk factors for neonatal and neurodevelopmental morbidity. Pediatrics 2007; 119:1165. Vida, V. L., Lago, P., Salvatori, S., Boccuzzo, G., Padalino, M. A., Milanesi, O., Speggiorin, S., Stellin, G. (2009). Is there an optimal timing for surgical ligation of patent ductus arteriosus in preterm infants?. Ann. Thorac. Surg. 87: 1509-1516 Noori, S., McCoy, M., Friedlich, P., Bright, B., Gottipati, V., Seri, I., Sekar, K. (2009). Failure of Ductus Arteriosus Closure Is Associated With Increased Mortality in Preterm Infants. Pediatrics 123: e138-e144 Sources

  20. El-Khuffash, A, Barry, D, Walsh, K, Davis, P G, Molloy, E J (2008). Biochemical markers may identify preterm infants with a patent ductus arteriosus at high risk of death or severe intraventricular haemorrhage. Arch. Dis. Child. Fetal Neonatal Ed. 93: F407-F412 Gaca, A. M., Jaggers, J. J., Dudley, L. T., Bisset, G. S. III (2008). Repair of Congenital Heart Disease: A Primer--Part 2. Radiology 248: 44-60 Roberts, P., Adwani, S., Archer, N., Wilson, N. (2007). Catheter closure of the arterial duct in preterm infants. Arch. Dis. Child. Fetal Neonatal Ed. 92: F248-F250 [Abstract] [Full Text] Chorne, N., Leonard, C., Piecuch, R., Clyman, R. I. (2007). Patent Ductus Arteriosus and Its Treatment as Risk Factors for Neonatal and Neurodevelopmental Morbidity. Pediatrics 119: 1165-1174 Patole, S K, Kumaran, V, Travadi, J N, Brooks, J M, Doherty, D A (2007). Does patent ductus arteriosus affect feed tolerance in preterm neonates?. Arch. Dis. Child. Fetal Neonatal Ed. 92: F53-F55 Manzar, S. (2006). High-Dose Indomethacin for Patent Ductus Arteriosus Closure: How Strong Is the Evidence?. Pediatrics 117: 1863-1863 Sperandio, M., Beedgen, B., Linderkamp, O. (2006). High-Dose Indomethacin for Patent Ductus Arteriosus Closure: How Strong Is the Evidence?: In Reply. Pediatrics 117: 1863-1864 Fowlie, P W (2005). Managing the baby with a patent ductus arteriosus. More questions than answers?. Arch. Dis. Child. Fetal Neonatal Ed. 90: F190-f190 Sources

  21. Thank You

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