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PubMed2003

Necrotizing enterocolitis and gastrointestinal complications after indomethacin therapy and surgical ligation in premature infants with patent ductus arteriosus.

BACKGROUND: Indomethacin is the most frequently used pharmacological agent for closure of a patent ductus arteriosus (PDA) in premature infants. However, reports of complications, particularly, necrotizing enterocolitis (NEC) and isolated gastrointestinal perforation have generated concerns about the use of this medication. OBJECTIVES: A retrospective study to compare the incidence of NEC, NEC-related gastrointestinal complications and isolated gastrointestinal perforation among premature infants treated for a PDA with either, indomethacin alone (I), surgical ligation alone (L), or indomethacin followed by surgical ligation (I-L). METHODS: The medical records of 224 infants that underwent treatment, either pharmacological or surgical, for a PDA, confirmed by echocardiography, over a 4-year period (1995 to 1998) were analyzed. Treatment history and gastrointestinal complications were reviewed. RESULTS: Of the 224 infants, 108 (48.2%) were treated with I, 50 (22.3%) by L, 66 (29.5%) with I-L. The clinical characteristics of the three treatment groups were similar and no differences in the incidence of NEC were observed between groups. NEC occurred in 14 (13%) of the I group, seven (14%) of the L group, and eight (12%) of the I-L group. The rate of NEC related gastrointestinal complications and isolated gastrointestinal perforation were also similar among groups. CONCLUSION: In this large retrospective study, indomethacin treatment for a significant PDA in premature infants was not associated with a greater risk for NEC or NEC-related gastrointestinal complications than surgical ligation.

Birth Weight↗
PubMed2005

The hemodynamic effects of neonatal patent ductus arteriosus shunting on superior mesenteric artery blood flow.

OBJECTIVE: To determine if the ratio of the pulsatility index (PI) of the left pulmonary artery to the PI of the descending aorta, the Rp/Rs index, correlates with the degree of ductal steal from the intestine in neonates with a patent ductus arteriosus (PDA). STUDY DESIGN: Echocardiograms and Doppler studies of the superior mesenteric artery (SMA) were performed in 41 neonates less than 35 weeks gestational age with a hemodynamically significant PDA (hsPDA). RESULTS: There was a significant negative correlation between the Rp/Rs index and the SMA PI after controlling for ductal size (r=-0.476, p<0.008). CONCLUSIONS: The Rp/Rs index can be used as an indicator of ductal steal on intestinal blood flow. The Rp/Rs index may be a useful adjunct to existing and new techniques for improving early assessment and treatment of hsPDA, and for evaluating the effects of hsPDA on systemic organs.

Aorta, Thoracic↗
PubMed2006

Patent ductus arteriosus: pathophysiology and management.

Patent ductus arteriosus (PDA) in preterm newborns prior to 28 weeks of gestation has led to many challenges regarding the type and timing of treatment regimens. A PDA results in increased pulmonary blood flow and redistribution of flow to other organs. Several co-morbidities (i.e., necrotizing enterocolitis, intracranial hemorrhage, pulmonary edema/hemorrhage, bronchopulmonary dysplasia, and retinopathy) are associated with the presence of a PDA, but whether or not a PDA is responsible for their development is still unclear. The prostaglandin inhibitor, indomethacin, is effective in the treatment of PDA. Questions regarding the optimal timing of the intervention--early prophylaxis or treatment, once signs and symptoms become evident--have challenged physicians for decades. Both evidence and experience are explored in this article. Comparative physiology between the full-term and preterm newborn and the barriers preventing the necessary cascade of events leading to permanent constriction of the PDA are reviewed.

Cardiac Surgical Procedures↗
PubMed2002

Plasma brain natriuretic peptide as a predictor of haemodynamically significant patent ductus arteriosus in preterm infants.

Patent ductus arteriosus (PDA) is an important cause of morbidity in extremely preterm infants. As increased plasma brain natriuretic peptide (BNP) is a common feature of adult cardiac disease, we investigated the value of plasma BNP concentration as a predictor of haemodynamically significant PDA in very preterm infants. We studied 18 preterm infants (12 male) of median gestational age 30 weeks (range 24-34), median birth weight 1.46 kg (0.54-2.13) and 11 healthy term controls. Plasma BNP levels were measured by double-antibody radioimmunoassay on days 3, 5 and 7 of life, and an echocardiogram was performed on day 7. Six infants of median gestation 26 weeks (26-30), median birth weight 0.92 kg (0.54-1.04) had PDA proven by echocardiography on day 7. BNP concentrations (pg/ml) on day 3 were significantly higher in these infants than in the remaining twelve [median 2012 (786-2759) versus 42 (7-704), P<0.001]. In four infants PDA was treated successfully (one surgically, three with non-steroidal anti-inflammatory drugs). Two had haemodynamically insignificant closing ducts. In these infants with therapeutic or spontaneous resolution of a PDA, plasma BNP fell to normal values [median after treatment 9 pg/ml (8-27)]. Early measurement of plasma BNP in the first few days of life is a useful method for predicting those preterm infants who may require intervention for PDA.

Biomarkers↗
PubMed1998

Anaesthesia for video-assisted thoracoscopic patent ductus arteriosus ligation.

The case notes of children undergoing video-assisted thoracoscopic ligation of a patent ductus arteriosus were reviewed with particular emphasis on the anaesthetic management. All children were managed using one-lung ventilation with no serious adverse sequelae. The lungs could be isolated easily in all cases and no special equipment was required. We describe our initial series of 13 cases and discuss the anaesthetic implications arising from this surgical technique. We also discuss the different ways of monitoring duct closure.

Anesthesia, Inhalation↗
PubMed2001

Transcatheter patent ductus arteriosus occlusion: evolution of techniques and results from the 1990s.

OBJECTIVE: To review the evolution of transcatheter patent ductus arteriosus (PDA) occlusion techniques and results. METHODS: A single institution, retrospective review including all patients with intention to close a PDA from 1991 to 1998, with no exclusions. RESULTS: Rashkind occluder (n = 65), sideris double-button (n = 6), Cook detachable coil (n = 28) and Amplatzer ductal occluder (n = 4) were used. Successful implantation occurred in 99 of 103 patients. There was a need for a second transcatheter procedure to close residual ductal shunting in 12% of patients: Rashkind umbrellas (n = 8), double-button (n = 1), coils (n = 3). Eight patients (8%) required surgery, including 4 of 6 patients with the double-button occluder. CONCLUSIONS: The Rashkind occluder and the Sideris double-button device both had an unacceptably high rate of residual shunts requiring a second transcatheter procedure or surgical closure. Detachable coils and the Amplatzer ductal occluder have become the current technology of choice for transcatheter PDA closure with high success rates.

Adolescent↗
PubMed2001

Diastolic flow velocity of the left pulmonary artery of patent ductus arteriosus in preterm infants.

BACKGROUND: The usefulness of diastolic pulmonary flow velocity determined by echocardiography in the assessment of symptomatic patent ductus arteriosus (sPDA) in preterm infants has not been confirmed. METHODS: Echocardiography was performed daily in infants ranging from 23 to 31 gestational weeks of age, and diastolic flow velocity of the left pulmonary artery (DFLPA) was measured. The DFLPA data before indomethacin administration for sPDA were compared with data obtained after indomethacin administration. The normal range of DFLPA was also determined from serial measurements performed in infants who did not develop sPDA during the first 7 days of life. Then, this range was compared with data from infants who did develop sPDA during this time. RESULTS: In infants who underwent indomethacin treatment, DFLPA increased with the development of sPDA and decreased when the symptoms of sPDA disappeared. On the basis of results from serial DFLPA measurement, the sensitivity and specificity of DFLPA for assessing sPDA was found to be 0.82 and 0.83, respectively. CONCLUSIONS: Measurement of DFLPA by echocardiography is a useful method for assessing sPDA in preterm infants.

Blood Flow Velocity↗
PubMed2001

Preventive management of hypoglycemia in very low-birthweight infants following indomethacin therapy for patent ductus arteriosus.

BACKGROUND: To evaluate the effects of an increase in glucose infusion rate of 2 mg/kg per min from the basal infusion rate on the prevention of hypoglycemia in very low-birthweight (VLBW) infants, following indomethacin therapy for patent ductus arteriosus (PDA). METHODS: Forty VLBW infants with PDA were given indomethacin 0.2 mg/kg intravenously up to three doses. In 15 of the 40 infants (supplemented group: between April 1995 and March 1996) the glucose infusion rate was increased in 2 mg/kg per min increments from the basal rate just before the initial indomethacin administration, compared with 25 historical control infants who received a fixed glucose infusion rate during the first 12 h after the initial dose. We evaluated the changes in blood glucose levels and glucose infusion rates in both groups. RESULTS: In the control group 11 of 25 (44%) infants had a blood glucose value below 40 mg/dL between 12 and 60 h (mean 32.7 h). In contrast only two out of 15 infants in the supplemented group reached the glucose level below 40 mg/dL between 72 and 96 h but both two were light-for-dates infants (defined as birthweight below the 10th percentile for gestational age on the standard intrauterine growth curve). Blood glucose values in the supplemented group were significantly higher than those in the control group between 12 and 96 h. However, glucose infusion rates were similar before and between 72 and 96 h. CONCLUSIONS: This retrospective study shows that an increase in glucose infusion rate of 2 mg/kg per min, in addition to the pre-existing stable maintenance glucose intake, might prevent against the occurrence of unexpected hypoglycemia in VLBW infants following indomethacin therapy.

Blood Glucose↗
PubMed2003

Transcatheter occlusion of patent ductus arteriosus using tornado platinum coils.

BACKGROUND: The purpose of the present study was to develop a method to occlude a patent ductus arteriosus (PDA) using a tornado platinum coil, which is compatible with magnetic fields. METHODS: Twelve patients with a PDA (5 boys and 7 girls; 0.6 to 7 yrs; 6.5 to 22.1 kg) were enrolled. The minimum size of the PDA ranged from 0.2 mm to 3.6 mm. Either the anterograde or retrograde method was applied using a retrievable system that consisted of a 5-Fr multipurpose catheter and a 3-Fr bioptome. Three to 3.5 loops of the larger end of a tornado platinum coil were placed in the aortic ampulla and the remaining 0.5-1.0 loop of the smaller end of the coil was placed in the main pulmonary artery. RESULTS: In 11 patients with minimum size of PDA </= 2.8 mm, the PDA was successfully occluded using one to five tornado platinum coils and, in 10 of 11 patients, an echocardiogram confirmed complete occlusion up to 6 months after the procedures. In the remaining patient with a relatively large PDA (3.6 mm), the PDA could not be occluded because of instability of the coils. CONCLUSIONS: It is feasible to occlude a relatively small PDA (</= 2.8 mm) using tornado platinum coils, but further study is warranted to evaluate the safety and efficacy of this method.

Child↗
PubMed2003

Cardiocirculatory effects of patent ductus arteriosus in extremely low-birth-weight infants with respiratory distress syndrome.

BACKGROUND: Cardiocirculatory effects of hemodynamically significant patent ductus arteriosus (hsPDA) have not been systematically studied in extremely low-birth-weight (ELBW) infants with respiratory distress syndrome (RDS). The objective of the present study was to evaluate the effects of hsPDA on the left ventricular output (LVO) and organ blood flows in ELBW infants with RDS. METHODS: Extremely low-birth-weight infants (birth-weight <1000 g) treated with surfactant for RDS were studied by serial Doppler flow examinations. Doppler flow variables in 19 infants in whom hsPDA developed (hsPDA group) were compared with those in 19 infants without hsPDA matched for gestational age, birth-weight, and postnatal age (non-hsPDA group). All infants in the hsPDA group had pharmacologic closure of ductus arteriosus when hsPDA developed. RESULTS: Before pharmacological closure of PDA, the hsPDA group had significantly higher LVO, lower blood flow volume of the abdominal aorta, and lower mean blood flow velocities in the celiac artery, superior mesenteric artery, and renal artery than the non-hsPDA group. These alterations in the hsPDA group reverted to the levels in the non-hsPDA group after the closure of PDA and had no deleterious effects on the cardiorespiratory status. No significant differences between the groups were found in mean blood flow velocities of the anterior cerebral artery throughout the study period. CONCLUSION: These results indicate that although LVO is increased, the splanchnic and renal blood flows are decreased when hsPDA develops in ELBW infants with RDS. The effects of these alterations of LVO and organ blood flows on the cardiorespiratory course seem to be minor when early pharmacologic closure of PDA is done.

Aorta, Abdominal↗
PubMed1997

High spinal anaesthesia for repair of patent ductus arteriosus in neonates.

General anaesthesia with high dose narcotics has traditionally been used for repair of patent ductus arteriosus (PDA) in high risk neonates. Spinal anaesthesia in infants has generally been limited to cases involving the lower abdomen and lower extremities. Regional anaesthesia for PDA repair could potentially offer a more rapid recovery and the possibility of blunting the stress response in this vulnerable group of patients. High spinal anaesthesia with tetracaine was utilized as an alternative to general anaesthesia in a series of fifteen consecutive patients. Patient demographics, medication dosages, level of anaesthesia, intraoperative and immediate postoperative data were obtained and recorded in a prospective fashion. Spinal anaesthesia was achieved in all patients. The average dose of tetracaine was 2.4 mg.kg-1. Two patients early in the series had an inadequate level and received supplemental isoflurane. The remainder of the patients received either no or minimal supplementation to the basic technique. Cardiovascular status of the group was very stable with minimal changes in blood pressure noted. Recovery was rapid. All three patients who were not intubated at the time of surgery were extubated soon after surgical repair was completed. No complications of the technique were noted. High spinal anaesthesia is a safe and effective alternative to general anaesthesia in high risk neonates. This technique may offer the advantage of a faster recovery time and a protective effect on the neonatal stress response. In addition the stability of this technique may encourage the use of higher levels of spinal anaesthesia in infants than has traditionally been used.

Anesthesia, Spinal↗
PubMed1999

Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus arteriosus ligation.

Adequate postoperative analgesia enhances deep breathing and minimizes respiratory complications after thoracotomy. This study compares postoperative outcomes after single injection caudal epidural vs continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing thoracotomy for patent ductus arteriosus (PDA) ligation. A retrospective chart review was performed for 27 children who had undergone PDA ligation. The children were divided into three groups. We compared patient demographics, surgical duration, anaesthesia duration, length of ICU stay, incidence of emesis requiring treatment, time required to establish regular oral intake, requirement for supplemental intravenous opioids during the first postoperative day, and length of hospital stay. For paediatric patients undergoing PDA ligation, postoperative analgesia with continuous infusion epidural via caudal approach produced shorter ICU stay, less occurrence of postoperative emesis, earlier oral intake, elimination of intravenous opioid supplementation, and shorter hospital stay compared with single injection caudal epidural techniques.

Analgesia, Epidural↗
PubMed2001

Ventilation strategy for video-assisted thoracoscopic clipping of patent ductus arteriosus in children.

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery but its application in children with congenital heart disease has been limited. We report the use of video-assisted thoracoscopic (VAT) technique of clipping patent ductus arteriosus (PDA) in children. Forty patients with PDA were divided into two groups: during VAT surgery patients in group A [mean age=3.6 +/- 2.4 (SD) years] were managed with right main stem bronchial intubation and those in the group B [mean age=3.7 +/- 2.7 (SD) years] received low tidal volume-high frequency ventilation using a Siemens 900C ventilator. The mean oxygen saturation (SpO2) observed during the surgical intervention was significantly lower in group A (90%) compared to group B (96.8%) while the surgical convenience was not different. We conclude that a low tidal volume-high frequency ventilation is acceptable and safe in patients with PDA undergoing VATS.

Bronchi↗
PubMedDate not supplied

Repair of recurrent patent ductus arteriosus in an adult with cardiopulmonary bypass.

Recurrence of ductal patency is a rarely encountered complication in surgical repair of patent ductus arteriosus (PDA). An adult patient with ductal recurrency underwent closure of ductus by using cardiopulmonary bypass via transpulmonary approach. She had significant improvement of symptoms and no residual shunt or pseudoneurysm seven months after surgery.

Adult↗
PubMed2005

Transarterial coil embolization for canine patent ductus arteriosus occlusion.

Left to right shunting patent ductus arteriosus (PDA) is the most common canine congenital heart defect. If not occluded PDA is associated with high morbidity and mortality. Historically, surgical ligation has been the standard method of correction. Although highly successful, surgical ligation is associated with some operative morbidity and mortality. More recently, minimally invasive transcatheter techniques have been employed for PDA occlusion. Transarterial PDA coil embolization is a safe, cost effective, less invasive alternative offered by many specialty centers for PDA occlusion. This procedure involves catheterization of the femoral artery under general anesthesia. An angiogram is then performed to delineate PDA morphology and facilitate coil selection. Coils are commercially available and composed of surgical stainless steel with prothrombotic poly-Dacron fibers. Coils are advanced through a catheter into the PDA under fluoroscopic guidance until satisfactory angiographic occlusion is documented. Patients are then recovered and released the following day. This procedure requires substantial technical expertise and specialized equipment.

Animals↗
PubMed2000

Ligation of a patent ductus arteriosus under fentanyl anesthesia improves protein metabolism in premature neonates.

BACKGROUND/PURPOSE: Although surgical ligation effectively reverses the cardiopulmonary failure associated with patent ductus arteriosus (PDA), previous findings have suggested that such surgery itself elicits a catabolic response in premature neonates. Therefore, the authors sought to quantitatively assess whether PDA ligation under fentanyl anesthesia aggravated or improved the protein metabolism of premature neonates. METHODS: Seven ventilated, premature neonates (birth weight 815 +/- 69 g) underwent PDA ligation with standardized fentanyl anesthesia (15 microg/kg) on day-of-life 8.4 +/- 1.2 and were studied immediately pre- and 16 to 24 hours postoperatively while receiving continuous total parenteral nutrition (TPN). Whole-body protein kinetics were calculated using intravenous 1-[13C]leucine, and skeletal muscle protein breakdown was measured from the urinary 3-methylhistidine to creatinine ratio (MH:Cr). RESULTS: Whole-body protein breakdown (10.9 +/- 1.2 v8.9 +/- 0.8 g/kg/d, P < .05), turnover (17.4 +/- 1.2 v 15.4 +/- 0.8 g/kg/d, P< .05), and MH:Cr (1.95 +/- 0.20 v 1.71 +/- 0.16 micromol:mg, P< .05) decreased significantly after operation. This resulted in a 60% improvement in protein balance (1.6 +/- 0.8 v 2.6 +/- 0.6 g/kg/d, P = 0.08) postoperatively. CONCLUSIONS: Because of decreased whole-body protein breakdown, whole-body protein turnover, skeletal muscle protein breakdown, and increased protein accrual, surgical PDA ligation under fentanyl anesthesia promptly improves the protein metabolism of premature neonates enduring the stress of a PDA.

Anesthetics, Intravenous↗
PubMedDate not supplied

Intraoperative hemorrhage during patent ductus arteriosus ligation in dogs.

OBJECTIVE: To determine the prevalence of intraoperative hemorrhage in a consecutive series of dogs undergoing patent ductus arteriosus (PDA) ligation at a veterinary teaching hospital, and to describe strategies to reduce the risk of ductus perforation and deal with hemorrhage when it occurs. STUDY DESIGN: Retrospective clinical study. ANIMALS: Sixty-four dogs. METHODS: The records of all dogs undergoing PDA ligation at the University Veterinary Center, Sydney between May 1989 and February 1998 were reviewed and the prevalence and nature of complications identified. RESULTS: Serious hemorrhage occurred in 4 of 64 dogs (6.25%) that underwent PDA ligation. In all cases, hemorrhage resulted from perforation of the craniomedial aspect of the ductus while attempting to expose the tips of the dissecting forceps. Hemorrhage was controlled in 3 dogs by clamping the main pulmonary artery, digital compression of the descending aorta, and completion of ductus ligation during an approximately 5-minute period of circulatory arrest. The remaining dog exsanguinated during an unsuccessful attempt to locate, clamp, and ligate the bleeding point. The mortality rate for PDA ligation was I of 64 dogs (1.6 %). CONCLUSIONS: The technique described in this report permits simple ligation of a range of different ductus morphologies in dogs of varying breeds, weights, and ages. In the event of serious hemorrhage, prompt ventricular outflow occlusion and ductus ligation followed by rapid whole blood transfusion is life saving in most cases.

Animals↗