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Review
. 2023 May 19;2(4):100968.
doi: 10.1016/j.jscai.2023.100968. eCollection 2023 Jul-Aug.

A Global Perspective on PDA Management in the Extremely Premature: Shifting Trend Toward Transcatheter Closure

Shyam Sathanandam  1 , Patrick McNamara  2 , Carlos Pedra  3 , Katsuaki Toyoshima  4 , Sophie Malekzadeh-Milani  5 , Juliana Patkai  6 , Osman Baspinar  7 , Hasan Sinan Uslu  8 , Worakan Promphan  9 , Meera Khorana  9 , Jieh-Neng Wang  10 , Yung-Chieh Lin  10 , Takanari Fujii  11 , Gur Mainzer  12 , David Salazar-Lizárraga  13 , Horacio Márquez-Gonzalez  13 , Himanshu Popat  14 , Jonathan Mervis  14 , Neoh Siew Hong  15 , Mazeni Alwi  16 , Ratthapon Wonwandee  17 , Dietmar Schranz  18 , Georgiev Stanimir  19 , Ranjit Philip  1 , Frank Ing  20
Affiliations
Review

A Global Perspective on PDA Management in the Extremely Premature: Shifting Trend Toward Transcatheter Closure

Shyam Sathanandam et al. J Soc Cardiovasc Angiogr Interv. .

Abstract

Patent ductus arteriosus (PDA) is a frequently encountered defect in infants born extremely premature (≤26 weeks' gestation). Historically, closure of the PDA was performed using cyclooxygenase inhibitor medications or by surgical ligations. However, the benefits of PDA closure using these therapies have never been demonstrated, albeit studies have previously not focused on the extremely premature infants. Therefore, there was a worldwide trend toward conservative management of the PDA. With improved survival of extremely premature infants, comorbidities associated with the PDA has increased, resulting in finding alternate treatments such as transcatheter patent ductus arteriosus closure (TCPC) for this population. Currently, there is a renewed interest toward selective treatment of the PDA in this high-risk cohort of small infants. This Comprehensive Review article inspects the globally changing trends in the management of the PDA in premature infants, with a special focus on the rising adoption of TCPC. Moreover, this article compiles data from several neonatal networks worldwide to help understand the problem at hand. Understanding the current management of premature infants and their outcomes is fundamentally essential if pediatric cardiologists are to offer TCPC as a viable therapeutic option for this population. This article aims to serve as a guide for pediatric cardiologists on this topic by compiling the results on landmark clinical trials on PDA management and the controversies that arise from these trials. Comparative outcomes from several countries are presented, including interpretations and opinions of the data from experts globally. This is a step toward coming to a global consensus in PDA management in premature infants.

Keywords: global perspective; patent ductus arteriosus; prematurity; transcatheter occlusion.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Morphology of the PDA in premature infants. The PDA resembles a hockey stick with the long axis of the duct in a 10- to 4-o’clock orientation on a clock dial laterally. If the PDA has stenosis, it is typically at the junction of the handle and the blade of the hockey stick. The stenosis is always just posterior to the pulmonary ampulla that is slightly more dilated. During TCPC, implanting a device co-axial to the long axis of the duct and distal to the stenosis is recommended. PDA, patent ductus arteriosus; TCPC, transcatheter patent ductus arteriosus closure.
Central Illustration
Central Illustration
Trends in PDA closure. The graph below demonstrates the increasing trend toward transcatheter PDA closure compared with that of surgical ligation. Source: NRN generic database. PDA, patent ductus arteriosus.
Figure 2
Figure 2
Meta-analysis of 60 clinical trials on PDA closure in 5515 subjects. Results suggest that the treatment groups showed no change in death or BPD rates and several other outcomes compared with no-treatment groups. Results were not different in trials categorized by type of medicines used, indications, timing of therapy, year of trial, or subject gestational age. BPD, bronchopulmonary dysplasia; CP, cerebral palsy; DD, developmental disorder; IVH, intraventricular hemorrhage; MDI, Mental Developmental Index; NEC, necrotizing enterocolitis; NSI, neurosensory impairment; PDA, patent ductus arteriosus; PDI, Psychomotor Developmental Index; PVL, paravalvular leak; ROP, retinopathy of prematurity; WPPSI, Wechsler Preschool & Primary Scale of Intelligence.
Figure 3
Figure 3
Bixler et alshowed a significant decrease in diagnosis and cyclooxygenase inhibitor (COI)/surgical treatment of PDA in a large cohort of >60,000 premature infants from 280 neonatal intensive care units (NICUs) across the United States. In particular, the rate of PDA ligation by surgery decreased between 2006 and 2015 from 8.4% to 2.9%, and the rate of PDA diagnosis also decreased from 51% to 38%. PDA, patent ductus arteriosus.
Figure 4
Figure 4
Survival of extremely preterm infants, between 22 and 26 weeks’ gestation, has improved tremendously over the past 2 decades as reported from various countries based on the following registries: (A) USA: NICHD-NRN 2019; (B) France: EPIPAGE-2 2011; (C) Japan: NRN, Japan 2017; (D) Australia and New Zealand: ANZNN report 2017; (E) Taiwan: PBFT 2007-2011; (F) Turkey: Turkish Neonatal Society 2019 report; (G) Germany: KiGGS 2019; (H) Sweden: EXPRESS (only live born and resuscitated) 2014-2016; (I) Israel: INN 2015-2019.
Figure 5
Figure 5
Cumulative incidence rate of ductal patency during hospitalization in infants with initial hsPDA according to the gestational age group based on 2 studies. (A) Semberova et al (B) Pierrat et al. hsPDA, hemodynamically significant patent ductus arteriosus.
Figure 6
Figure 6
Results from 139 NICUs around the world including 39,096 infants between 2007 and 2015 as part of the International Network for Evaluating Outcomes of Neonates (iNeo)study suggests a worldwide decrease in both medical and surgical PDA treatment. Both low and high PDA treatment rates were associated with death or severe neurologic injury, whereas a moderate approach was associated with optimal outcomes. NICU, neonatanal intensive care unit; PDA, patent ductus arteriosus.
Figure 7
Figure 7
Early TCPC could allow for faster weaning off ventilator and oxygen support. This Kaplan-Meier analysis suggests a lower proportion of patients with a respiratory severity score (RSS) of ≥2 after TCPC before 4 weeks than that of TCPC after 8 weeks of age in infants born at <27 weeks’ gestation. TCPC, transcatheter patent ductus arteriosus closure.
Figure 8
Figure 8
List of RCTs with the percentage of patients in the control group who received PDA treatment.
See this image and copyright information in PMC

References

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