Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants

Borràs-Novell, Cristina; Riverola, Ana; Aldecoa-Bilbao, Victoria; Izquierdo, Montserrat; Domingo, Monica; Iriondo, Martín

doi:10.1016/j.jped.2018.10.004

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Original articles • J. Pediatr. (Rio J.) 96 (2) • Mar-Apr 2020 • https://doi.org/10.1016/j.jped.2018.10.004 copy

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants^☆ ☆ Please cite this article as: Borràs-Novell C, Riverola A, Aldecoa-Bilbao V, Izquierdo M, Domingo M, Iriondo M. Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants. J Pediatr (Rio J). 2020;96:177-83.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation.

Method:

Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared.

Results:

This study included 188 patients (27 ± 2 weeks, 973 ± 272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p < 0.001) and surgical closure (34.5% P1 versus 16.1% P2, p < 0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p = 0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p = 0.403), necrotizing enterocolitis (15.5% versus 6.9%, p = 0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p = 0.264), mortality (17.5% versus 15.2%, p = 0.690) or survival-without-morbidity adjusted OR = 1.10 (95% CI: 0.55-2.22); p = 0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n = 82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p = 0.019) and more survival-without-morbidity (20% versus 45.6%, p = 0.028) were found.

Conclusion:

A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

KEYWORDS
Patent ductus arteriosus; Ductal patency; Preterm infant; Ibuprofen; Surgical ligation; Surgical closure

	Period 1 (n = 63)	Period 2 (n = 125)	p-value
Gestational age (weeks)	26.9 (2.0)	27.0 (1.7)	0.488
Birth weight (g)	962 (272)	979 (273)	0.684
Male gender	40 (63.5)	75 (60.0)	0.643
Antenatal steroids	49 (77.8)	101 (80.8)	0.626
Intubation in delivery room	41 (65.1)	60 (48.0)	0.027
Surfactant administration	50 (79.4)	94 (75.2)	0.524
Early sepsis	12 (19.0)	16 (12.8)	0.256

	Period 1 (n = 63)	Period 2 (n = 125)	p-value
Ductus size (mm)	2.6 (0.9)	2.6 (0.9)	0.629
Ibuprofen administration	54 (85.7)	70 (56.0)	<0.001
Time medical treatment^a a Days of life at the time that medical treatment was started.	3 [2-4]	6 [4-7]	<0.001
Surgical closure	20 (34.5)	18 (16.1)	0.006
Time surgical closure^b b Days of life at the time that surgical closure was performed.	24.5 [17-30]	27 [18-35]	0.766
Days of PDA	9 [6-23]	20 [12-61]	0.019
PDA at discharge	0 (0)	26 (24.5)	<0.001

	Period 1 (n = 63)	Period 2 (n = 125)	p-value
Chronic lung disease^a a Chronic lung disease as supplemental oxygen use at 36 weeks postmenstrual age.	15 (28.8)	17 (15.9)	0.056
Severe retinopathy of prematurity^b b Severe retinopathy grade 2 plus, 3, and 4 according to the international classification.	4 (7.5)	13 (11.8)	0.403
Necrotizing enterocolitis^c c Necrotizing enterocolitis grade 2 and 3 according to the Bell classification.	9 (15.5)	8 (6.9)	0.071
Severe intraventricular hemorrhage^d d Severe intraventricular hemorrhage grade 3 and 4 according to the Papille classification.	16 (25.4)	23 (18.4)	0.264
Nosocomial infection	26 (44.1)	51 (41.5)	0.739
Mechanical ventilation (days)	18 (20)	14 (17)	0.238
Non-invasive ventilation (days)	32 (28)	38 (28)	0.248
Oxygen (days)	54 (54)	38 (39)	0.051
Length of stay (days)	89 (36)	85 (38)	0.595
Mortality	11 (17.5)	19 (15.2)	0.690
Survival without morbidity	31 (49.2)	71 (56.8)	0.324

	23-26 weeks (n = 82)			27-30 weeks (n = 106)
	P1(n = 25)	P2 (n = 57)	p-value	P1 (n = 38)	P2 (n = 68)	p-value
Ibuprofen administration	22 (88.0)	38 (66.7)	0.045	32 (84.2)	32 (47.1)	<0.001
Time medical treatment^a a Days of life at the time that medical treatment was started.	3 (1)	6 (3)	<0.001	4 (2)	7 (5)	<0.001
Surgical closure	7 (35)	12 (24.5)	0.375	13 (34.2)	6 (9.5)	0.002
Time surgical closure^b b Days of life at the time that surgical closure was performed.	29 (19)	28 (17)	0.871	30 (15)	24 (13)	0.445
PDA days	19 (20)	84 (221)	0.199	16 (18)	61 (117)	0.023
PDA at discharge	0 (0)	9 (19.6)	0.056	0 (0)	17 (28.3)	0.001
Chronic lung disease	8 (50)	9 (19.6)	0.019	7 (19.4)	8 (13.1)	0.405
Severe retinopathy of prematurity	3 (18.8)	10 (20.8)	0.858	1 (2.7)	3 (4.8)	0.602
Necrotizing enterocolitis	5 (23.8)	7 (13.5)	0.280	4 (10.8)	1 (1.6)	0.039
Severe intraventricular hemorrhage	11 (44)	14 (24.6)	0.078	5 (13.2)	9 (13.2)	0.991
Mortality	9 (36)	11 (19.3)	0.105	2 (5.3)	8 (11.8)	0.272
Survival without morbidity	5 (20)	26 (45.6)	0.028	26 (68.4)	45 (66.2)	0.814

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[1] * Corresponding author. E-mail:cborrasn@clinic.cat (C. Borràs-Novell).