Hemodynamically significant ductus arteriosus:a new targeted approach
Italian Journal of Pediatrics volume 41, Article number: A2 (2015)
Debate on hemodynamically significant ductusarteriosus (hsDA) in premature infants remains unresolved.
The association between patent ductus arteriosus (PDA) and the most adverse outcomes and comorbidities in preterms (peri-intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, pulmonary haemorrhage and mortality) has led to the integration of ductal closure into neonatal intensive care.
The recent theory that describes PDA as “an innocent bystander” is supported by the lack of evidence of significant benefits on long-term outcomes with therapeutic interventions. So, the causal relationship between PDA and comorbidities is questioned. Moreover, PDA can close spontaneously in a significant proportion of preterms.
Both the traditional assumption that all PDA are pathological and the most recent theory in favor of a conservative attitudeare oversimplifications.
The current management of PDA does not take into account the wide range of effects attributable to a ductal shunt. A more logical approach should considerthe ductus as a clinical continuum, from thephysiological PDA to the pathological hsDA. Placingthe patient in the spectrum of “ductal disease” seems to be possible through a continuous evaluation of the hemodynamic and clinical consequences of ductal patency.
The current definition of an hsDA is almost entirely based on size. However, the magnitude of transductal shunt relates not only to the transductal diameter, but also to the pulmonary and systemic vascular resistance and to the compensatory ability of the immature myocardium.
New echocardiography markers have been evaluated to estimate the impact of transductal flow on both pulmonary over circulation (left atrial/aortic ratio, anterograde pulmonary artery diastolic flow) and systemic blood flow (retrograde diastolic flow in descending aorta, left ventricular output/superior vena cava flow ratio).
The possibility to evaluate flows in the middle cerebral artery, renaland superior mesenteric artery with Doppler ultrasound, allows anearly and plausible detection of regional hypoperfusion due to the “ductal steal”.
According to the current understanding, it seems appropriate to proposea more tailored approach to the management of PDA in preterms, based on the integration between clinical and hemodynamic status.
Schena F, Ciarmoli E, Mosca F: Patent ductus arteriosus: wait and see?. J Matern Fetal Neonatal Med. 2011, 24 (Suppl 3): 2-4.
Evans N: Preterm patent ductus arteriosus: A continuing conundrum for the neonatologist?. Semin Fetal Neonatal Med. 2015
McNamara PJ, Sehgal A: Disease Staging. 424-427.
Evans N: Current controversies in the diagnosis and treatment of patent ductus arteriosus in preterm infants. Adv Neonatal Care. 2003, 3 (4): 168-177. 10.1016/S1536-0903(03)00143-7.
Sehgal A, McNamara PJ: Does echocardiography facilitate determination of hemodynamic significance attributable to the ductus arteriosus?. Eur J Pediatr. 2009, 168 (8): 907-914. 10.1007/s00431-009-0983-3.
Lemmers PM, Toet MC, van Bel F: Impact of patent ductus arteriosus and subsequent therapy with indomethacin on cerebral oxygenation in preterm infants. Pediatrics. 2008, 121 (1): 142-147. 10.1542/peds.2007-0925.
Cerbo RM, Cabano R, Di Comite A, Longo S, Maragliano R, Stronati M: Cerebral and somatic rSO2 in sick preterm infants. J Matern Fetal Neonatal Med. 2012, 25 (Suppl 4): 97-100.
Dagle JM, Lepp NT, Cooper ME, Schaa KL, Kelsey KJP, Orr KL, Caprau D, Zimmerman CR, Steffen KM, Johnson KJ, Marazita ML, Murray JC: Determination of genetic predisposition to patent ductus arteriosus in preterm infants. Pediatrics. 2009, 123 (4): 1116-1123. 10.1542/peds.2008-0313.
Kulkarni M, Gokulakrishnan G, Price J, Fernandes CJ, Leeflang M, Pammi M: Diagnosing Significant PDA Using Natriuretic Peptides in Preterm Neonates: A Systematic Review. Pediatrics. 2015, 135 (2): e510-e525. 10.1542/peds.2014-1995.
Inayat M, Bany-mohammed F, Valencia A, Tay C, Aranda JV, Beharry KD: Antioxidants and Biomarkers of Oxidative Stress in Preterm Infants with Symptomatic Patent Ductus Arteriosus. Am J Perinatol. 2015, Feb 25 [Epub ahead of print]
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Cerbo, R.M., Borellini, M., Pozzi, M. et al. Hemodynamically significant ductus arteriosus:a new targeted approach. Ital J Pediatr 41 (Suppl 1), A2 (2015). https://doi.org/10.1186/1824-7288-41-S1-A2
- Superior Mesenteric Artery
- Patent Ductus Arteriosus
- Necrotizing Enterocolitis
- Diastolic Flow
- Innocent Bystander