Letter to the Editor Received: December 8, 2014 Accepted: December 29, 2014 Published online: February 20, 2015
Neonatology 2015;107:256 DOI: 10.1159/000371788
Adequate Timely Treatment of Patent Ductus Arteriosus in Extremely Low Birth Weight Infants: An Ongoing Challenge Sascha Meyer Department of Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
the real and clinically important question seems to be how to change a hemodynamically relevant PDA into a PDA that does not compromise the infant’s circulation (either decreased in size or fully closed). For the physician at the cotside, it is very important to be aware that assessment of a PDA in a preterm infant constitutes a dynamic rather than a static process. Moreover, it is interesting to note that 102 out of 290 neonates had to undergo secondary surgical closure in the report from Gudmundsdottir et al. [1]. Clinical reasons that favor active treatment include low arterial blood pressure requiring inotropes/vasopressors, oliguria requiring diuretics, respiratory failure secondary to pulmonary edema leading to increased oxygen requirements, and feeding intolerance requiring prolonged use of parenteral nutrition, given that these complications can be attributed to a hemodynamically relevant PDA (which I admit can be a difficult task). These clinical findings are corroborated by serial echocardiographic studies demonstrating increased left atrium/aortic ratio, size of PDA, and hemodynamic compromise of the systemic circulation (pathological diastolic flow in middle cerebral artery, and mesenteric and renal artery). It is important to perform serial echocardiography to demonstrate changes over time as demonstrated by O’Rourke et al. [2]. Of note, in their study, serial echocardiographic assessment allowed significantly earlier identification and treatment of PDA compared to awaiting the evolution of clinical signs. Moreover, and of impor-
© 2015 S. Karger AG, Basel 1661–7800/15/1074–0256$39.50/0 E-Mail [email protected] www.karger.com/neo
tance, severe intraventricular hemorrhage and ventilator days were significantly decreased after introduction of echocardiography [3]. Moreover, the use of various biomarkers (BNP and N-terminal pro-BNP) may be promising diagnostic tools for the assessment of the significance of PDA [3]. Hence, it is prudent to reserve treatment of PDA to infants with clinically significant PDA on the basis of clinical status complemented by serial echocardiography and to individualize the decision to treat. By using this individualized approach taking into consideration much information gathered at the cotside over time, we will be able to provide vulnerable preterm infants with adequate, timely treatment, thus avoiding unnecessary complications and the need for secondary surgical closure in many as in the study by Gudmundsdottir et al. [1]. References 1 Gudmundsdottir A, Johansson S, Håkansson S, Norman M, Källen K, Bonamy AK: Timing of pharmacological treatment for patent ductus arteriosus and risk of secondary surgery, death or bronchopulmonary dysplasia: a population-based cohort study of extremely preterm infants. Neonatology 2015;107:87–92. 2 O’Rourke DJ, El-Khuffash A, Moody C, Walsh K, Molloy EJ: Patent ductus arteriosus evaluation by serial echocardiography in preterm infants. Acta Paediatr 2008;97:574–578. 3 Attridge JT, Kaufman DA, Lim DS: B-type natriuretic peptide concentrations to guide treatment of patent ductus arteriosus. Arch Dis Child Fetal Neonatal Ed 2009; 94:F178– F182.
Prof. Dr. Sascha Meyer Department of Pediatrics and Neonatology, University Hospital of Saarland Building 9, Kirrberger Strasse DE–66421 Homburg (Germany) E-Mail sascha.meyer @ uks.eu
Downloaded by: UCSF Library & CKM 169.230.243.252 - 3/7/2015 8:21:14 PM
Dear Sir, In their retrospective study, Gudmundsdottir et al. [1] demonstrated that timing pharmacological patent ductus arteriosus (PDA) treatment either early (0–2 days), intermediate (3–6 days), or late (≥7 days) in 290 very preterm infants
Neonatology 2015;107:256 DOI: 10.1159/000371788
Adequate Timely Treatment of Patent Ductus Arteriosus in Extremely Low Birth Weight Infants: An Ongoing Challenge Sascha Meyer Department of Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
the real and clinically important question seems to be how to change a hemodynamically relevant PDA into a PDA that does not compromise the infant’s circulation (either decreased in size or fully closed). For the physician at the cotside, it is very important to be aware that assessment of a PDA in a preterm infant constitutes a dynamic rather than a static process. Moreover, it is interesting to note that 102 out of 290 neonates had to undergo secondary surgical closure in the report from Gudmundsdottir et al. [1]. Clinical reasons that favor active treatment include low arterial blood pressure requiring inotropes/vasopressors, oliguria requiring diuretics, respiratory failure secondary to pulmonary edema leading to increased oxygen requirements, and feeding intolerance requiring prolonged use of parenteral nutrition, given that these complications can be attributed to a hemodynamically relevant PDA (which I admit can be a difficult task). These clinical findings are corroborated by serial echocardiographic studies demonstrating increased left atrium/aortic ratio, size of PDA, and hemodynamic compromise of the systemic circulation (pathological diastolic flow in middle cerebral artery, and mesenteric and renal artery). It is important to perform serial echocardiography to demonstrate changes over time as demonstrated by O’Rourke et al. [2]. Of note, in their study, serial echocardiographic assessment allowed significantly earlier identification and treatment of PDA compared to awaiting the evolution of clinical signs. Moreover, and of impor-
© 2015 S. Karger AG, Basel 1661–7800/15/1074–0256$39.50/0 E-Mail [email protected] www.karger.com/neo
tance, severe intraventricular hemorrhage and ventilator days were significantly decreased after introduction of echocardiography [3]. Moreover, the use of various biomarkers (BNP and N-terminal pro-BNP) may be promising diagnostic tools for the assessment of the significance of PDA [3]. Hence, it is prudent to reserve treatment of PDA to infants with clinically significant PDA on the basis of clinical status complemented by serial echocardiography and to individualize the decision to treat. By using this individualized approach taking into consideration much information gathered at the cotside over time, we will be able to provide vulnerable preterm infants with adequate, timely treatment, thus avoiding unnecessary complications and the need for secondary surgical closure in many as in the study by Gudmundsdottir et al. [1]. References 1 Gudmundsdottir A, Johansson S, Håkansson S, Norman M, Källen K, Bonamy AK: Timing of pharmacological treatment for patent ductus arteriosus and risk of secondary surgery, death or bronchopulmonary dysplasia: a population-based cohort study of extremely preterm infants. Neonatology 2015;107:87–92. 2 O’Rourke DJ, El-Khuffash A, Moody C, Walsh K, Molloy EJ: Patent ductus arteriosus evaluation by serial echocardiography in preterm infants. Acta Paediatr 2008;97:574–578. 3 Attridge JT, Kaufman DA, Lim DS: B-type natriuretic peptide concentrations to guide treatment of patent ductus arteriosus. Arch Dis Child Fetal Neonatal Ed 2009; 94:F178– F182.
Prof. Dr. Sascha Meyer Department of Pediatrics and Neonatology, University Hospital of Saarland Building 9, Kirrberger Strasse DE–66421 Homburg (Germany) E-Mail sascha.meyer @ uks.eu
Downloaded by: UCSF Library & CKM 169.230.243.252 - 3/7/2015 8:21:14 PM
Dear Sir, In their retrospective study, Gudmundsdottir et al. [1] demonstrated that timing pharmacological patent ductus arteriosus (PDA) treatment either early (0–2 days), intermediate (3–6 days), or late (≥7 days) in 290 very preterm infants
