Patent ductus arteriosus in micropreemies and full-term infants: the relative merits of surgical ligation versus indomethacin treatment.

OBJECTIVE

Treatment of ductus arteriosus is controversial. The merits and timing of ductus ligation versus indomethacin treatment were compared.

METHODS

Study parameters for infants with PDA (June 1988 through March 2001) included age, weight, physical findings, echocardiograph, success/complications of treatment, and length of stay (LOS). Statistical analysis was by descriptive univariate analysis.

RESULTS

Two hundred twelve infants were included. Median gestational age was 26 weeks (range, 22-38); weight, 836 g (447 to 2,863). Findings included murmur (94%), congestion (20%), cardiomegaly (15%), bounding pulses (6%), hyperdynamic precordium (4%), and CHF (2%). Echocardiographic measurements were left atrial diameter, 0.92 cm; posterior wall thickness, 0.26 cm; PDA diameter, 2.5 mm; septal thickness, 0.27 cm; aortic root diameter, 0.64 cm; ejection fraction, 39%; left ventricular internal diameter-diastole, 1.3 cm; left ventricular internal diameter-systole, 0.82 cm; right ventricular internal diameter-diastole, 0.51 cm. No measurement, except PDA diameter, was predictive of medical failure or need for reoperation. However, weight less than 1,000 g was highly predictive of medical failure. Additional cardiac anomalies included ASD (69%), VSD (3%), and aortic coarctation (1%). One hundred sixty-seven babies (79%) received indomethacin, closing the PDA in 88 cases (53%, recurrence = 47%). Indomethacin complications (73%) included thrombocytopenia (36%), BUN increase (31%), sepsis (30%), oliguria (25%), hyponatremia (25%), IVH (16%), pulmonary interstitial emphysema (11%), NEC (8%), intestinal perforation (4%), and bleeding (3%). Seventy-seven babies (36%) required operations (92% in the NICU) performed by pediatric surgeons. Ligation criteria included hypoxia, hypercapnia, decreasing compliance, CHF, and contraindications/failure of indomethacin. Complications included pneumothorax (4%), IVH (4%), bleeding (4%), NEC (1%), and wound infection (1%). LOS averaged 82 days.

CONCLUSIONS

Although indomethacin therapy is a reasonable treatment alternative, it is associated with significant complications. Ductus ligation may be preferable, especially in very low birth weight babies, because it is associated with low morbidity and almost certain degree of success.