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John W Moore - One of the best experts on this subject based on the ideXlab platform.
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Patent Ductus Arteriosus
Circulation, 2006Co-Authors: Douglas J Schneider, John W MooreAbstract:The patent Ductus Arteriosus (PDA) is a vascular structure that connects the proximal descending aorta to the roof of the main pulmonary artery near the origin of the left branch pulmonary artery. This essential fetal structure normally closes spontaneously after birth. After the first few weeks of life, persistence of ductal patency is abnormal. The physiological impact and clinical significance of the PDA depend largely on its size and the underlying cardiovascular status of the patient. The PDA may be “silent” (not evident clinically but diagnosed incidentally by echocardiography done for a different reason), small, moderate, or large. Regardless of the size, complications may arise, and it is important for both pediatric and adult cardiologists to have an understanding of the pathophysiology, clinical implications, and management of PDA. The Ductus Arteriosus is a normal and essential fetal structure that becomes abnormal if it remains patent after the neonatal period. In normal cardiovascular development, the proximal portions of the sixth pair of embryonic aortic arches persist as the proximal branch pulmonary arteries, and the distal portion of the left sixth arch persists as the Ductus Arteriosus, connecting the left pulmonary artery with the left dorsal aorta (Figure 1). Normally, the distal right sixth aortic arch loses its connection to the dorsal aorta and degenerates. This transformation is complete by 8 weeks of fetal life. Figure 1. Schematic of embryonic aortic arch system. The 6 pairs of embryonic aortic arches are demonstrated (left-sided arches are numbered). The portions that normally involute are indicated by broken lines. The distal left sixth embryonic arch normally persists and becomes the PDA, connecting the left pulmonary artery to the proximal descending aorta. The right distal sixth arch normally involutes, as does the eighth segment of the right dorsal aorta (*), which results in a leftward aortic …
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interventional treatment of patent Ductus Arteriosus in 2004
Catheterization and Cardiovascular Interventions, 2005Co-Authors: John W Moore, Douglas J Schneider, Daniel S Levi, Sarah D Moore, Farhouch BerdjisAbstract:In 2004, the interventional treatment of patent Ductus Arteriosus (PDA) is definitive and curative. In current practice, coils are used for smaller PDA, and devices are employed for larger PDA. Developing technologies offer small improvements in control and results, but do not appear to promise major changes in practice. This review summarizes the current and emerging interventional technologies directed at PDA closures.
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Percutaneous closure of the small patent Ductus Arteriosus using occluding spring coils
Journal of the American College of Cardiology, 1994Co-Authors: John W Moore, George L, Stanley E. Kirkpatrick, James W. Mathewson, Robert L. Spicer, Karen Uzark, Abraham Rothman, Patrick A. Cambier, Michael C. Slack, William C. KirbyAbstract:Abstract Objectives . This report summarizes our experience with the use of occluding spring coils to close the small patent Ductus Arteriosus. Background . Several patent Ductus Arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent Ductus Arteriosus in a small group of patients. This report describes our series of patients having patent Ductus Arteriosus closure with occluding spring coils. Methods . Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent Ductus Arteriosus closure by occluding spring coils. Selection criteria were age >6 months and narrowest patent Ductus Arteriosus internal dimension ⪯3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent Ductus Arteriosus and into the aortic diverticulum. Patent Ductus Arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging. Results . Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent Ductus Arteriosus. Average Ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the Ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent Ductus Arteriosus noted on color flow imaging. One patient did not have successful implantation. This patient had a 3.2-mm Ductus, and two coils migrated to the distal left pulmonary artery and could not be retrieved. There were no deaths or any significant complications noted during early or late follow-up in these patients. Conclusions . Occluding spring coils may have additional application in closing the small patent Ductus Arteriosus.
William E. Benitz - One of the best experts on this subject based on the ideXlab platform.
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Patent Ductus Arteriosus in Preterm Infants
Pediatrics, 2016Co-Authors: William E. BenitzAbstract:Despite a large body of basic science and clinical research and clinical experience with thousands of infants over nearly 6 decades,(1) there is still uncertainty and controversy about the significance, evaluation, and management of patent Ductus Arteriosus in preterm infants, resulting in substantial heterogeneity in clinical practice. The purpose of this clinical report is to summarize the evidence available to guide evaluation and treatment of preterm infants with prolonged ductal patency in the first few weeks after birth.
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predictors of bronchopulmonary dysplasia or death in premature infants with a patent Ductus Arteriosus
Pediatric Research, 2014Co-Authors: Valerie Y Chock, William E. Benitz, Rajesh Punn, Anushri Oza, Krisa P Van Meurs, Alice S Whittemore, Fariborz Behzadian, Norman H SilvermanAbstract:Predictors of bronchopulmonary dysplasia or death in premature infants with a patent Ductus Arteriosus
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patent Ductus Arteriosus to treat or not to treat
Archives of Disease in Childhood, 2012Co-Authors: William E. BenitzAbstract:Persistent patency of the Ductus Arteriosus in the preterm infant is associated with numerous morbidities, including higher rates of bronchopulmonary dysplasia and increased mortality. These strong associations have led to widespread use of cyclooxygenase inhibitors and surgical ligation to achieve ductal closure in the expectation that closing the Ductus will reduce these complications. Each of these interventions has its own associated adverse effects. Neither individual randomised controlled trials nor meta-analyses of those trials have been able to demonstrate long-term benefits of these treatments despite their efficacy in inducing ductal closure and reducing the need for ductal ligation. Despite the potential shortcomings of those trials, they provide substantial cumulative evidence that early, routine treatment to close a persistently patent Ductus Arteriosus in preterm infants does not improve outcomes and should therefore be abandoned. Future trials of these interventions for patent Ductus management should address different questions. Persistence of ductal patency should be considered a sign of rather than a direct cause of the several morbidities with which it is clearly associated. Practitioners should tolerate ductal patency and learn to manage its causes and consequences rather than focusing on achievement of ductal closure.
Patrick J. Mcnamara - One of the best experts on this subject based on the ideXlab platform.
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late oral acetaminophen versus immediate surgical ligation in preterm infants with persistent large patent Ductus Arteriosus
The Journal of Thoracic and Cardiovascular Surgery, 2018Co-Authors: Sally Mashally, Patrick J. Mcnamara, Lynne E Nield, Fernando De Freitas Martins, Afif Elkhuffash, Amish Jain, Dany E WeiszAbstract:Abstract Objective The study objective was to evaluate the association of oral acetaminophen therapy versus immediate surgical ligation with neonatal outcomes in infants with persistent patent Ductus Arteriosus. Methods We performed a retrospective cohort study of preterm infants born 28+6 weeks or less gestational age with persistent large patent Ductus Arteriosus being considered for surgical ligation after unsuccessful medical therapy. Infants in epoch 1 (July 2009 to June 2012) were immediately referred for ligation, and infants in epoch 2 (July 2012 to June 2015) were treated with oral acetaminophen and referred for ligation in the absence of improvement. The primary outcome was a composite of death or chronic lung disease. Results A total of 92 infants with median (interquartile range) gestational age 25.2 weeks (24.4-26.3) had persistent large patent Ductus Arteriosus (43 in epoch 1, 49 in epoch 2). Infants in epoch 2 had decreased surgical ligation (26 [53%] vs 31 [72%]; adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.12-0.89) but increased chronic lung disease (36 [73%] vs 25 [58%]; aOR, 3.34; 95% CI, 1.05-10.58) and increased death/chronic lung disease of borderline significance (39 [80%] vs 29 [67%]; aOR, 3.09; 95% CI, 0.99-9.63). Infants in epoch 2 took longer to wean off of positive pressure ventilation (28.5 vs 24 days after enrollment; aOR, 0.52; 95% CI, 0.31-0.85). Conclusions Late oral acetaminophen therapy for infants with persistent patent Ductus Arteriosus is associated with reduced surgical ligation but increased chronic lung disease. In light of a lack of improvement in clinical outcomes, the individual contributory effects of acetaminophen, surgical ligation, and prolonged exposure to patent Ductus Arteriosus require further study to define the optimal approach.
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application of npe in the assessment of a patent Ductus Arteriosus
Pediatric Research, 2018Co-Authors: David Van Laere, Patrick J. Mcnamara, Bart Van Overmeire, Afif Elkhuffash, Samir Gupta, Marilena Savoia, Christoph E Schwarz, Willem P De BoodeAbstract:In many preterm infants, the Ductus Arteriosus remains patent beyond the first few days of life. This prolonged patency is associated with numerous adverse outcomes, but the extent to which these adverse outcomes are attributable to the hemodynamic consequences of ductal patency, if at all, has not been established. Different treatment strategies have failed to improve short-term outcomes, with a paucity of data on the correct diagnostic and pathophysiological assessment of the patent Ductus Arteriosus (PDA) in association with long-term outcomes. Echocardiography is the selected method of choice for detecting a PDA, assessing the impact on the preterm circulation and monitoring treatment response. PDA in a preterm infant can result in pulmonary overcirculation and systemic hypoperfusion, Therefore, echocardiographic assessment should include evaluation of PDA characteristics, indices of pulmonary overcirculation with left heart loading conditions, and indices of systemic hypoperfusion. In this review, we provide an evidence-based overview of the current and emerging ultrasound measurements available to identify and monitor a PDA in the preterm infant. We offer indications and limitations for using Neonatologist Performed Echocardiography to optimize the management of a neonate with a PDA.
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assessment and treatment of post patent Ductus Arteriosus ligation syndrome
The Journal of Pediatrics, 2014Co-Authors: Afif Elkhuffash, Amish Jain, Dany E Weisz, Luc Mertens, Patrick J. McnamaraAbstract:Objective To compare differences in tissue Doppler imaging, global longitudinal strain (GLS), and cardiac troponin T (cTnT) between infants with low ( 200 mL/kg/min) left ventricular (LV) output 1 hour after duct ligation and assess the impact of milrinone treatment on cardiac output and myocardial performance. Study design LV function was assessed preoperatively and 1 and 18 hours postoperatively. Infants were categorized into a low-output or a normal-output group based on the echocardiographic assessment of LV output at 1 hour. Results Thirty infants with a mean gestation of 25.3 weeks were enrolled. LV basal lateral S′, basal septal S′, and basal right ventricular S′ were lower in the low-output group (n = 19) at 1 hour postoperatively, with no significant difference in GLS (low-output −10.3% vs high-output −14.4%, P >.05) or cTnT between the groups. Patients in the low-output group were treated with milrinone, and by 18 hours LV performance recovered to levels comparable with the high output group. cTnT values increased at 18 hours in the whole cohort with no significant difference between the groups. Conclusion Tissue Doppler imaging and GLS provide novel insights and further characterization of myocardial performance immediately after patent Ductus Arteriosus ligation. A reduction in tissue Doppler-derived LV systolic velocity may further help in monitoring cardiac performance after patent Ductus Arteriosus ligation and for monitoring the effects of treatment.
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patent Ductus Arteriosus ligation is associated with impaired left ventricular systolic performance in premature infants weighing less than 1000 g
The Journal of Thoracic and Cardiovascular Surgery, 2010Co-Authors: Patrick J. Mcnamara, Lilian Stewart, Sandesh Shivananda, Derek Stephens, Arvind SehgalAbstract:Objective Patent Ductus Arteriosus ligation is often complicated by systemic hypotension and oxygenation failure. The ability of the immature myocardium to compensate for altered afterload is poorly understood. The aim of this study was to characterize the effects of patent Ductus Arteriosus ligation on myocardial performance in preterm infants. Methods Serial echocardiographic analysis was performed before and after patent Ductus Arteriosus ligation. Characteristics of the patent Ductus Arteriosus, myocardial performance (fractional shortening, mean velocity of circumferential fiber shortening, and left ventricular output) and left ventricular afterload (end-systolic wall stress) were assessed. The stress–velocity relationship was measured as a preload-independent, afterload-adjusted measure of myocardial contractility. Results Forty-six preterm infants were assessed at 28.5 ± 11.3 days and a weight of 1058 ± 272 g. Patent Ductus Arteriosus ligation was followed by increased left ventricular exposed vascular resistance temporally coinciding with reduced left ventricular preload, decreased left ventricular contractility, and low left ventricular output. Neonates weighing 1000 g or less had a higher rate of low fractional shortening ( −1 · h −1 ) and increased need for cardiotropes and demonstrated a trend toward an impaired stress–velocity relationship. Neonates with impaired left ventricular systolic performance were more likely to require cardiotropes and have low systolic arterial pressure, increased heart rate, and abnormal base deficit. Conclusion Patent Ductus Arteriosus ligation is sometimes associated with impaired left ventricular systolic performance, which is most likely attributable to altered loading conditions. Neonates weighing 1000 g or less are at increased risk of impaired left ventricular systolic performance, which might relate to maturational differences and decreased tolerance to altered loading conditions.
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Does echocardiography facilitate determination of hemodynamic significance attributable to the Ductus Arteriosus?
European Journal of Pediatrics, 2009Co-Authors: Arvind Sehgal, Patrick J. McnamaraAbstract:Introduction The assignment of hemodynamic significance to a patent Ductus remains a challenge for neonatal intensivists. The impact is medical uncertainty and ongoing debate as to when treatment should be provided if ever. Discussion Patent Ductus Arteriosus is associated with significant neonatal morbidities including necrotizing enterocolitis and brain injury; causality has not been proven. In addition, there are limited data suggesting a beneficial effect of therapeutic intervention. The inability to accurately differentiate the pathological Ductus Arteriosus from the innocent Ductus Arteriosus may contribute, in part, to the lack of scientific evidence of benefit or causality. Our group has previously proposed the need for a staging system to characterize the clinical and echocardiography impact of the Ductus Arteriosus. This approach requires comprehensive echocardiography evaluation to assess ductal size and the degree of pulmonary overcirculation/systemic hypoperfusion related to the transductal shunt. Conclusion In this review, we will highlight the evidence for echocardiography markers of hemodynamic significance and speculate as to how they may facilitate improved decision making in the neonatal intensive care unit.
Afif Elkhuffash - One of the best experts on this subject based on the ideXlab platform.
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late oral acetaminophen versus immediate surgical ligation in preterm infants with persistent large patent Ductus Arteriosus
The Journal of Thoracic and Cardiovascular Surgery, 2018Co-Authors: Sally Mashally, Patrick J. Mcnamara, Lynne E Nield, Fernando De Freitas Martins, Afif Elkhuffash, Amish Jain, Dany E WeiszAbstract:Abstract Objective The study objective was to evaluate the association of oral acetaminophen therapy versus immediate surgical ligation with neonatal outcomes in infants with persistent patent Ductus Arteriosus. Methods We performed a retrospective cohort study of preterm infants born 28+6 weeks or less gestational age with persistent large patent Ductus Arteriosus being considered for surgical ligation after unsuccessful medical therapy. Infants in epoch 1 (July 2009 to June 2012) were immediately referred for ligation, and infants in epoch 2 (July 2012 to June 2015) were treated with oral acetaminophen and referred for ligation in the absence of improvement. The primary outcome was a composite of death or chronic lung disease. Results A total of 92 infants with median (interquartile range) gestational age 25.2 weeks (24.4-26.3) had persistent large patent Ductus Arteriosus (43 in epoch 1, 49 in epoch 2). Infants in epoch 2 had decreased surgical ligation (26 [53%] vs 31 [72%]; adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.12-0.89) but increased chronic lung disease (36 [73%] vs 25 [58%]; aOR, 3.34; 95% CI, 1.05-10.58) and increased death/chronic lung disease of borderline significance (39 [80%] vs 29 [67%]; aOR, 3.09; 95% CI, 0.99-9.63). Infants in epoch 2 took longer to wean off of positive pressure ventilation (28.5 vs 24 days after enrollment; aOR, 0.52; 95% CI, 0.31-0.85). Conclusions Late oral acetaminophen therapy for infants with persistent patent Ductus Arteriosus is associated with reduced surgical ligation but increased chronic lung disease. In light of a lack of improvement in clinical outcomes, the individual contributory effects of acetaminophen, surgical ligation, and prolonged exposure to patent Ductus Arteriosus require further study to define the optimal approach.
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application of npe in the assessment of a patent Ductus Arteriosus
Pediatric Research, 2018Co-Authors: David Van Laere, Patrick J. Mcnamara, Bart Van Overmeire, Afif Elkhuffash, Samir Gupta, Marilena Savoia, Christoph E Schwarz, Willem P De BoodeAbstract:In many preterm infants, the Ductus Arteriosus remains patent beyond the first few days of life. This prolonged patency is associated with numerous adverse outcomes, but the extent to which these adverse outcomes are attributable to the hemodynamic consequences of ductal patency, if at all, has not been established. Different treatment strategies have failed to improve short-term outcomes, with a paucity of data on the correct diagnostic and pathophysiological assessment of the patent Ductus Arteriosus (PDA) in association with long-term outcomes. Echocardiography is the selected method of choice for detecting a PDA, assessing the impact on the preterm circulation and monitoring treatment response. PDA in a preterm infant can result in pulmonary overcirculation and systemic hypoperfusion, Therefore, echocardiographic assessment should include evaluation of PDA characteristics, indices of pulmonary overcirculation with left heart loading conditions, and indices of systemic hypoperfusion. In this review, we provide an evidence-based overview of the current and emerging ultrasound measurements available to identify and monitor a PDA in the preterm infant. We offer indications and limitations for using Neonatologist Performed Echocardiography to optimize the management of a neonate with a PDA.
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assessment and treatment of post patent Ductus Arteriosus ligation syndrome
The Journal of Pediatrics, 2014Co-Authors: Afif Elkhuffash, Amish Jain, Dany E Weisz, Luc Mertens, Patrick J. McnamaraAbstract:Objective To compare differences in tissue Doppler imaging, global longitudinal strain (GLS), and cardiac troponin T (cTnT) between infants with low ( 200 mL/kg/min) left ventricular (LV) output 1 hour after duct ligation and assess the impact of milrinone treatment on cardiac output and myocardial performance. Study design LV function was assessed preoperatively and 1 and 18 hours postoperatively. Infants were categorized into a low-output or a normal-output group based on the echocardiographic assessment of LV output at 1 hour. Results Thirty infants with a mean gestation of 25.3 weeks were enrolled. LV basal lateral S′, basal septal S′, and basal right ventricular S′ were lower in the low-output group (n = 19) at 1 hour postoperatively, with no significant difference in GLS (low-output −10.3% vs high-output −14.4%, P >.05) or cTnT between the groups. Patients in the low-output group were treated with milrinone, and by 18 hours LV performance recovered to levels comparable with the high output group. cTnT values increased at 18 hours in the whole cohort with no significant difference between the groups. Conclusion Tissue Doppler imaging and GLS provide novel insights and further characterization of myocardial performance immediately after patent Ductus Arteriosus ligation. A reduction in tissue Doppler-derived LV systolic velocity may further help in monitoring cardiac performance after patent Ductus Arteriosus ligation and for monitoring the effects of treatment.
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efficacy of paracetamol on patent Ductus Arteriosus closure may be dose dependent evidence from human and murine studies
Pediatric Research, 2014Co-Authors: Afif Elkhuffash, Amish Jain, D Corcoran, Prakesh S Shah, Christopher W Hooper, Naoko Brown, Stanley D Poole, Elaine L Shelton, Ginger L Milne, Jeff ReeseAbstract:Efficacy of paracetamol on patent Ductus Arteriosus closure may be dose dependent: evidence from human and murine studies
G Grunkemeier - One of the best experts on this subject based on the ideXlab platform.
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what happens when the patent Ductus Arteriosus is treated less aggressively in very low birth weight infants
Journal of Perinatology, 2012Co-Authors: Joseph W Kaempf, A J Kaempf, L Wang, G GrunkemeierAbstract:What happens when the patent Ductus Arteriosus is treated less aggressively in very low birth weight infants?
