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Transcatheter patent ductus arteriosus closure—will history repeat itself?

Journal of Perinatology volume 39, pages 1435–1436 (2019)Cite this article

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Forty-five years ago life was much simpler. We knew that the PDA increased pulmonary blood flow and edema, altered pulmonary compliance, and rearranged systemic flow to the gut, kidneys, and brain. As far as what could be done about it—we had only two choices: surgical ligation or continued “standard medical care”. Dr. Cotton and co-investigators designed the first RCT to address this question [1]. The trial was designed for a very specific group of infants: VLBW (with average gestational age 29 weeks), who were 8–10 days old (because that was when they had the ability to determine if a moderate-to-large PDA shunt was present), and who still required mechanical ventilation. The trial tested whether routine ligation was better or worse than no ligation and continued “standard medical care” (which included: mechanical ventilation, fluid restriction, digoxin, and furosemide). Despite the small size of their study, it showed that “routine” early surgery led to earlier extubations and smaller hospital bills.

During the ensuing 45 years, many changes have occurred in our standard medical care of infants with a PDA. In addition to the VLBW infants that Dr Cotton’s group studied, we now care for much more immature infants who make up the bulk of babies with a PDA and who are at greater risk for lung injury and maladaptive repair mechanisms. We also have better and more sensitive ways of detecting a PDA and determining its shunt magnitude. We take care of babies in completely different ways with antenatal steroids, delayed cord clamping, surfactant, better nutrition, more judicious fluid management, less use of bicarbonate therapy, different devices for ventilatory support and more reliance on noninvasive ventilatory approaches. In addition, we now have pharmacologic agents (indomethacin, ibuprofen and paracetamol) that can constrict the PDA. As a result, more recent studies have shown that compared with current “standard medical care”, early routine PDA ligation actually leads to worse rather than better respiratory outcomes [2, 3]. Similarly, as demonstrated in nearly 60 controlled trials, routine use of cyclo-oxygenase inhibitors also appears to have no long-term benefits when compared with “standard medical care” [4].

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Funding

This work was supported by a grant from the U.S. Public Health Service National Heart, Lung and Blood Institute (HL109199) and a gift from the Jamie and Bobby Gates Foundation.

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Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA

    Ronald I. Clyman

  2. Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA

    William E. Benitz

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  1. Ronald I. Clyman
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Correspondence to Ronald I. Clyman.

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Clyman, R.I., Benitz, W.E. Transcatheter patent ductus arteriosus closure—will history repeat itself?. J Perinatol 39, 1435–1436 (2019). https://doi.org/10.1038/s41372-019-0483-x

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