Our suggested approach to managing hemodynamically significant patent ductus arteriosus (PDA) in preterm neonates

This figure summarizes our suggested approach to managing preterm infants with hemodynamically significant (large) PDA on echocardiography. Echocardiographic parameters that indicate a hemodynamically significant PDA in the preterm infant include:

PDA diameter >1.5 mm or PDA:LPA ratio ≥1
Diastolic flow reversal in the abdominal aorta
Unrestrictive flow across the PDA (Ao-PDA flow velocity <2 m/s or mean pressure gradient ≤8 mmHg across the PDA)
Left atrial and/or ventricular enlargement not otherwise explained

In general, a combination of multiple findings is more suggestive than a single isolated finding. The optimal management approach for infants with hemodynamically significant PDA is uncertain, and practice varies. At the author's center, we use a step-wise management approach that begins with supportive care alone in most cases. We prefer this approach because spontaneous closure will occur in many patients. However, other centers may use different management approaches (eg, early therapy for any EPT infant with a large PDA). Refer to UpToDate topics on PDA in preterm infants for further details.

PDA: patent ductus arteriosus; EPT: extremely preterm; GI: gastrointestinal; AKI: acute kidney injury; NEC: necrotizing enterocolitis; CHD: congenital heart disease; PMA: postmenstrual age; LPA: left pulmonary artery; Ao: aorta.

* Supportive care measures include a neutral thermal environment, optimal respiratory support, monitoring for anemia, and modest fluid restriction. For additional details, refer to separate topics on neonatal respiratory support, fluid therapy, and anemia of prematurity.

¶ Options for pharmacologic therapy include ibuprofen, acetaminophen (paracetamol), and indomethacin. The choice is center-dependent. All 3 agents appear to have similar efficacy, but the risk of adverse effects (eg, GI bleeding, AKI) is highest with indomethacin. Contraindications to ibuprofen and indomethacin include AKI/oliguria, GI bleeding, NEC (proven or suspected), thrombocytopenia and/or coagulopathy, acute infection, and ductal-dependent CHD. In most of these circumstances, if the infant requires pharmacotherapy for PDA closure, acetaminophen can be used. The exception is infants with ductal-dependent CHD who should not be given any medication to close the PDA.

Δ For patients who fail to respond to 2 courses of therapy, subsequent treatment courses are unlikely to close the PDA. If the infant remains symptomatic from the PDA (eg, ventilator-dependent), options for definitive closure include surgical ligation or transcatheter occlusion. The choice between these is dependent on the expertise available at the center. Refer to UpToDate topic on management of PDA in preterm neonates for additional details.

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Our suggested approach to managing hemodynamically significant patent ductus arteriosus (PDA) in preterm neonates