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PubMed1981

Indomethacin treatment for symptomatic patent ductus arteriosus: a double-blind control study.

A double-blind control study was designed to determine the efficacy and safety of indomethacin treatment of patients with symptomatic patent ductus arteriosus. Infants with severe respiratory distress syndrome and symptomatic patent ductus arteriosus were eligible for the prospective study if the ratio of left atrial/aortic root diameter remained greater than or equal to 1.3:1 following a 24-hour period of medical management. Thirty-nine eligible infants were randomly assigned to the control or indomethacin group and given 0.2 mg/kg of enteral indomethacin or placebo in a double-blind manner. Second and third doses were administered at 24-hour intervals in phase 1 (17 patients), and at eight-hour intervals in phase 2 (22 patients). The 75% patent ductus arteriosus closure rate with indomethacin treatment in phase 1 was not statistically significant due to a 44% spontaneous closure rate in the control group. In phase 2, however, 85% of the indomethacin group demonstrated patent ductus arteriosus closure vs only 11% in the matched control group (P less than .01). Although no indomethacin side effects occurred in phase 1, in phase 2 indomethacin administration was associated with minimal, but statistically significant, transient impaired renal function and, in three infants (23%), mild upper gastrointestinal bleeding. In summary, enteral administration of three 0.2 mg/kg indomethacin doses at eight-hour intervals thus appears to be a safe and effective alternative to surgical closure.

Clinical Trials as Topic↗
PubMedDate not supplied

Angiographic evidence of absent ductus arteriosus in severe right ventricular outflow obstruction.

The angiocardiograms of 5 newborn infants with autopsy and/or surgically-proven congenital absence of the ductus arteriosus (ADA) and right ventricular outflow obstruction (Group A), and of 14 neonates with pulmonary atresia complex and patent ductus arteriosus (Group B) were reviewed. Aortic size was similar in both groups; however, the diameters of the right and left pulmonary arteries were much smaller in Group A than in Group B (right pulmonary artery: 2.6 vs 4.5 mm, P less than 0.005; left pulmonary artery: 2.5 vs 4.3 mm, P less than 0.005). Extensive bronchial collaterals were observed in Group A but not in Group B. Tricuspid aortic valve stenosis was present in 2 patients in Group A but in none in Group B. The diagnosis of ADA may be made in newborn infants with severe right ventricular outflow obstruction if the angiocardiograms reveal hypoplasia of the pulmonary arteries, extensive bronchial collaterals, and nonvisualization of the ductus arteriosus. Other suggestive features include aortic valve stenosis and/or right aortic arch with aberrant left subclavian artery.

Angiocardiography↗
PubMed1982

Congenital heart disease and respiratory distress syndrome. Reversal of indomethacin closure of patent ductus arteriosus by prostaglandin therapy in a preterm infant.

Two relatively large premature newborn infants with respiratory distress syndrome and ductus-dependent congenital heart disease were treated. In one, pharmacologic closure of the ductus arteriosus resulted in severe hypoxemia. The patency of the ductus as reestablished with the infusion of alprostadil (PGE1), until palliative surgery was performed. In the second case, persistent pulmonary hypertension was clinically suspected, and pharmacologic therapy was initiated without adequate cardiac evaluation. In large premature infants with respiratory distress syndrome, closure of the ductus arteriosus should not be attempted before ruling out the presence of ductus-dependent congenital heart disease. Furthermore, pharmacologic closure of ductus arteriosus can be reversed by the infusion of prostaglandin.

Alprostadil↗
PubMed1991

Persistent ductus arteriosus in adults. A review of surgical experience with 25 patients.

OBJECTIVE: To review the clinical features, operative details and course of adults with persistent ductus arteriosus. DESIGN: Retrospective study. Information on subjects was obtained by case records review. SETTING: The Cardiothoracic Unit, Royal Prince Alfred Hospital, Sydney. PATIENTS: Twenty-five adults aged 16 years and over with persistent ductus arteriosus, from 1974-1990. INTERVENTION: Surgical division or ligation of persistent ductus, via left thoracotomy or median sternotomy. MAIN OUTCOME MEASURES: Preoperative clinical features; postoperative mortality and morbidity. RESULTS: There was a high incidence of symptoms in this group of adults with persistent ductus arteriosus, many having anatomical (aneurysm, calcification) and/or haemodynamic (heart failure, pulmonary hypertension) complications. There was one death (mortality, 4%) of a young woman with significant preoperative pulmonary hypertension. The remaining 24 patients (96%) left hospital completely well between 4 and 12 days after surgery. CONCLUSIONS: Persistent ductus arteriosus, although primarily a paediatric problem, may present in adulthood. Closure by operative means (or in selected cases, by interventional catheter) is warranted in all adult subjects with left to right shunt, other than for patients over 60 years of age with neither heart failure nor cardiomegaly.

Abnormalities, Multiple↗
PubMed2003

A comparison of oral ibuprofen and intravenous indomethacin for closure of patent ductus arteriosus in preterm infants.

BACKGROUND: Indomethacin is widely accepted as the treatment for patent ductus arteriosus (PDA) in preterm infants but it has various side effects. Ibuprofen is the alternative treatment and believed to be less likely to induce side effects. OBJECTIVE: To compare efficacy and side effects of ibuprofen versus indomethacin treatment for symptomatic patent ductus arteriosus (PDA) in preterm infants. METHOD: The authors studied 30 infants (gestational age < or = 35 weeks, aged < or = 10 days) who were diagnosed as having symptomatic PDA confirmed by echocardiogram. The infants were randomly assigned to receive three intravenous doses of indomethacin given at 12-hour intervals or three doses of ibuprofen given at 24-hour intervals, starting within ten days of life. The demographic data, rate of clinical closure, need for additional treatment, side effects, complications and the infants' clinical course were recorded within 28 days. RESULTS: The rate of ductal closure was similar with the two treatment regimes. Ductal closure occurred in 7 of 15 infants given ibuprofen (46.67%) and 10 of 15 infants given indomethacin (66.67%). (Relative risk 0.669; 95% confidence interval, 0.328 to 1.364; p = 0.462) The number of infants who needed a second pharmacologic treatment was not significantly different between the two groups, (6 cases in the ibuprofen group, 5 cases in the indomethacin group) but surgical ligation was performed in two cases in the indomethacin group. There was a significant difference in using the diuretic drug (furosemide) in the indomethacin group (11 cases), compared to the ibuprofen group (3 cases), (p = 0.009). More cases of necrotizing enterocolitis were seen in the indomethacin group (66.67% compared to 40% in the ibuprofen group) but there was no statistically significant difference. CONCLUSION: Ibuprofen has the same efficiency as indomethacin for the treatment of symptomatic patent ductus arteriosus in preterm infants and less likely to induce necrotizing enterocolitis and renal toxicity than indomethacin.

Administration, Oral↗
PubMed1996

[A 66-year-old woman with a patent ductus arteriosus and no significant progression of pulmonary arterial pressure over 17 years].

We report the case of a 66-year-old woman with a patent ductus arteriosus and no significant progression of pulmonary arterial pressure over 17 years. She was admitted to our hospital in 1978 because of palpitations on exertion and chest discomfort. Cardiac catheterization was done, and she was given a diagnosis of patent ductus arteriosus. Because the left-to-right shunt was small (15%) and because there was no evidence of pulmonary hypertension (38/18 mmHg), she was treated medically. In 1995 she was admitted again, to determine the cause of a cerebral infarction. The cerebral infarction was believed to have been caused by an embolism due to atrial fibrillation. She underwent cardiac catheterization again. The left-to-right shunt had increased to 41%, but the pulmonary artery pressure had not changed (27/14 mmHg). Intravascular ultrasound imaging was used to evaluate the ductus arteriosus. The diameter of the ductus was 4.4 mm and calcification was not observed. During the 17 years of follow-up, heart size increased slightly, but pulmonary artery pressure did not change. In addition, intravascular ultrasound was very useful for evaluating the condition of the ductus arteriosus.

Aged↗
PubMed1996

Effect of ligation of patent ductus arteriosus on left ventricular performance and its determinants in premature neonates.

OBJECTIVES: The purpose of this study was to determine in preterm newborn infants the effects of ductal ligation on ventricular performance and its determinants: preload, afterload and contractility. BACKGROUND: Neonatal ventricular performance is highly sensitive to afterload. Therefore, the increase in systemic vascular resistance associated with ligation of a patent ductus arteriosus might worsen ventricular performance in the preterm infant. METHODS: All 14 premature infants undergoing patent ductus arteriosus ligation in a 1-year period at our institution underwent echocardiography at three times: before, immediately after and 24 h after ligation. Indexes studied included ventricular performance (fractional area change), preload (left ventricular end-diastolic dimension), afterload (end-systolic wall stress) and contractility (the difference between the measured and predicted velocity of circumferential fiber shortening). Blood pressure was measured; systemic resistance was calculated. These data were compared with those of 14 preterm infants without patent ductus arteriosus. RESULTS: The infants with patent ductus arteriosus had higher values for ventricular performance (mean +/- SD fractional area change 60 +/- 9% vs. 52 +/- 11%, p < 0.05) and lower values for wall stress (22 +/- 6 vs. 44 +/- 17 g/cm2, p < 0.05) before ligation than did the control group. At 24 h after ligation, ventricular performance was not significantly changed (fractional area change 60 +/- 9% to 57 +/- 12%). There were significant increases in blood pressure and systemic vascular resistance but no changes in wall stress or contractility. CONCLUSIONS: Ventricular performance is higher in premature infants with than in those without patent ductus arteriosus because afterload is lower in the former group. Although ductal ligation increases blood pressure and systemic resistance, wall stress and ventricular performance are maintained. Our results suggest that the premature newborn maintains ventricular performance during stress, at least in part, by manipulating afterload.

Blood Pressure↗
PubMed2002

Aortic thrombus after coil occlusion of a type E patent ductus arteriosus.

A 5-year-old girl was referred to our institution for closure of a silent patent ductus arteriosus. Cardiac catheterization revealed a tiny-to-small patent ductus arteriosus of the elongated, conical type (Type E). Coil occlusion was performed with a Gianturco coil, 0.035-4 cm(-3) mm. A follow-up echocardiogram showed a very small residual ductal shunt and a moderate-sized thrombus at the aortic end of the ductus arteriosus. The patient remained asymptomatic.

Aorta, Thoracic↗
PubMed1983

Cryosurgery of the fetal ductus arteriosus.

The effects of cryosurgical treatment of the fetal ductus arteriosus (DA) on the structure and function of the neonatal DA are assessed for the first time. A cryosurgical probe, cooled with nitrous oxide, was used to freeze the wall of the DA in 5 fetal lambs. Six fetal lambs were used as control animals. After birth, all the cryosurgically treated lambs had a patent DA whereas all the control lambs had a closed DA. Only the cryosurgically treated group had these histologic findings: calcific deposits, necrosis, and focal ganglion cell necrosis in the outer one third to two thirds of the media with a decrease or loss of muscle cells and elastic fibers. This study suggests the feasibility of developing a cryosurgical approach for maintaining patency of the DA.

Animals↗
PubMed1989

[Closure of patent ductus arteriosus in elderly cases].

A technique for closure of patent ductus arteriosus in the elderly cases is described. We have operated on eleven adult cases of patent ductus arteriosus cases in 10 years. In five cases cardiopulmonary bypass used and in the other six cases it was not used. The cardiopulmonary bypass was used especially for the patients with pulmonary hypertension (pulmonary artery mean pressure greater than 40 mmHg), or high aged (older than 40 years) patients. No operative death have occurred in both groups, and no complication from air embolism or hemorrhage have been encountered. The technique embodies the profound hypothermia, low flow, and direct suture of the pulmonary end of the ductus arterious through a pulmonary arteriotomy. The ductus has been obstructed by using a Hegar's dilator before core cooling was started. Hegar's dilator is useful for establishing profound hypothermia and satisfactory visualization of the operative field.

Adult↗
PubMed2001

[Echocardiographic findings before and after interventional occlusion of persistently patent ductus arteriosus with the amplatzer duct occluder].

AIM: The Amplatzer duct occluder(R) is a new system for interventional occlusion of persistently patent ductus arteriosus. The purpose of our study was to determine, whether adequate evaluation of this occluder system can be obtained by echocardiography. METHOD: From 11/1999 until 12/2000, 18 patients were included in the study. All underwent interventional occlusion of a patent ductus arteriosus with the Amplatzer duct occluder(R). Echocardiography was performed on admission, on day one and three and six months following the intervention. RESULTS: The mean age of our patients was 4.8 years (9 months - 18.7 years, median 3.2 years), the mean weight was 18.4 kg (6.5 - 66 kg, median 14 kg). All echocardiographic findings prior to intervention were confirmed during cardiac catheterization. Following intervention we were able to visualize the occluder system and its relation to surrounding structures in all patients. In none of our patients we found an obstruction of the left pulmonary artery. In 1/18 patients there was a minor protrusion of the distal occluder into the descending aorta. Doppler-sonography however revealed no obstruction. Complete occlusion of the ductus arteriosus was confirmed by color Doppler echocardiography in all patients within 5 days, in 17/18 patients no residual shunt was detectable within 24 hours. CONCLUSION: According to our experience the results of interventional occlusion of patent ductus arteriosus in children and adolescents can be well determined by echocardiography.

Adolescent↗
PubMed2000

Blood flow velocity waveforms of the fetal pulmonary artery and the ductus arteriosus: reference ranges from 13 weeks to term.

OBJECTIVE: To establish reference ranges for blood flow velocity waveforms of the fetal main pulmonary artery and the ductus arteriosus during the second and third trimesters of pregnancy. METHODS: A prospective cross-sectional echocardiographic study was performed in 222 normal fetuses from 13 to 41 weeks of gestation using high resolution/color Doppler ultrasound equipment. RESULTS: Gestational age-specific reference ranges are given for peak velocity across the pulmonary valve, velocities in the ductus arteriosus, peak systolic velocity in the ductus arteriosus-to-peak velocity across the pulmonary valve ratio, ductal systolic velocity-to-diastolic velocity ratio, ductal resistance index and ductal pulsatility index. In the ductus arteriosus, increasing fetal heart rate was significantly associated with increasing end-diastolic velocity and decreasing systolic-to-diastolic ratio, decreasing resistance index, and decreasing pulsatility index. CONCLUSIONS: Based on a prospective study in more than 200 normal fetuses, the data provide gestational age specific reference ranges for blood flow velocity waveforms of the fetal pulmonary artery and the ductus arteriosus. The reference ranges may be helpful in prenatal diagnosis of cardiac malformations and ductal obstruction from 13 to 41 weeks of gestation.

Blood Flow Velocity↗
PubMed2000

Isolated ductus arteriosus aneurysm in the fetus and infant: a multi-institutional experience.

OBJECTIVES: The purpose of this study was to describe the clinical characteristics and outcome and to elucidate the pathogenesis of ductus arteriosus aneurysm (DAA). BACKGROUND: Ductus arteriosus aneurysm is a rare lesion that can be associated with severe complications including thromboembolism, rupture and death. METHOD: We reviewed the clinical records, diagnostic imaging studies and available histology of 24 cases of DAA, diagnosed postnatally (PD) in 15 and antenatally (AD) in 9 encountered in five institutions. RESULTS: Of PD cases, 13 presented at <2 months, and all AD cases were detected incidentally after 33 weeks of gestation during a late trimester fetal ultrasound study. Of the 24, only 4 had DAA-related symptoms and 6 had associated syndromes: Marfan, Smith-Lemli-Opitz, trisomies 21 and 13 and one possible Ehlers-Danlos. Three had complications related to the DAA: thrombus extension into the pulmonary artery, spontaneous rupture, and asymptomatic cerebral infarction. Six underwent uncomplicated DAA resection for ductal patency, DAA size or extension of thrombus. In the four examined, there was histologic evidence of reduced intimal cushions in two and abnormal elastin expression in two. Five of the 24 died, with only one death due to DAA. Of 19 survivors, all but one remain clinically asymptomatic at a median follow-up of 35 months; however, two have developed other cardiac lesions that suggest Marfan syndrome. A review of 200 consecutive third trimester fetal ultrasounds suggests an incidence of DAA of 1.5%. CONCLUSIONS: Ductus arteriosus aneurysm likely develops in the third trimester perhaps due to abnormal intimal cushion formation or elastin expression. Although it can be associated with syndromes and severe complications, many affected infants have a benign course. Given the potential for development of other cardiac lesions associated with connective tissue disease, follow-up is warranted.

Aneurysm↗
PubMed1989

Pharmacologic management of patent ductus arteriosus.

The incidence, pathophysiology, and clinical findings of symptomatic patent ductus arteriosus (PDA) are reviewed, and the pharmacologic management of symptomatic PDA is discussed. Spontaneous closure of the ductus arteriosus (DA) usually occurs within four days after birth in most premature and full-term infants. The incidence of PDA is related to birth weight in premature infants and has been shown to decrease with an increase in birth weight. Clinical findings are reviewed. Prophylactic treatment in the first few hours after birth may not be needed in most premature infants. Treatment should be considered only if the ductus becomes symptomatic. Medical management consists of respiratory support, fluid restriction, diuretics, digoxin, and indomethacin. Respiratory support, fluid restriction, and diuretics are used as first-line treatment of symptomatic PDA. Digoxin cannot be recommended as part of first-line therapy, since its risks seem to outweigh the benefits in preterm infants. Indomethacin should be used only if other standard measures including fluid restriction and diuretic treatment fail. The mechanism of action, pharmacokinetics, adverse effects, and drug interactions of indomethacin are discussed. Symptomatic PDA can increase morbidity and mortality, especially in very low birth weight infants. Treatment of symptomatic PDA may decrease the morbidity associated with this condition.

Digoxin↗
PubMed1996

Follow-up of coil occlusion of patent ductus arteriosus.

OBJECTIVE: We sought to determine the prevalence and fate of residual ductal shunting following coil occlusion of patent ductus arteriosus. BACKGROUND: Although transcatheter coil occlusion of patent ductus arteriosus has gained popularity, few follow-up data have been reported. METHODS: A review of 75 patients who underwent coil occlusion was performed. Residual shunting was investigated by Doppler echocardiography in follow-up. Angiograms were reviewed to obtain minimal ductal diameter and ductal angiographic type. RESULTS: Residual shunts were found in 31 patients (41%) on the day of the procedure, and of these, spontaneous closure was noted in 17 (55%) at 2 weeks to 20 months of follow-up. Of the 75 patients studied, 5 (7%) required a second coil procedure, and 10 (13%) remained with persistent residual shunts at most recent follow-up. Actuarial analysis estimated a 6 +/- 5% prevalence of residual shunts 20 months after a single coil procedure and 3 +/- 3% after all coil procedures. Minimal ductal diameter was associated with immediate complete ductal occlusion by a single coil. These patients had significantly smaller (p = 0.003) minimal ductal diameters (1.2 +/- 0.7 mm) than those who required two coils during their initial procedure to achieve immediate occlusion (1.9 +/- 0.7 mm), those who required a second coil procedure (2.0 +/- 0.9 mm), those who had spontaneous closure of residual shunts (1.9 +/- 0.7 mm) and those with persistent residual shunts (2.0 +/- 0.9 mm). No association was identified between ductal angiographic type and outcome of coil occlusion. No late adverse clinical events of coil occlusion or evidence of recanalization was found. CONCLUSIONS: Small residual shunts are common after coil embolization of patent ductus arteriosus, but most close spontaneously. Actuarial analysis estimates complete closure in 94% at 20 months, and reintervention was required in only 7% of patients.

Actuarial Analysis↗