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PDA. Surgical closure.

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Hello Stefan and all the members!

I have a question about therapy of PDA. In Russia we have neither ibuprofen nor indomethacin, as official registered medication, up till now. That is why we can’t use them commonly. Generally, if we see the hemodynamicaly significant PDA, after some conservative cure, we close it surgically. I am interested how early we must operate? As example, the patient (1000 g, GA - 28W) was on the NCPAP after birth, than he was intubated. On the 2nd day diameter of the duct was 3,5 mm, La/Ao=1,6; on the 3d day(on HFOV) – diameter- 3,0 mm, LA/Ao=1,8. Should we wait for any age, more suitable for operation, not the first days of life? What is your experience?

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Dear Darya,

there's really a lot of opinions and experience about PDA, its diagnostic criteria and treatment, but I personally think it's not easy to get really good evidence-based strategies.

Maybe you could find some useful info in a very recent Cochrane-review about surgery vs indo: http://www.ncbi.nlm.nih.gov/pubmed/18254035

Interestingly, authors write

It is possible that the duration of the "waiting-time" and transport to another facility with surgical capacity to have the PDA ligated could adversely affect outcomes

suggesting that early surgery would be better than late surgery.

My personal opinion is that a drug is better than a knife. So, if you would get ibu or indo as treatment options, I would advocate that to be the primary treatment option. PDA (open) surgery, although a short procedure, is a major surgical trauma to a tiny infant, and can often be avoided when NSAIDs are initiated during first postnatal days.

With regard to the example above - it seems that the duct is wide-open (3 mm in a small infant), although the LA/Ao-ratio is not very high. It may be so that you still have elevated pulmonary resistance, keeping shunting volumes relatively low. My experience is also that LA/Ao-ratio is not easy to interpret when the baby is on HFOV, since the constantly elevated intrathoracic pressure has a similar effect on shunting. I would vote for PDA closure!

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Thank you very much, Stefan, for your consultation and link (our clinic hasn’t free access, but I read an abstract).

Our surgeons have closed the duct today, and it was really wide. We have a possibility to operate directly in NICU, without transportation.

You wrote:

"With regard to the example above - it seems that the duct is wide-open (3 mm in a small infant), although the LA/Ao-ratio is not very high"

But I read, that LA/Ao ratio > or =1.4 is a marker of significant PDA. Absolutely agree with you, that LA/Ao very difficult to interpret when the baby is on ventilation. Would you be so kind to tell me criteria of PDA significance, using in your hospital.

Thank you once more.

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I envy you doing PDA surgery in the NICU, we need to transport infants to the operating theatre.

LA/Ao-ratios... your right, 1.4 is what's considered to be the lower limit for enlargement. However, I personally think LA/Ao-ratio is somewhat difficult, depending on the angle of the ultrasound probe it is easy to mis-judge this ratio, especially in tiny patients.

When we do echoes (ourselves) we look try to look also for functional indications of shunting, such as diastolic velocity in the left pulm artery, doppler wave-form in the duct itself, and diastolic flow in postductal aorta.

I wished we used systemic venous return as a indication of shunting (see publications by NIck Evans & co-workers in Sydney, Australia).

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Dear Stefan!

We also do echoes ourselves and I’ve read about estimation of systemic venous return, but never do it. It’s time to try. And what do you think about evaluation of resistitive index in ACA as a marker of significant PDA? Do you use it routinely?

Thanks a lot for your patience and detailed replies.

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