Hello everyone! I'd love to hear your thoughts on the management of hemodynamically significant patent ductus arteriosus (PDA). This new article and its recommendations have left me with many questions.

before the releae of these news recommendation , in our service, we only treat hemodynamically significant PDA within the first 7 days of life, primarily in patients under 28 weeks' gestational age. We know that the efficacy of medical treatment drops significantly after this age. Our approach is to opt for surgery only if the PDA doesn't close after two series of medical treatment, and we try not to delay the surgical intervention too much.

I'm very interested in learning about your management strategies.

jamapediatrics_buvaneswarran_2025_oi_250021_1747406474.87605.pdf

During the latest 99nicu Meetup, we had this session, enjoy!

Perfect, thanx Stefan!

Our approach is somewhat similar but we consider the hemodynamic parameters rather than gestational age or postnatal age. We have had no surgical ligatüions in the past 3 years.

Thank you all for your input on this topic. My question revolves around the current guidelines and practices for pharmacological closure of a patent ductus arteriosus (PDA).

We understand that prophylactic, early, or asymptomatic pharmacological closure offers no benefit and can even be detrimental. However, recent meta-analyses suggest that treating a PDA with hemodynamic clinical signs before 14 days of life increases both mortality and the risk of bronchopulmonary dysplasia.

This evidence seems to point towards a scenario where pharmacological closure might never be indicated.

Given this, I'm curious: In your units, what is your approach when managing an infant under 28 weeks of gestational age , specifically between 3 and 14 days of life, who presents with both echocardiographic evidence and clinical signs of a hemodynamically significant PDA (hsPDA)?

It feels like the current data leaves us in a challenging position regarding the optimal timing and indication for pharmacological intervention. Any insights into your unit's protocols or recent experiences would be greatly appreciated.

I also feel a bit frustrated about no-mans-land we may end up in with PDA questions... There are more data on what-not-to-do, than about what-to-do!

Regarding your specific question, a common take would probably be along the lines of the recent AAP Clinical Report (link here), to wait and until the infants is >2 weeks of age. And, then go for pharmacological closure attempt, especially if <28 weeks, on invasive ventilation and with clear echocardiographic signs of cardiac load. Very few surgical ligation are done in Sweden nowadays (as compared to the less good "good old days")

BTW, there is a new national PDA guideline to be launched in Sweden, hope to share a translation here once it is published!

This is my personal approach:

If a baby remains on invasive ventilation with a hsPDA, and high peak inspiratory pressures (PIPs) are required to achieve adequate tidal volumes despite relatively low oxygen requirements (FiO₂ <40%), I tend to initiate treatment for the duct. I also generally opt to close the PDA before starting systemic steroids, particularly if there are signs of feeding intolerance or if steroid therapy is being considered for evolving BPD.

However, I remain conflicted regarding the role of prophylactic PDA closure, particularly in a specific subset of extremely preterm infants—those born at <26 weeks’ gestation and weighing <500 grams. This group appears particularly vulnerable to pulmonary haemorrhage within the first 72 hours of life. I have witnessed several such infants deteriorate rapidly, ventilated or not, following pulmonary haemorrhage and, unfortunately, some do not survive. This experience continues to shape my cautious stance on routine early treatment in this population.

My approach is… table 1- table 2

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Souvik Mitra ,

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3 Audrey Hébert,4 Michael Castaldo,1 Tim Dishe

My approach is… table 1- table2bmjopen-14-7.pdf