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Establishing a Robust Transcatheter PDA Closure Program for Extremely Low Birth Weight Infants

By Shyam Sathanandam, MD; Leah Apalodimas, MSN, APN, CCRN, CPNP; Mark Weems, MD; B. Rush Waller, MD; Ranjit Philip, MD

Introduction

Extremely Low Birth Weight (ELBW) infants (weight <1kg at birth) frequently present with a large, hemodynamically significant Patent Ductus Arteriosus (PDA).1 The PDA in ELBW infants can contribute to worse outcomes.2-4 However, there are no management algorithms that exist for ELBW infants with a hemodynamically significant PDA. Established treatment options include the administration of cyclooxygenase (COX) inhibitors and surgical ligation of the PDA (SLP) via a thoracotomy. COX-inhibitors are not always effective.5-7 SLP has not been shown to positively impact survival.5,7-9 Procedural complications and long-term sequelae7-9 have made this option less attractive. There is also a general belief that treatment of the PDA beyond the first few weeks of life in the ELBW infants may not significantly alter outcomes.1,3,5-6 This has led to a practice of a trial of medical therapy in the first 2-3 weeks of life, and if unsuccessful, no further intervention is sought.2-3, 6-7 Many neonates continue to languish with a large, hemodynamically significant PDA on a ventilator with evolving Chronic Lung Disease (CLD) and Pulmonary Hypertension (PHT).

Transcatheter PDA closure (TCPC) is the established mode of treatment for PDAs in children >5 kg.10. TCPC in ELBW infants is slowly being implemented by many centers.11-13 Advantages of TCPC in ELBW newborns include immediate PDA closure compared to several days to weeks until closure with medications,11-12 and that TCPC is less invasive than SLP.11-12 Despite these perceived advantages, TCPC does not feature in the current treatment algorithm for PDA in the ELBW newborn. The challenges that prevent this therapy from becoming readily available to this population of patients include: a general concern for any procedural adverse events in extremely small babies, need for miniaturizing catheters and devices required for TCPC, concern of transporting the patient to a different environment for the procedure, use of radiation and contrast to perform TCPC, and lack of awareness of the availability of TCPC as a treatment option for ELBW newborns, among others. The aim of this report is to describe how we established a robust TCPC program for ELBW infants.

To read the full article, please go to the March 2018 Issue of CCT, where it was originally published.

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