**8. Highlights of transcatheter PDA closure**


*Update on Critical Issues on Infant and Neonatal Care*

gestation [24–26].

dard of care.

**7.2 Surgical ligation**

is not possible [12].

**7.3 Transcatheter therapy**

even among ELBW infants.

indomethacin, ibuprofen, or acetaminophen in varying dosages. The two most common options are intravenous standard doses of indomethacin and ibuprofen. In 2018, a meta-analysis of 68 RCT of 4802 infants found that among all preterm infants <37 weeks gestation, the overall PDA closure rate with one of the above treatment modalities was 67%. Oral ibuprofen was the most effective treatment, and none of the treatments increased the risk of mortality, NEC, or IVH compared to placebo or no treatment controls [25]. Slower absorption rates and a longer half-life of oral ibuprofen may increase the time of contact with the PDA, possibly explaining its improved effectiveness over intravenous routes [25]. The effectiveness of medical therapy is at best 50–70% and lower for those <32 weeks

Conservative management without the use of pharmacotherapeutics has become a recent trend in management of the PDA [16, 22]. Because many preterm infants will spontaneously close the ductus within the first week, early routine treatment with pharmacological therapy may not offer any benefit. Targeted therapy towards hsPDA based on clinical and echocardiographic thresholds is becoming the stan-

Surgical ligation through a limited left thoracotomy, although invasive, offers

Transcatheter PDA closure (TCPC) is a minimally invasive therapy associated with low rate of adverse events that has become the procedure of choice for children >5 kg [29]. Historically, transcatheter closure of PDA has not been performed in premature neonates for a variety of reasons including: fear of patient fragility, concerns regarding vascular access and arterial injury, unknown effects of intravenous contrast media, concerns regarding catheter manipulation, and most importantly, absence of a suitable PDA closure device. Recently, a growing body of clinical evidence has emerged suggesting that transcatheter closure of PDA can be performed safely and effectively in premature infants [24, 30]. Risks of transcatheter therapy include embolization requiring surgery, cardiac perforation, aortic coarctation, and LPA obstruction, however these risks are very low

definitive, immediate closure of the PDA. Robert Gross performed the first successful PDA surgical ligation at Children's Hospital of Boston in 1939 while his chief was out of town. While surgical ligation carries minimal risk of mortality, other risks include pneumothorax, recurrent laryngeal nerve paralysis, chylous effusions, and post-ligation syndrome [12, 24, 26, 27]. Post-ligation syndrome occurs in the first 6–24 h in approximately 30% of neonates who undergo surgical ligation; neonates experience hypotension, which in some cases may be resistant to catecholamines, as a result of changes in myocardial function and impaired vascular tone [20, 21]. Long term complications such as thoracic scoliosis and neurosensory impairment have been reported in some cases following surgical ligation [24, 26, 27]. Only one trial has compared surgical ligation to nonintervention and found that infants undergoing ligation required longer ventilation, oxygen therapy, and hospitalization than control subjects, although differences did not reach statistical significance [28]. Even so, surgical ligation may still be desirable in infants for whom medical therapy has failed and transcatheter closure

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