RESUMO
OBJECTIVE: To compare early routine pharmacologic treatment of moderate-to-large patent ductus arteriosus (PDA) at the end of week 1 with a conservative approach that requires prespecified respiratory and hemodynamic criteria before treatment can be given. STUDY DESIGN: A total of 202 neonates of <28 weeks of gestation age (mean, 25.8 ± 1.1 weeks) with moderate-to-large PDA shunts were enrolled between age 6 and 14 days (mean, 8.1 ± 2.2 days) into an exploratory randomized controlled trial. RESULTS: At enrollment, 49% of the patients were intubated and 48% required nasal ventilation or continuous positive airway pressure. There were no differences between the groups in either our primary outcome of ligation or presence of a PDA at discharge (early routine treatment [ERT], 32%; conservative treatment [CT], 39%) or any of our prespecified secondary outcomes of necrotizing enterocolitis (ERT, 16%; CT, 19%), bronchopulmonary dysplasia (BPD) (ERT, 49%; CT, 53%), BPD/death (ERT, 58%; CT, 57%), death (ERT,19%; CT, 10%), and weekly need for respiratory support. Fewer infants in the ERT group met the rescue criteria (ERT, 31%; CT, 62%). In secondary exploratory analyses, infants receiving ERT had significantly less need for inotropic support (ERT, 13%; CT, 25%). However, among infants who were ≥26 weeks gestational age, those receiving ERT took significantly longer to achieve enteral feeding of 120 mL/kg/day (median: ERT, 14 days [range, 4.5-19 days]; CT, 6 days [range, 3-14 days]), and had significantly higher incidences of late-onset non-coagulase-negative Staphylococcus bacteremia (ERT, 24%; CT,6%) and death (ERT, 16%; CT, 2%). CONCLUSIONS: In preterm infants age <28 weeks with moderate-to-large PDAs who were receiving respiratory support after the first week, ERT did not reduce PDA ligations or the presence of a PDA at discharge and did not improve any of the prespecified secondary outcomes, but delayed full feeding and was associated with higher rates of late-onset sepsis and death in infants born at ≥26 weeks of gestation. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01958320.
Assuntos
Acetaminofen/uso terapêutico , Tratamento Conservador , Inibidores de Ciclo-Oxigenase/uso terapêutico , Permeabilidade do Canal Arterial/terapia , Ibuprofeno/uso terapêutico , Indometacina/uso terapêutico , Pressão Positiva Contínua nas Vias Aéreas , Permeabilidade do Canal Arterial/classificação , Feminino , Idade Gestacional , Humanos , Lactente Extremamente Prematuro , Recém-Nascido , Masculino , Estudos Prospectivos , Método Simples-Cego , Resultado do TratamentoRESUMO
Transcatheter closure of arterial duct (AD) remains challenging in low-weight patients and using Amplatzer Duct Occluder devices is still considered off-label in infants < 6 kg. This study aimed to report a large, single-center experience of percutaneous AD closure in infants < 6 kg as well as to compare the most frequently used devices, Amplatzer Duct Occluder type I (ADO I) and Amplatzer Duct Occluder type II Additional Sizes devices (ADO II-AS) (St. Jude Medical Corp, St. Paul, MN, USA). From March 2000 to March 2017, among the 762 patients submitted to percutaneous closure of AD at our Institution, 33 were infants < 6 kg (age 4.8 ± 2.1 months; weight 5.0 ± 0.9 kg). Fourteen patients (45%) underwent ADO I (Group I) and 19 patients ADO II-AS (Group II) device implantation. AD diameter was 2.6 ± 0.8 (range 1.5-4.0) mm resulting in QP/QS of 2.6 ± 0.0.9 (range 1.1-4.5). Successful device deployment was achieved in all patients without procedural morbidity or mortality. Procedural and fluoroscopy times were not significantly different between the groups. However, total X-ray absorbed dose was significantly higher in Group I (121 ± 69 vs 29 ± 16 mGy/cm2, p < 0.01). Immediate, 24 h, and mid-term (46 ± 37 months, median 39) complete occlusion were recorded in 72.7, 90.9, and 97% of patients, respectively without significant difference between the groups. In conclusion, transcatheter closure of AD with Amplatzer Duct Occluder devices is feasible, safe, and effective also in infants less than 6 kg, without significant difference between the most commonly used devices, namely, ADO I and ADO II-AS.
Assuntos
Cateterismo Cardíaco/instrumentação , Permeabilidade do Canal Arterial/cirurgia , Dispositivo para Oclusão Septal , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Feminino , Fluoroscopia , Humanos , Lactente , Recém-Nascido de Baixo Peso , Masculino , Desenho de Prótese , Radiografia , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to describe and differentiate the morphology of patent ductus arteriosus (PDA) seen in children born prematurely from other PDA types. BACKGROUND: PDAs are currently classified as types A-E using the Krichenko's classification. Children born prematurely with a PDA morphology that did not fit this classification were described as Type F PDA. METHODS: A review of 100 consecutive children who underwent transcatheter device closure of PDA was performed. The diameter and length (L) of the PDA and the device diameter (D) were indexed to the descending aorta (DA) diameter. RESULTS: Comparison of 26 Type F PDAs was performed against, 29 Type A, 7 Type C and 32 Type E PDAs. Children with Type F PDAs (median 27.5 weeks gestation) were younger during the device occlusion compared with types A, C, and E (median age: 6 vs. 32, 11, and 42 months; P = 0.002). Type F PDAs were longer and larger, requiring a relatively large device for occlusion than types A, C, and E (Mean L/DA: 1.88 vs. 0.9, 1.21, and 0.89, P ≤ 0.01 and Mean D/DA: 1.04 vs. 0.46, 0.87, and 0.34, P ≤0.01). The Amplatzer vascular plug-II (AVP-II) was preferred for occlusion of Type F PDAs (85%; P <0.001). CONCLUSIONS: Children born prematurely have relatively larger and longer PDAs. These "fetal type PDAs" are best classified separately. We propose to classify them as Type F PDAs to add to types A-E currently in use. The AVP-II was effective in occluding Type F PDAs.
Assuntos
Aortografia , Cateterismo Cardíaco/instrumentação , Permeabilidade do Canal Arterial/diagnóstico , Canal Arterial/diagnóstico por imagem , Ecocardiografia Doppler em Cores , Recém-Nascido Prematuro , Dispositivo para Oclusão Septal , Criança , Pré-Escolar , Canal Arterial/anormalidades , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/terapia , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Masculino , Seleção de Pacientes , Valor Preditivo dos Testes , Desenho de Prótese , Estudos Retrospectivos , Terminologia como Assunto , Resultado do TratamentoRESUMO
OBJECTIVE: To categorise records according to primary cardiac diagnosis in the United Kingdom Central Cardiac Audit Database in order to add this information to a risk adjustment model for paediatric cardiac surgery. DESIGN: Codes from the International Paediatric Congenital Cardiac Code were mapped to recognisable primary cardiac diagnosis groupings, allocated using a hierarchy and less refined diagnosis groups, based on the number of functional ventricles and presence of aortic obstruction. SETTING: A National Clinical Audit Database. Patients Children undergoing cardiac interventions: the proportions for each diagnosis scheme are presented for 13,551 first patient surgical episodes since 2004. RESULTS: In Scheme 1, the most prevalent diagnoses nationally were ventricular septal defect (13%), patent ductus arteriosus (10.4%), and tetralogy of Fallot (9.5%). In Scheme 2, the prevalence of a biventricular heart without aortic obstruction was 64.2% and with aortic obstruction was 14.1%; the prevalence of a functionally univentricular heart without aortic obstruction was 4.3% and with aortic obstruction was 4.7%; the prevalence of unknown (ambiguous) number of ventricles was 8.4%; and the prevalence of acquired heart disease only was 2.2%. Diagnostic groups added to procedural information: of the 17% of all operations classed as "not a specific procedure", 97.1% had a diagnosis identified in Scheme 1 and 97.2% in Scheme 2. CONCLUSIONS: Diagnostic information adds to surgical procedural data when the complexity of case mix is analysed in a national database. These diagnostic categorisation schemes may be used for future investigation of the frequency of conditions and evaluation of long-term outcome over a series of procedures.
Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Bases de Dados Factuais , Cardiopatias Congênitas/cirurgia , Garantia da Qualidade dos Cuidados de Saúde/métodos , Adolescente , Algoritmos , Criança , Pré-Escolar , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/epidemiologia , Permeabilidade do Canal Arterial/cirurgia , Feminino , Cardiopatias Congênitas/classificação , Cardiopatias Congênitas/epidemiologia , Comunicação Interventricular/classificação , Comunicação Interventricular/epidemiologia , Comunicação Interventricular/cirurgia , Humanos , Lactente , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Prevalência , Medição de Risco , Tetralogia de Fallot/classificação , Tetralogia de Fallot/epidemiologia , Tetralogia de Fallot/cirurgia , Reino Unido/epidemiologiaRESUMO
OBJECTIVE: Patent ductus arteriosus (PDA) is common in preterm infants and is associated with significant morbidities. B type natriuretic peptide (BNP) is synthesized in the ventricles secondary to volume overload and excreted as urinary N-terminal pro-brain natriuretic peptide (NT-proBNP). STUDY DESIGN: We report an observational prospective study of 64 preterm infants with birth weight ⩽1000 g. Echocardiographic parameters were obtained from clinical echocardiograms performed in the first week of life. Urinary NT-proBNP/creatinine ratios (pg mg-1) were measured on the same day of the echocardiograms. RESULTS: Infants with medium to large PDA (n=39) had significantly higher NT-proBNP/creatinine levels compared with infants with small PDA (n=10) (median (IQ range): 2333 (792-6166) vs 714 (271-1632) pg mg-1, P=0.01) and compared with infants with no PDA (n=15) (2333 (792-6166) vs 390 (134-1085) pg mg-1, P=0.0003). Urinary NT-proBNP/creatinine ratios were significantly lower post treatment if PDA closed (n=17), P=0.001 or if PDA became smaller after treatment (n=9), P=0.004. Urinary NT-proBNP/creatinine levels correlated with ductal diameter (P⩽0.0001), but not with LA/Ao ratio (P=0.69) or blood flow velocity through the ductus (P=0.06). CONCLUSION: Our findings indicate that there is a positive correlation between ductal diameter and urinary NT-proBNP in preterm infants.
Assuntos
Permeabilidade do Canal Arterial/patologia , Ecocardiografia Doppler em Cores/métodos , Peptídeo Natriurético Encefálico/urina , Fragmentos de Peptídeos/urina , Biomarcadores/urina , Creatinina/urina , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Humanos , Lactente , Recém-Nascido de Baixo Peso , Tamanho do Órgão , Curva ROC , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: This study was performed to determine the frequency of patent ductus arteriosus (PDA) reopening and the factors that may predict reopening after successful coil occlusion. BACKGROUND: Transcatheter coil occlusion is a widely used and accepted method to close a PDA. After documented successful coil occlusion, we found PDAs that reopened. We hypothesized that specific factors are involved in those that reopened. METHODS: All patients who underwent percutaneous transarterial PDA coil occlusion were studied. Successful coil occlusion was documented. PDA reopening was determined when Doppler-echocardiography (DE) performed after the procedure was negative for PDA flow but at follow-up demonstrated PDA shunting. Patients with a reopened PDA were compared with all other patients in evaluating independent variables. RESULTS: Coil occlusion for PDA was attempted in 22 patients. Clinical success was achieved in 20 patients (91%), and DE was negative for PDA shunting in 19 patients (90%). At follow-up, five patients demonstrated reopening. The PDA minimal diameter was 1.4 +/- 0.5 mm (mean +/- SD) for the reopened group and 1.2 +/- 0.7 mm for the other patients. The PDA length was 2.9 +/- 1.9 mm for the reopened group and 7.1 +/- 3.2 mm for all other patients. All those with type B PDA were in the reopened group. When independent variables were compared between groups, only PDA length and type B PDA predicted reopening (p < 0.05). CONCLUSIONS: PDA reopening may occur after successful coil occlusion. Short PDA length and type B PDA are associated with reopening. The data suggest that in such anatomy, alternative strategies to the current coil occlusion technique should be considered.
Assuntos
Permeabilidade do Canal Arterial/terapia , Embolização Terapêutica/instrumentação , Adolescente , Aorta Torácica/diagnóstico por imagem , Aortografia , Cateterismo Cardíaco , Criança , Pré-Escolar , Cinerradiografia , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Permeabilidade do Canal Arterial/patologia , Ecocardiografia Doppler , Seguimentos , Previsões , Humanos , Incidência , Lactente , Modelos Logísticos , Recidiva , Fatores de Risco , Resultado do TratamentoRESUMO
A rare window type of patent ductus arteriosus is reported that was large (15 mm in maximal transverse dimension) but had virtually no length and hence was externally invisible. The smaller aortic isthmus (4 mm in diameter), which was intrapericardial, was mistaken for the ductus and was inadvertently clip-occluded, leading to death. After a specific diagnosis is made, the large window ductus should be patched on cardiopulmonary bypass with a transpulmonary approach.
Assuntos
Permeabilidade do Canal Arterial/classificação , Aorta Torácica/anormalidades , Aorta Torácica/cirurgia , Ponte Cardiopulmonar , Constrição , Coração Triatriado/cirurgia , Vasos Coronários/cirurgia , Permeabilidade do Canal Arterial/patologia , Permeabilidade do Canal Arterial/cirurgia , Evolução Fatal , Comunicação Interatrial/cirurgia , Humanos , Hipertensão Pulmonar/cirurgia , Lactente , Masculino , Pericárdio/patologia , Pericárdio/cirurgia , Artéria Pulmonar/anormalidades , Artéria Pulmonar/cirurgia , Veia Cava Superior/anormalidades , Veia Cava Superior/cirurgiaRESUMO
The paper deals with the diagnosis of defective development of the patent ductus atrioventricularis. Electrocardiographic changes in 81 patients with firmly established hemodynamic form of the patent ductus atrioventricularis, ascertained during surgery and catheterization, are summarized. Characteristic electrocardiographic signs of the defect distinguishing it from other congenital diseases and differential-diagnostic symptoms of diverse anatomo-hemodynamic forms of the patent ductus atrioventricularis were educed.
Assuntos
Permeabilidade do Canal Arterial/diagnóstico , Eletrocardiografia , Adolescente , Adulto , Criança , Pré-Escolar , Diagnóstico Diferencial , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/complicações , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/diagnóstico , Comunicação Interventricular/complicações , Comunicação Interventricular/diagnóstico , Humanos , Lactente , Masculino , Valva Mitral/anormalidades , Valva Tricúspide/anormalidadesRESUMO
BACKGROUND: Outcomes after surgical ligation of patent ductus arteriosus (PDA) in preterm infants are often complicated by prematurity associated comorbidities. The Aristotle comprehensive complexity score (ACCS) has been proposed as a useful tool for complexity adjustment in the analysis of outcome after congenital heart surgery. The aims of this study were to define preoperative risk factors for mortality and to demonstrate the usefulness of ACCS to predict mortality after surgical ligation of PDA in the preterm. METHODS: Included were 49 preterm babies (≤35 weeks of gestation) who had surgical ligation of PDA between May 2009 and July 2012. Median gestational age was 27.6 weeks (range, 23 to 35 weeks) and median birth weight was 1,040 g (range, 520 to 2,280 g). Median age at operation was 15 days (range, 4 to 44 days) and median weight was 1,120 g (range, 400 to 2,880 g). Initial oral ibuprofen was ineffective in 24 patients and contraindicated in 25. All surgical ligations were done at bedside in the neonatal intensive care unit. Preoperative clinical and laboratory profiles were reviewed and ACCS was derived. RESULTS: Eight of 49 patients (16.3%) died at a median of 14 days (range, 2 to 73 days) after PDA ligation. Patients who had contraindications for oral ibuprofen (odds ratio [OR] 8.94; p=0.049), coagulopathy (OR 12.13; p=0.025), renal dysfunction (OR 28.88; p=0.003), intraventricular hemorrhage greater than grade II or seizure (OR 34.00; p=0.002), and ACCS points (OR 29.594; p<0.05) were significantly associated with an increased risk for mortality. Among the risk factors, ACCS showed the largest area under curve (0.991) by receiver-operating characteristic curve analysis. Optimal cutoff value of ACCS for mortality were 15 or greater, with sensitivity of 87.5%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 97.6%. CONCLUSIONS: The ACCS, especially for procedure-independent complexity factors, is a useful tool to predict mortality after ligation of PDA in preterm infants.
Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/normas , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/cirurgia , Mortalidade Hospitalar/tendências , Recém-Nascido Prematuro , Análise de Variância , Causas de Morte , Estudos de Coortes , Permeabilidade do Canal Arterial/mortalidade , Educação Médica Continuada , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Ligadura/métodos , Modelos Logísticos , Masculino , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: Identify echocardiographic parameters at Assuntos
Permeabilidade do Canal Arterial/diagnóstico por imagem
, Recém-Nascido de Peso Extremamente Baixo ao Nascer
, Índice de Gravidade de Doença
, Permeabilidade do Canal Arterial/classificação
, Idade Gestacional
, Humanos
, Recém-Nascido
, Masculino
, Valor Preditivo dos Testes
, Fluxo Sanguíneo Regional
, Estudos Retrospectivos
, Ultrassonografia
Assuntos
Cardiopatias Congênitas/classificação , Artéria Pulmonar/anormalidades , Angiocardiografia , Autopsia , Cateterismo Cardíaco , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/complicações , Cardiopatias Congênitas/complicações , Humanos , Circulação PulmonarAssuntos
Permeabilidade do Canal Arterial/patologia , Miocárdio/patologia , Adolescente , Adulto , Fatores Etários , Aorta/patologia , Cardiomegalia/complicações , Cardiomegalia/patologia , Criança , Pré-Escolar , Anormalidades Congênitas/complicações , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/cirurgia , Feminino , Átrios do Coração/patologia , Cardiopatias Congênitas/complicações , Comunicação Interventricular/complicações , Comunicação Interventricular/patologia , Valvas Cardíacas/patologia , Ventrículos do Coração/patologia , Humanos , Lactente , Recém-Nascido , Masculino , Artéria Pulmonar/patologia , Circulação Pulmonar , Fatores Sexuais , Valva Tricúspide/patologiaRESUMO
BACKGROUND: Coil occlusion of patent ductus arteriosus (PDA) is now widely accepted as the first-line treatment, but there are few reports of age-dependent differences in the complications associated with this technique. METHODS AND RESULTS: Sixteen patients (11 adults, 5 children) with a PDA larger than 3 mm, who underwent coil occlusion at Sapporo Medical University Hospital between September 1995 and August 2004, were enrolled. Immediate and intermediate outcomes and complications were analyzed. Procedural success rate was 72.7% (8/11) in the children and 100% (5/5) in the adults. Coil migration occurred in 4 children and 1 adult, and 3 adult patients had hemolysis. CONCLUSION: Hemolysis was more frequent in adults than in children even though the residual shunt was trivial.
Assuntos
Oclusão com Balão , Permeabilidade do Canal Arterial/terapia , Hemólise , Idoso , Oclusão com Balão/efeitos adversos , Oclusão com Balão/métodos , Criança , Pré-Escolar , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/complicações , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-IdadeRESUMO
A persisting ductus arteriosus (PDA) was closed with the Rashkind occlusion system in 15 patients (12 children, aged 1.0 to 10.8 years, and three adults, aged 21, 33 and 56 years). The method consists of the implantation of a double umbrella of polyurethane foam mounted on platinum or steel wire introduced into the PDA via a transport catheter, the ductus being closed by thrombosing and epithelialization of the implant. The mean diameter of the PDA (as measured in the lateral aortogram) was 2.4 (1.4-5.3) mm. There were no complications of the procedure, nor any embolization or other serious complications. The PDA was completely occluded in eight patients, while a residual shunt remained in seven. In the oldest patient, aged 56 years, who had a residual shunt, increasing haemolysis required surgical closure of the ductus with a pericardial patch. These results indicate that, for patients weighing over 5 kg and with a ductus diameter of less than 10 mm, the closure method after Rashkind is a sparing and only slightly invasive procedure.
Assuntos
Cateterismo Cardíaco/métodos , Permeabilidade do Canal Arterial/terapia , Próteses e Implantes , Adulto , Anemia Hemolítica/etiologia , Criança , Pré-Escolar , Permeabilidade do Canal Arterial/classificação , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Próteses e Implantes/efeitos adversos , Desenho de PróteseRESUMO
We successfully closed the isolated patent ductus arteriosus in 58 of 61 consecutive patients using the transfemoral-catheter method originally introduced by Porstmann in 1968. To perform this technique more safely and reliably, some instrumental and technical improvements were made. The indications for this method have been expanded to include the cylindrical or window-type ductus as well as the conical-shaped ductus. Classification into three groups of the configuration of the ductus by angiography has been useful in selecting the shape of the closing plug. Whenever feasible, we consider the catheter technique to be the method of choice to close the ductus.
Assuntos
Cateterismo Cardíaco/métodos , Permeabilidade do Canal Arterial/cirurgia , Artéria Femoral , Próteses e Implantes/métodos , Adolescente , Adulto , Aortografia , Criança , Pré-Escolar , Permeabilidade do Canal Arterial/classificação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , PlásticosRESUMO
UNLABELLED: Postnatally, therapeutic indomethacin administration is usually effective in mediating patent ductus arteriosus (PDA) constriction in premature infants. There are infants, however, who remain resistant to indomethacin and require more aggressive surgical intervention to facilitate ductal closure. Indomethacin tocolysis has been reported to increase the incidence of persistent PDA in premature infants. It was our impression that infants exposed to antenatal indomethacin not only suffered from an increased incidence of PDA, but that they were more symptomatic from PDA and that for them, PDA was more resistant to medical closure. It is this observation that we sought to examine in this study. METHODS: Medical records of all mothers and premature neonates with birth weight =1500 g, admitted to the neonatal intensive care unit of the Shaare Zedek Medical Center during 1996 and 1997, who survived for at least 1 week, were reviewed retrospectively. Data on maternal indomethacin and steroid exposure, birth weight and gestational age, and ductus status and treatment were analyzed. In our obstetrics department, indomethacin is the medication of choice to inhibit premature labor. Mothers who arrive in premature labor are started on indomethacin therapy, if delivery is not imminent. All infants =1500 g were studied by a pediatric cardiologist between 24 and 72 hours of life using two-dimensional echocardiography with color flow mapping to assess ductal patency. Decisions to treat were based on echocardiographic evidence of PDA, along with any of the following clinical signs: bounding pulses, diastolic pressure of =25 mm Hg, pulmonary plethora and/or cardiomegaly on chest x-ray, or increasing oxygen requirement with no other explanation. Initial treatment is with indomethacin, if there are no contraindications. Our general approach is to begin therapy with a continuous indomethacin infusion, followed by a course of bolus indomethacin if the infant does not respond. However, each attending neonatologist may treat according to his/her preference (ie, bolus vs continuous). All infants with PDA are followed with serial echocardiographic examinations until the ductus is closed. RESULTS: A total of 105 premature infants met the above criteria. Thirty-six of these 105 infants had echocardiographic signs of a PDA (34.3%). Those with PDA were less mature (gestational age, 28.9 +/- 2.6 vs 30.3 +/- 2.6 weeks, respectively) and tended to be smaller (1060 +/- 270 vs 1166 +/- 261 g). Of the 36 infants with PDA, 15 (42%) resolved spontaneously and 21 (58%) were symptomatic and required treatment with indomethacin. There were no differences in gestational age or birth weight between infants whose PDA resolved spontaneously and those requiring indomethacin therapy. Four of the 21 (19%) treated infants remained unresponsive to indomethacin and required ductal ligation. Of 17 infants with PDA who responded to indomethacin therapy, 1 (6%) was treated with a single course of bolus indomethacin, to which he responded, and 16 (94%) were treated with continuous indomethacin and responded promptly. The differences in therapeutic responsiveness to initial treatment with continuous vs bolus indomethacin were not significant. Of the 105 infants, 29 were exposed to indomethacin tocolysis. Those who were exposed to antenatal indomethacin and those who were not were well-matched with respect to birth weight and gestational age. Fifteen (52%) of the 29 exposed infants versus 18 (24%) of the 76 infants not exposed to antenatal indomethacin developed a PDA postnatally (relative risk = 2.1; 95% confidence interval: 1.22-3.74), and 45% of the antenatally exposed infants versus 12% of the nonexposed infants were symptomatic and required indomethacin (relative risk = 1.9; 95% confidence interval: 1.17-3.20). Four of the exposed infants versus none of the unexposed infants required surgical ligation. (ABSTRACT TRUNCATED)