Background: Surgical ligation of patent ductus arteriosus (PDA) is an invasive procedure that associated with neonatal mortality and bronchopulmonary dysplasia (BPD). Currently, the stepwise management of hemodynamic significant PDA (hsPDA) and the optimal timing to perform surgical ligation after failed first-line medication are still unclear.
Objective: To compare short-term outcomes between early and late surgical PDA ligation after failed medical closure with indomethacin in very preterm infants.
Methods: This retrospective cohort study was conducted at Chiang Mai University Hospital, Thailand in VLBW (< 1500 grams) preterm infants who were born before 32-week gestational age (GA) and underwent surgical PDA ligation after failed indomethacin between January 2006 and December 2018. The patients who had congenital anomalies were excluded. We divided our subjects into two groups according to the timing of surgery after starting indomethacin: early (within 21 days) and late (after 21 days) ligation group. Baseline characteristics and outcomes during hospitalization between two groups were analyzed and compared. Multi-variated logistic regression analysis were performed to evaluate risk factors associated with overall mortality and/ or severe BPD.
Results: A total of 70 preterm infants were enrolled. The mean of GA and birth weight were 27.6±2.3 weeks, 888.7±216.3 grams, respectively. Forty-eight (68.6%) patients were in the early ligation group and twenty-two (31.4%) patients were in the late ligation group. The baseline characteristics were not statistically significant between two groups in terms of GA, birth weight, gender and co-morbidities including respiratory distress syndrome, hypotension, and culture-proven sepsis. There were more patients required ventilator support before surgery (91.7% VS 68.2%, p-value=0.029) and higher overall mortality rate (16.7% VS 0%, p-value=0.050) in the early ligation group. The multi-variated logistic regression analysis demonstrated that delayed PDA ligation significantly decreased the overall mortality and/ or severe BPD (adjusted OR = 0.29, 95% CI= 0.08-0.98).
Conclusion: Extension of surgical PDA ligation to more than 21 days after starting medical closure with indomethacin had better in-hospital outcomes for very preterm infants.
Keywords: patent ductus arteriosus, ligation, very preterm, mortality, bronchopulmonary dysplasia
