Association for Academic Surgery
Patent ductus arteriosus ligation in premature infants in the United States

https://doi.org/10.1016/j.jss.2014.02.003Get rights and content

Abstract

Background

Patent ductus arteriosus (PDA) is a condition that commonly affects premature and low birth weight (BW) infants at times necessitating surgical intervention. We examined outcomes after surgical ligation (SL).

Materials and methods

We analyzed the Kids' Inpatient Database for premature infants diagnosed with PDA, admitted at <8 d of age. Patient demographics, disposition, morbidity, and mortality were analyzed. All cases were weighted appropriately to project nationally representative estimates.

Results

A total of 63,208 patients were identified with diagnosis of PDA. Of these, 6766 (10.7%) underwent SL. Lower gestational age (GA) and BW patients had higher incidence of PDA and rates of SL. Overall survival was 90.8% for the cohort. Survival for the SL group was 88.0% and 91.2% for the non-SL group; however, infants undergoing SL had higher survival rates up to 28 wk and 1250 g for GA and BW, respectively. GA did not affect post-SL survival adversely. Rather, lower BW was associated with extremely high mortality rates. Black infants and boys had lower survival compared with other races and girls, respectively. Larger hospitals had higher survival rates, but hospital location, teaching status, and type did not affect survival. Payer status and income quartile did not affect survival.

Conclusions

PDA and SL are more common in lower BW and GA groups. Higher survival rates are found for infants with SL versus non-SL in the lowest BW and GA groups. Morbidity and mortality are not affected by SL timing. BW, rather than GA, determines survival of infants undergoing SL.

Introduction

Patent ductus arteriosus (PDA) is found in approximately 57 of every 100,000 live term births in the United States [1]. With prematurity, the incidence rises dramatically as up to 65% of preterm (PT) infants born at <30 wk gestation with respiratory difficulty have been shown to have a PDA on the fourth day of life [2], [3]. Prematurity presents several challenges in an infant diagnosed with PDA. In comparison with term infants, those born prematurely have (1) physiological forces that promote patency of the ductus, (2) a higher incidence of comorbidities, including respiratory distress or congenital anomalies, and (3) are less likely to be optimal surgical candidates for a variety of reasons [4], [5]. Therefore, significant controversy surrounds the decision on whether to proceed with medical therapy or surgical ligation (SL), their respective timing, and whether to intervene at all [2], [6], [7], [8], [9], [10], [11].

Prolonged PDA has been associated with a wide range of complications, from bronchopulmonary dysplasia to necrotizing enterocolitis (NEC), and has raised questions regarding the optimal timing of SL, if indicated [6], [7], [8], [9]. Studies of clinical outcomes after SL have examined pneumothorax, vocal cord paralysis (VCP) due to recurrent laryngeal nerve injury, and mortality [5], [8], [9], [12], [13]. Thus far, studies have been based on institutional or multifacility treatment network cohorts with few exceptions [11], [13]. A recent investigation drawing from the US national experience has yet to be performed. This study represents the largest analysis describing clinical outcomes, including potential complications and risk-adjusted mortality, for premature infants diagnosed with PDA undergoing SL and non-SL therapy.

Section snippets

Materials and methods

The Kids' Inpatient Database (KID) was used to identify cases of premature infants diagnosed with PDA for this analysis. The KID is a national database sampling admissions of pediatric patients in the US available from the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Approximately 2–3 million admissions are included in each triennial release. The datasets included are derived from the 1997, 2000, 2003, 2006, and 2009 releases.

Infants with

Results

A total of 63,208 weighted cases were identified as diagnosed with PDA during the study period. Of these patients, 6766 (10.7%) underwent SL. Lower GA and BW patients had higher incidence of PDA and rates of SL, as evidenced by the positive skew (Fig. 1). Factors associated with SL were examined on bivariate analysis (Table 1). Infants born at lower BW, early GA (up to 30 wk), and those coded as extremely immature underwent SL at higher rates compared with higher BW, later GA, and PT birth,

Discussion

Since the first SL was performed by Robert E. Gross in 1938, the procedure has represented a definitive therapy for failed closure of PDA, either after medical therapy or spontaneous means [17]. However, the advent of improved medical therapies with anti-inflammatory agents, such as indomethacin and ibuprofen, introduced nonsurgical alternatives for effective PDA closure [18]. Trials of spontaneous closure or medical therapy are not without complications; however, as prolonged PDA has been

Conclusions

SL of PDA remains a controversial topic. The incidence of PDAs and the use of SL follow trends with extremely low BW and GA. However, survival rates were higher for infants undergoing SL in the lowest BW and GA groups compared with the non-SL group. This finding may act to clarify the need for prompt SL in infants born in the lowest BW and GA groups. Morbidity and mortality were not affected by SL timing. Survival is determined by BW, rather than GA, for infants undergoing SL. Thus, BW appears

Acknowledgment

Author contributions: J.T. contributed to conception and design, analysis and interpretation, data collection, writing the article. B.W. contributed to conception and design and critical revision of the article. J.E.S. contributed to conception and design, analysis and interpretation, and critical revision of the article. A.R.H. contributed to conception and design and critical revision of the article. H.L.N. contributed to conception and design and critical revision of the article. E.A.P

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