Study On Risk Factors Associated With Failed Closure Of Ductus Arteriosus In Preterm Infants And Perioperative Management

BackgroundHemodynamically significant patent ductus arteriosus(hsPDA)has been a challenging and controversial problem in the management of very-low-birth-weight(VLBW)and extremely-low-birth(ELBW).It is associated with increasing mortality,severe cardiopulmonary dysfunction,and harmful long-term outcomes.Most of VLBW and ELBW infants with hsPDA require pharmacological treatment or surgical ligation,with pharmacological management focusing on promoting successful closure and postoperative management focusing on reducing post-ligation cardiac syndrome(PLCS),as PLCS increases the risk of death and adverse long-term outcomes.The first part of this study is to assess the risk factors associated with failed closure of PDA following pharmacological treatment,and to explore the clinical predictive model of unsuccessful closure of PDA.The second part of this study is to evaluate the hemodynamic changes in VLBW infants following PDA ligation and assess factors influence these changes,and to explore the impact of early targeted hemodynamic monitoring guide postoperative management on postoperative outcomes.Part Ⅰ:The risk factors associated with failed closure of PDA following pharmacological treatment in VLBW infantsObjectiveTo investigate the risk factors associated with failed closure of PDA following pharmacological treatment in VLB W infants.MethodsThis was a retrospective review of a cohort of VLB W with hs PDA between January,2010 and December,2020.Perinatal factors,pharmacological treatment and echocardiographic data were included in the univariate and multivariate generalized estimating equation analysis and final model was selected using backward elimination method,and predictability was assessed using the area under the ROC curve(AUC).ResultA total of 243 VLBW infants with hsPDA were involved,including 161 infants with PDA successfully closed following pharmacological treatment,and 82 infants with failed closure and required secondary ligation.The included infants had a gestational age of 29.08±1.69 weeks and a birth weight of 1.15±0.22kg.Multivariate analysis showed that cesarean section(OR 220,P=0.02),multiple pharmacological courses(OR 1.62,P=0.04,AUC 0.651),a larger PDA diameter(OR 2.17,P<0.001,AUC 0.732)and a larger left atrial-to-aortic dimension ratio(OR 2.98,P=0.02,AUC 0.722)were significant risk factors for secondary ligation.Conclusion:Cesarean section multiple pharmacological courses,a larger PDA diameter,and a larger left atrial-to-aortic dimension ratio were associated with unsuccessful closure of PDA after pharmacological treatment A larger PDA diameter(>3 mm/kg)and a larger left atrial-to-aortic dimension ratio(>2)might be predictors for unsuccessful closure of PDA following pharmacological treatment in VLB W infants with hsPDAPart Ⅱ:Application of perioperative targeted hemodynamic monitoring in VLBW infants undergoing PDA ligationObjectiveTo evaluate the hemodynamic characteristics in VLBW infants following PDA ligation and assess factors that may influence these changes,and to access the impact of targeted hemodynamic monitoring on postoperative outcomes in these infants.MethodsA single center non-randomized controlled study of a cohort of VLBW infants undergoing PDA ligation between January,2010 and December,2020 was conducted.The infants were divided into observation group and control group.Patients in the observation group received early targeted hemodynamics monitoring to guide postoperative care,while cases without receiving targeted hemodynamics monitoring were assigned to control group.Hemodynamic measurements were performed in infants of observation group using a USCOM preoperatively,as well as 0-1 h,8-10 h,and 24 h postoperatively.The incidence of PLCS,cardiopulmonary function status,and other complications after ligation were compared between the observation group and the control group.ResultA total of 77 VLBW infants who underwent PDA ligation were included,including 33 cases in the observation group,who receiving early targeted hemodynamic monitoring to guide postoperative management,and 44 cases in the control group.The PDA ligation was associated with reductions of the left ventricular cardiac output(LVCO)(P<0.001),cardiac index(P<0.001),flow time corrected(FTC)(P<0.001),Smith-Madigan inotropy index(SMII)(P<0.001),oxygen delivery(DO2)(P<0.001),and oxygen delivery index(DO2I)(P<0.001)and an increase of the systemic vascular resistance index(SVRI)(P<0.001)at 0-1 h,8-10 h,and 24 h post-ligation compared with the respective preoperative values.Compared with the respective values at 0-1h post-ligation,there was no significant difference in the CI,SMII,or FTC at 8-10 h and 24 h post-ligation.However,the SVRI decreased at 8-10 h and 24 h post-ligation.Moreover,the DO2I increased at 8-10 h and 24 h post-ligation,and the LVCO and DO 2 increased at 24 h post-ligation.Compared with the control group,there was no significant reduction of PLCS(24.24%vs 3636%,P=0.188)in the observation group,but with a declining trend.The demand for postoperative vasoactive drugs in the observation group was significantly lower than that in the control group(30.3%vs 54.55%,P=0.029),and there was no significant difference in the other outcomes between the two groups.ConclusionSignificant changes in hemodynamics occur immediately after PDA ligation,and early targeted hemodynamic monitoring guide treatment might reduce hemodynamic fluctuations and reduce the need for vasoactive drugs in early postoperative period.