PDA . . . three seemingly innocuous letters that send chills down the spine of any neonatology provider. Determining which patient’s patent ductus arteriosus (PDA) is hemodynamically significant enough to warrant an intervention, and subsequently deciding when and how to intervene, remain some of the most controversial decisions in the field.
However, recent advances have brought a promising new option: a percutaneous transcatheter occlusion device approved in 2019 for use in infants as small as 700g. But the question remains, what is the safety profile and how widely adopted is this device?
This week, Pediatrics is early releasing an article and accompanying video abstract by Brianna Leahy, MBBS, and colleagues from the University of Vermont, entitled “Transcatheter and Surgical Ductus Arteriosus Closure in Very Low Birth Weight Infants: 2018-2022” (10.1542/peds.2024-065905).
In this article, authors utilize the Vermont Oxford Network (VON) database, representing over 200,000 very low birth weight (VLBW) neonates from 726 US NICUs. Authors describe the epidemiology of PDA management, comparing survival and short-term outcomes for transcatheter device versus surgical PDA closure.
The authors found that:
- 19.4% (n=41,976) of eligible neonates diagnosed with a PDA received some form of treatment.
- The vast majority (96.3%) received initial pharmacologic treatment, and ~12% of these patients underwent a subsequent invasive procedure (transcatheter device closure=6.4%, surgery=5.6%, both=0.06%).
- Of the remaining 3.7% who received only an invasive intervention, 51.8% received transcatheter device closure, 47.2% surgical intervention, and 1% received both.
- While annual rates of invasive closures remained similar over time, the proportion of transcatheter closures increased from 29.8% in 2018 to 71.7% in 2022.
- There was a distinct trend based on birth weight (BW) as well, with transcatheter use increasing by 40.1% for those born <750g, 47.2% for BW 751–1250g, and 10.8% for BW >1250g.
When compared to those who underwent surgical closure, infants who underwent transcatheter closure had marginally improved survival, both at baseline (transcatheter 96.1% versus surgical 93%) and when adjusting for clinically significant variables (aRR 1.03; 95% CI: 1.02, 1.04).
Although supplemental oxygen at discharge and tracheostomy were less likely for those undergoing transcatheter closure, the transcatheter cohort had significantly higher birth weight and lower respiratory severity at baseline. Overall, when adjusting for clinically significant variables, no differences were found in length of stay or complications of prematurity between the 2 invasive methods.
What to take from this article? Of the almost 20% of VLBW infants diagnosed with a PDA who were treated, ~15% underwent an invasive procedure. The method of choice for definitive closure has shifted away from surgery and toward transcatheter occlusion.
However, as discussed in the accompanying commentary by Reese Clark, MD, and Veeral Tolia, MD, entitled “The Importance of Timing when Evaluating PDA Treatment Outcomes,” retrospective data alone do not provide enough evidence to fully support these changes and prove safety (10.1542/peds.2024-067063). Prospective studies evaluating transcatheter PDA closure that include long-term follow-up are needed to better guide clinical decision making.
And just because we can treat a PDA doesn’t mean we always should. But that’s a blog for another day . . .
