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Heart of the matter: predicting need for PDA surgical ligation from an early echocardiogram

Pediatric Research volume 98, pages 11–13 (2025)Cite this article

Among preterm infants, a hemodynamically significant patent ductus arteriosus (PDA) is associated with significant morbidity and mortality.1 The adjudication of hemodynamic significance represents a significant challenge in the field of neonatology to delineate shunts which are pathologic from those that are either physiologic or are non-significant and likely to close spontaneously.2 To date, keystone trials of PDA management including the recent BeNeDuctus and Baby-OSCAR trials have failed to demonstrate the benefit of pharmacologic attempts to close the PDA.3,4 These trials adjudicated hemodynamic significance based solely on PDA diameter and shunt directionality, the former of which has been shown to be poorly correlated to actual PDA shunt volume relative to a gold-standard of cardiac MRI.5 There is thus a significant need for a more comprehensive assessment of a pathologic PDA shunt.

Multiple more expansive echocardiographic estimates of PDA shunt significance have been developed, each attempting to balance sensitivity and specificity. Several comprehensive, quantitative, and multi-parametric assessments have been developed (Table 1); namely, the McNamara-Sehgal, El-Khuffash, Shaare Zedek Medical Center, and Iowa PDA score models.2,6,7,8 While sensitive, the broad applicability of these models can be limited by their need to be performed and interpreted by neonatologists and/or Pediatric Cardiologists who have been trained in comprehensive targeted neonatal echocardiography.9 Other models with fewer and often easier-to-attain images/measurements have similarly been developed including the PDA and Left Atrial Size Evaluation (PLASE) that utilizes a two-component estimate of pathologic PDA shunt presence.10 Each of these assessments has been validated against a PDA-related morbidity to imply hemodynamic significance and the need for shunt elimination.

Table 1 Summary of multiparametric PDA scoring systems.
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References

  1. Hamrick, S. E. G. et al. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 146 (2020).

  2. Wren J. T., M. P., Gillam-Krakauer M. Contemporary perspectives on the patent ductus arteriosus in preterm neonates: a hemodynamics-driven approach. Curr. Opin. Treat. Opt. Peds. (2024).

  3. Gupta, S. et al. Trial of selective early treatment of patent ductus arteriosus with Ibuprofen. N. Engl. J. Med. 390, 314–325 (2024).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Hundscheid, T. et al. Expectant management or early Ibuprofen for patent Ductus Arteriosus. N. Engl. J. Med. 388, 980–990 (2023).

    Article  CAS  PubMed  Google Scholar 

  5. Broadhouse, K. M. et al. Assessment of Pda shunt and systemic blood flow in newborns using cardiac MRI. NMR Biomed. 26, 1135–1141 (2013).

    Article  PubMed  Google Scholar 

  6. El-Khuffash, A. et al. A patent ductus arteriosus severity score predicts chronic lung disease or death before discharge. J. Pediatr. 167, 1354–1361.e1352 (2015).

    Article  PubMed  Google Scholar 

  7. Fink, D., El-Khuffash, A., McNamara, P. J., Nitzan, I. & Hammerman, C. Tale of two patent ductus arteriosus severity scores: similarities and differences. Am. J. Perinatol. 35, 55–58 (2018).

    Article  PubMed  Google Scholar 

  8. Sehgal, A., Paul, E. & Menahem, S. Functional echocardiography in staging for ductal disease severity : role in predicting outcomes. Eur. J. Pediatr. 172, 179–184 (2013).

    Article  PubMed  Google Scholar 

  9. McNamara, P. J. et al. Guidelines and recommendations for targeted neonatal echocardiography and cardiac point-of-care ultrasound in the Neonatal Intensive Care Unit: An update from the American Society of Echocardiography. J. Am. Soc. Echocardiogr. 37, 171–215 (2024).

    Article  PubMed  Google Scholar 

  10. Toyoshima, K. et al. What echocardiographic indices are predictive of patent ductus arteriosus surgical closure in early preterm infants? A prospective multicenter cohort study. J. Cardiol. 74, 512–518 (2019).

    Article  PubMed  Google Scholar 

  11. Mitra, S. et al. Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen with Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-Analysis. JAMA 319, 1221–1238 (2018).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Weisz, D. E. et al. Association of Patent Ductus Arteriosus ligation with death or neurodevelopmental impairment among extremely preterm infants. JAMA Pediatr. 171, 443–449 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13. Masutani, S. et al. Generation of Plase Score for patent ductus arteriosus using the Plase Study Database. Pediatr. Res. (in the press).

  14. Masutani, S. et al. Ductus diameter and left pulmonary artery end-diastolic velocity at 3 days of age predict the future need for surgical closure of patent ductus arteriosus in preterm infants: a post-hoc analysis of a prospective multicenter study. J. Cardiol. 78, 487–492 (2021).

    Article  PubMed  Google Scholar 

  15. Ruoss, J. L., Bazacliu, C., Giesinger, R. E. & McNamara, P. J. Patent ductus arteriosus and cerebral, cardiac, and gut hemodynamics in premature neonates. Semin. Fetal Neonatal Med. 25, 101120 (2020).

    Article  CAS  PubMed  Google Scholar 

  16. Clyman, R. I. The role of patent ductus arteriosus and its treatments in the development of bronchopulmonary dysplasia. Semin. Perinatol. 37, 102–107 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Deng, Y. et al. Impact of patent ductus arteriosus shunt size and duration on risk of death or severe respiratory morbidity in preterm infants born in China. Eur. J. Pediatr. 181, 3131–3140 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  18. Nawaytou, H., Hills, N. K. & Clyman, R. I. Patent ductus arteriosus and the risk of bronchopulmonary dysplasia-associated pulmonary hypertension. Pediatr. Res. 94, 547–554 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Alagarsamy, S. et al. Comparison of clinical criteria with echocardiographic findings in diagnosing pda in preterm infants. J. Perinat. Med. 33, 161–164 (2005).

    Article  PubMed  Google Scholar 

  20. Skelton, R., Evans, N. & Smythe, J. A blinded comparison of clinical and echocardiographic evaluation of the preterm infant for patent ductus arteriosus. J. Paediatr. Child Health 30, 406–411 (1994).

    Article  CAS  PubMed  Google Scholar 

  21. Smith, A., Mullaly, R., Franklin, O. & El-Khuffash, A. Reproducibility of the El-Khuffash Pda severity score and Pda diameter measurements in extremely preterm infants. Early Hum. Dev. 184, 105832 (2023).

    Article  PubMed  Google Scholar 

  22. Zonnenberg, I. & de Waal, K. The definition of a haemodynamic significant duct in randomized controlled trials: a systematic literature review. Acta Paediatr. 101, 247–251 (2012).

    Article  PubMed  Google Scholar 

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  1. Division of Neonatology, Department of Pediatrics, University of Iowa Healthcare, Iowa City, IA, USA

    John T. Wren Jr & Patrick J. McNamara

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  1. John T. Wren Jr
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Wren, J.T., McNamara, P.J. Heart of the matter: predicting need for PDA surgical ligation from an early echocardiogram. Pediatr Res 98, 11–13 (2025). https://doi.org/10.1038/s41390-025-03896-3

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