212 - Management Approaches and Timing of Patent Ductus Arteriosus Closure Affect Patient Outcomes

Poster Number: 212
Publication Number: 212.220

Kelsey Kenaan, Medical College of Wisconsin, Milwaukee, WI, United States; Ruby Gupta, Medical College of Wisconsin, Milwaukee, WI, United States; Erwin T. Cabacungan, Medical College of Wisconsin, Wauwatosa, Wisconsin/53202, WI, United States

Background: Numerous studies have outlined medical and surgical approaches for ductal closure. However, the effect of different approaches on outcomes remains a topic of debate. The critical question remains whether the timing of surgical closure of the patent ductus arteriosus (PDA) reduces morbidity. We hypothesize that the management approach and PDA closure timing affect patient outcomes.

Objective: To characterize PDA closure management approaches and timing, and associated adverse outcomes.

Design/Methods: This is a retrospective cohort study of infants ( < 1500g) admitted to a regional Level IV NICU with a PDA confirmed by echocardiogram from 1/2013 to 12/2019. Our predictor variables were the four PDA management approaches: conservative, medical only, and surgical closure (≤ 28 days(d) and > 28d), with or without medication. Infant and maternal characteristics, length of stay (LOS), comorbidities, and outcomes were collected. Statistical analysis included Chi-square or Fisher's exact tests, Kruskal-Wallis test, one-way ANOVA, and linear or logistic regressions. Analysis was adjusted for covariates.

Results: Of the 787 infants, 205 (26%) had hemodynamically significant PDA. 28% were conservatively managed, 41% were medically treated only, and 35% were surgically closed (14% in ≤ 28d and 18% in > 28d). More of the surgically closed infants had younger gestational age, smaller birth weight, lower 5-minute APGAR scores, increased intraventricular hemorrhage (IVH), bronchopulmonary dysplasia, retinopathy of prematurity (ROP), pulmonary hypertension, and were discharged on home oxygen (Table1). In Figure 1, the surgically closed groups were associated with longer median LOS (closure > 28d – 125d, closure ≤ 28d – 116d, medical only – 91d, and conservative – 76d). In Figure 2, the mean surgical closure > 28d discharge weight z-score was significantly lower when compared to each of the other groups. Also, in surgical closure >28d, there was a higher odds ratio for ROP (aOR = 5.16, p< 05) compared to conservative PDA management. Surgical closure ≤ 28d was associated with higher odds ratio for IVH (aOR = 6.41, p< 0.01) than conservative PDA management.Conclusion(s): We found poor growth, increased comorbidities, and adverse outcomes with surgical management of PDA, especially when done >28d. We speculate that PDA closure, either medical or surgical ≤ 28days, leads to better outcomes. Further evidence-based research is needed for optimal timing and approach for PDA closure, and determining what infants would be best suited for closure.
Table 1: Infant and Maternal Characteristics, Comorbidities and Outcomes for the Four Management Approaches of PDA Treatment (Conservative, Medical Only, Surgical Closure ≤ 28 Days and Surgical Closure > 28 Days)More of the surgically closed infants had younger gestational age, smaller birth weight, lower 5 minute APGAR scores, increased intraventricular hemorrhage (IVH), bronchopulmonary dysplasia, retinopathy of prematurity (ROP), and pulmonary hypertension. Also, a higher number of surgically closed infants were discharged on home oxygen.
Figure 1: Length of Stay (Days) for the Four Management Approaches of PDA Treatment (Conservative, Medical Only, Surgical Closure ≤ 28 Days and Surgical Closure > 28 Days) †Using the Kruskal-Wallis test, there were significant differences in median length of stay (days) for the four management approaches of PDA treatment [Conservative = median (25th -95th CI), 76 (57 – 101), Medical Only = 90.5 (68 – 118), Surgical Closure ≤ 28 Days = 16 ( 90 – 139), Surgical Closure > 28 Days = 124.5 (101- 174.5)], p < 0.001. Using Poisson regression, with Conservative as the reference group, there continued to be significant differences in length of stay: Medical Only = aIRR (95th CI), 1.36 (1.30 -1.42), p < 0.001; Surgical Closure ≤ 28 Days = 1.25 (1.18 -1.32), p < 0.001, and Surgical Closure > 28 Days = 1.38 (1.32 -1.45), p < 0.001.††