O2051: A Survey Regarding the Care of the Hemodynamically Significant Patent Ductus Arteriosus (HSPDA)

Background: A hemodynamically significant patent ductus arteriosus (HSPDA) is a common concern in the care of premature infants, but its definition and preferred treatment remain controversial. The adoption of point of care (POC) echocardiography performed by neonatologists, prophylactic medical treatment and catheter occlusion of the HSPDA have not been previously addressed by a survey of practicing providers.

Methods: We surveyed members of the AAP Sections on Neonatal and Perinatal Care and Cardiology and Cardiac Surgery as well as the Pediheart.net community regarding their diagnosis and treatment of the HSPDA in premature infants.

Results: 488 providers completed the survey (Table 1). Routine echocardiography to screen for a HSPDA was recommended by 13% of respondents. If recommended, the average recommended age for a screening echocardiogram was at 28.2 weeks’ gestation. Formal echocardiographic and clinical scoring systems for the PDA were used infrequently (15% and 14% respectively). 18/377 (4.8%) of responding neonatologists performed POC echocardiography for evaluating the HSPDA.
Respondents were asked to report the importance of 14 echocardiographic parameters in their assessment of a HSPDA. Those most often designated as very important were retrograde diastolic flow in the post-ductal aorta and PDA diameter (Table 2). Statistically, there was disagreement in the importance of these parameters between neonatologists and pediatric cardiologists for 10/14 of these parameters.
Prophylactic medical treatment for the PDA prior to imaging was recommended by 14% of respondents. The preferred first line of medical therapy for the HSPDA was acetaminophen (32%), ibuprofen (29%), and indomethacin (23%). The recommended number of attempts at medical treatment before surgical or catheter closure were one (6%), two (59%) or three (24%).
Therapies available in-house to respondents included medical therapy (99%), surgical ligation (74%) and catheter closure (66%). Surgical ligation was less frequently recommended {never (13%), rarely (71%), often (8%) or always (0%)} than catheter closure {never (4%), rarely (38%), often (40%) or always (4%)}. The Piccolo device was the most used for catheter occlusion (89%).

Conclusion: This survey reflects the perceived current best practice in the care of the HSPDA and suggests an emphasis on imaging and treatment based on clinical condition with prophylactic medical treatment, screening echocardiograms and formalized clinical scoring systems used infrequently. POC echocardiography was performed by a minority of neonatologists. The difference in perceived value of various echocardiographic parameters between neonatologists and cardiologists may contribute to uncertainty in the determination of a HSPDA. Despite being a relatively new technology, catheter occlusion of the HSPDA appears to have been widely accepted in the neonatology and cardiology communities.