2
analysis, Fisher’s exact test, and the Mann-Whitney rank sum test.
NeoNotes
Journal Club
Andrew
B. Kairalla MD, Editor
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Objective. Although indomethacin produces ductus arteriosus constriction in extremely premature newborns, a recurrent symptomatic patent ductus arteriosus (PDA) frequently develops after the initial course of indomethacin. Currently, there is little information available to determine the effectiveness of a second course of indomethacin in producing permanent ductus closure. The objective of this study was to determine the rate of permanent ductus closure after a second course of indomethacin for a recurrent, symptomatic PDA and to identify the factors associated with permanent ductus closure.
Methods.
We identified 32 infants (<28 weeks’ gestational age) 1) whose ductus
was considered to be clinically closed after an initial course of
indomethacin and 2) who subsequently developed a symptomatic PDA and
received a second course of indomethacin. Clinical variables were
evaluated for their association with failure of the second course
(defined as surgical ligation after the second course for recurrence
of a hemodynamically significant PDA). Data were analyzed by 2
analysis, Fisher’s exact test, and the Mann-Whitney rank sum test.
Results. After the second course of indomethacin, 56% (18 of 32) of the infants had persistent or recurrent PDA-related symptoms that were considered to be hemodynamically significant. The only significant predictor of failure of the second indomethacin course was the demonstration (by Doppler echocardiogram) of persistent ductus flow within 24 hours of completing the initial indomethacin course. All of the 9 newborns with persistent Doppler ductus flow after the initial indomethacin course failed the second course of indomethacin. In contrast, only 39% (9 of 23) of newborns with absent Doppler flow after the initial indomethacin course failed the second course of indomethacin.
Conclusions. Newborns who are <28 weeks’ gestational age and develop a recurrent, symptomatic PDA after completion of an initial indomethacin course rarely respond to multiple courses of indomethacin if there was persistent Doppler evidence of ductus flow after completion of the initial course. Additional indomethacin treatment is unlikely to produce permanent ductus closure.
Comment. I know it’s a small point, but babies who have persistent ductal flow 24 hours after an initial course of indomethacin still have an open ductus. This study demonstrates that if the ductus fails to completely close after the first course of indomethacin, and then the ductus becomes hemodynamically significant again, more indomethacin probably won’t help. We are not told how many infants who had persistent ductal flow after the first course of indomethacin never went on to develop further problems from their PDA. This information would be important to know before making a recommendation that all infants who receive indomethacin for PDA get a follow up Doppler-echocardiogram to document ductal closure. ABK
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