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      Initial Experience With Patent Ductus Arteriosus Ligation in Pre-term Infants With Bidirectional Shunt Pattern

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          Abstract

          Background: Patent ductus arteriosus (PDA) with a bidirectional shunt reflects critical clinical conditions. The operability of PDA with a bidirectional shunt in pre-term infants is still not clearly clarified. This study aimed to investigate the feasibility and the outcomes of PDA ligation in pre-term infants with a bidirectional shunt PDA.

          Methods: All pre-term infants receiving PDA ligation between 2013 and 2019 were enrolled in this prospective study. Patients were allocated into two groups based on the shunting direction of PDA, which were the left-to-right group (group A) and the bidirectional group (group B). Clinical characteristics and pre-op comorbidities were analyzed. Intraoperative complications, post-op neurological sequelae, necrotizing enterocolitis, survival, and mortality were compared between these two groups.

          Results: Thirty-seven pre-term infants were enrolled (18 in group A, 19 in group B). The mean post-menstrual age at PDA surgery was 32.0 ± 1.3 and 32.8 ± 1.5 weeks, respectively. Before surgery, 44.4 and 89.5% (group A vs. B) of the patients were using invasive mechanical ventilator ( p < 0.01). The requirement of high-frequency oscillatory ventilatory support was significantly higher in group B. PDA rupture-related bleeding during exposing PDA or ligating PDA occurred in four infants, and all were all in group B, including one with delayed hemothorax. Early surgical mortality within 30 days of surgery was higher in group B (0 vs. 21.1%, p < 0.05), but only one death could be attributed to the surgery, which was caused by a pain-induced pulmonary hypertension crisis. The 5-year survival was 100% in group A, and 73.7% in group B ( p < 0.05).

          Conclusion: We did not recommend routine PDA ligation in pre-term infants with a bidirectional shunt. However, a bidirectional shunt should not be an absolute contraindication if they fulfill indications of PDA closure. Unexpected intraoperative PDA rupture and delayed hemothorax in a bidirectional shunt PDA should be carefully monitored. Aggressive post-op pain control is also warranted to avoid pulmonary hypertension crisis. The post-op early mortality rate was higher in the bidirectional group, which could be inherent to their poor pre-operative lung condition. Only one death was directly related to the surgery.

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          Most cited references30

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          Haemodynamic definitions and updated clinical classification of pulmonary hypertension

          Since the 1st World Symposium on Pulmonary Hypertension (WSPH) in 1973, pulmonary hypertension (PH) has been arbitrarily defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterisation. Recent data from normal subjects has shown that normal mPAP was 14.0±3.3 mmHg. Two standard deviations above this mean value would suggest mPAP >20 mmHg as above the upper limit of normal (above the 97.5th percentile). This definition is no longer arbitrary, but based on a scientific approach. However, this abnormal elevation of mPAP is not sufficient to define pulmonary vascular disease as it can be due to an increase in cardiac output or pulmonary arterial wedge pressure. Thus, this 6th WSPH Task Force proposes to include pulmonary vascular resistance ≥3 Wood Units in the definition of all forms of pre-capillary PH associated with mPAP >20 mmHg. Prospective trials are required to determine whether this PH population might benefit from specific management. Regarding clinical classification, the main Task Force changes were the inclusion in group 1 of a subgroup “pulmonary arterial hypertension (PAH) long-term responders to calcium channel blockers”, due to the specific prognostic and management of these patients, and a subgroup “PAH with overt features of venous/capillaries (pulmonary veno-occlusive disease/pulmonary capillary haemangiomatosis) involvement”, due to evidence suggesting a continuum between arterial, capillary and vein involvement in PAH.
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            Bronchopulmonary dysplasia.

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              2019 Updated Consensus Statement on the Diagnosis and Treatment of Pediatric Pulmonary Hypertension. The European Pediatric Pulmonary Vascular Disease Network (EPPVDN), endorsed by AEPC, ESPR and ISHLT

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                Author and article information

                Contributors
                Journal
                Front Pediatr
                Front Pediatr
                Front. Pediatr.
                Frontiers in Pediatrics
                Frontiers Media S.A.
                2296-2360
                26 October 2020
                2020
                : 8
                : 591441
                Affiliations
                [1] 1Department of Pediatrics, E-Da Hospital , Kaohsiung City, Taiwan
                [2] 2School of Chinese Medicine for Post Baccalaureate, I-Shou University , Kaohsiung City, Taiwan
                [3] 3School of Medicine for International Students, I-Shou University , Kaohsiung City, Taiwan
                [4] 4Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital , Kaohsiung City, Taiwan
                Author notes

                Edited by: Ömer Erdeve, Ankara University, Turkey

                Reviewed by: Hannes Sallmon, Charité–Universitätsmedizin Berlin, Germany; Hanifi Soylu, Selçuk University, Turkey

                *Correspondence: Jiunn-Ren Wu jirewu@ 123456gmail.com

                This article was submitted to Neonatology, a section of the journal Frontiers in Pediatrics

                †These authors have contributed equally to this work and share first authorship

                Article
                10.3389/fped.2020.591441
                7649389
                23327b66-c0a0-4d39-85c5-afb82401a0e1
                Copyright © 2020 Yang, Liu, Wu, Tey, Yang, Wu and Wu.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 04 August 2020
                : 28 September 2020
                Page count
                Figures: 2, Tables: 4, Equations: 0, References: 30, Pages: 9, Words: 6374
                Categories
                Pediatrics
                Original Research

                pre-term infant,pulmonary hypertension,patent ductus arteriosus ligation,outcomes,bidirectional shunt,contraindication,surgery

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