The term haemodynamic significance should be avoided when treating premature infants with patent ductus arteriosus
Year: 2024
Type: article
Abstract: There have been ongoing debates about the definition of haemodynamically significant patent ductus arteriosus (hsPDA) in premature infants and the criteria for treatment.1, 2 In our view, merely using the term adds to the confusion and complicates decision-making in daily practice. In many places, echocardiographic assessments are performed by neonatologists. However, paediatric cardiologists are getting increasingly involved in treatment choices now that it is possible to close open ducts with devices that are inserted using a catheter. We believe that cardiologists and neonatologists have different understandings of the term haemodynamically significant. This complicates the communication between these specialties, as well as between medical institutions and scientific authors. It is well established around the world that neonatologists perform echocardiography and this has been described as an indispensable tool in the haemodynamic assessment of PDA.3 In 2007, McNamara proposed a PDA staging system in which information obtained from echocardiographic assessments was analysed in conjunction with clinical parameters.4 This ground-breaking proposal comprised four separate gradings of clinical and echocardiographic parameters indicating different levels of severity. Much of the ongoing debates on treatment indications have been based on this framework. However, the terminology seems to have disintegrated, particularly when it comes to interpreting haemodynamic significance. Some authors stick to McNamara's four-level haemodynamic grading system, which are none, small or non-significant, moderate and large haemodynamic significant ducts.5 Others consider a haemodynamically significant PDA as more or less synonymous with the need for treatment.6 Even clinical criteria like a lung haemorrhage or respiratory failure have been used as diagnostic criteria for a haemodynamic significant PDA.7 This term is also used in the headings of risk scores for PDA, including both echocardiographic and clinical parameters.1 The possibility of closing the defect by catheter calls for paediatric cardiologists to be involved in decisions on the treatment of premature infants with PDA. That is how we first became aware of the confusing terminology. In paediatric cardiology, haemodynamic significance is lesion-specific, but generally applies to echocardiographic or invasive signs of abnormal flow patterns and/or pressures. There is a clear difference between haemodynamic significance and indications for treatment.8 For example, haemodynamically significant septal defects are often left untreated, in the hope that they will spontaneously improve, or to allow for catheter treatment. Treatment is also commonly postponed for complex heart defects like tetralogy of Fallot or balanced univentricular defects, although their haemodynamic significance is unquestionable. The timing of interventions in paediatric cardiology is based on a total assessment of the patient's condition, including clinical parameters and the expected course. This is in line with MacNamara's proposal. Today, paediatric cardiologists undergoing training must learn that haemodynamic significance has a different, and less well-defined, meaning when assessing a PDA in a premature infant. No single echocardiographic parameter can determine the haemodynamic significance of a PDA, and the various definitions are based on different combinations of standardised echocardiographic parameters. Composite scores of risk or severity have been suggested, in order to define the need for treatment. They include combined clinical and echocardiographic parameters and correspond to the understanding in paediatric cardiology. One of the best known is the El-Khuffash risk score, which is based on the risk of future morbidity, and some evidence have supported its relationship with clinical outcomes.9 Others include additional, or slightly different, criteria for determining risk.1, 10 All these scoring systems use the term haemodynamic significance, but with different meanings. Using the term haemodynamic significance is not helpful when we are dealing with a premature infant with a PDA, because it is so difficult to define. These patients need individualised treatment criteria based on standardised clinical findings, combined with echocardiographic signs of left heart volume overload, systemic underperfusion, ductal size and flow patterns. We suggest that the term haemodynamic significant PDA should be abandoned and that it should not be used as a proxy for a PDA that should be closed in preterm infants or as a heading in composite scores. That might reduce the confusion in clinical practice and make it easier to interpret scientific results. Henrik Holmstrøm: Conceptualization; writing – original draft. Atle Moen: Conceptualization; writing – review and editing. Charlotte Tscherning: Writing – review and editing. The authors have no conflicts of interest to declare. Henrik Holmstrøm Atle Moen Charlotte Tscherning
Source: Acta Paediatrica
DOI: 10.1111/apa.17401
Institutions: Oslo University Hospital, University of Oslo
Language: English
Subfield: Radiology, Nuclear Medicine and Imaging
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,270
OpenAlex ID: W4401815575