Differential effects of ibuprofen and indomethacin on cerebral oxygen kinetics in the very preterm baby.

Background: Ibuprofen is preferred to indomethacin for treatment of a significant patent ductus arteriosus (PDA) in preterm babies despite indomethacin being associated with a lower risk of intraventricular haemorrhage. This difference is thought to relate to the discrepant effects of each medication on cerebral oxygen kinetics yet the effect of ibuprofen on cerebral perfusion is uncertain. Methods: Forty-eight babies < 30 weeks with a significant PDA, defined by echocardiography, were randomly assigned to either indomethacin or ibuprofen (n = 24 per group) and stratified by gestation and chronologic age. Cerebral blood flow [total internal carotid blood flow (TICF)] and oxygen physiology [oxygen delivery (modCerbDO2) and consumption (modCerbVO2)] were measured using cranial Doppler ultrasound and near-infrared spectroscopy, and cerebral oxygen extraction (cFTOE) calculated, immediately before and following administration. Temporal and treatment related changes were analysed. Results: A fixed effect of time was seen for TICF (p = 0.03) and therefore modCerbDO2 (p = 0.046) and cFTOE (p = 0.04) for indomethacin alone. In the indomethacin group, TICF and modCerbDO2 fell from baseline to 5 and 30 min respectively (TICF p < 0.01, cDO2 p = 0.01) before increasing from 5 min to 24 h (p < 0.01) and 30 min and 24 h (p < 0.01) timepoints. cFTOE peaked at 30 min (p = 0.02) returning to baseline at 24 h. There was a parallel increase in arterial lactate. Conclusion: Indomethacin significantly reduces cerebral blood flow soon after administration, resulting in a parallel increase in oxygen extraction and arterial lactate. This implies that the balance of oxygen kinetics at the time of treatment may be critical in very preterm babies with significant PDA.

Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort.

OBJECTIVE: Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation. METHODS: Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings. RESULTS: Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) (P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement. CONCLUSION: Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration. LEVEL OF EVIDENCE: 2b.

Efficacy and safety of ultrasound-guided percutaneous retrograde closure of patent ductus arteriosus / 中国胸心血管外科临床杂志

@#Objective    To evaluate the efficacy and safety of transcatheter closure of patent ductus arteriosus (PDA) with transthoracic echocardiography (TTE). Methods    From February 2016 to November 2018, 98 patients of pure PDA were selected, including 43 patients of funnel type and 55 patients of tube type. There were 38 males and 60 females at age of 2-48 (9.8±10.4) years. All patients underwent TTE-guided retrograde closure of the PDA through the femoral artery to establish a femoral-abdominal aorta-thoracic aorta-ductus arteriosus-aorta-right ventricle trajectory.Under the guidance of TTE, a suitable closure umbrella was placed through the femoral artery. One month, 3 months, 6 months, 12 months after the surgery, the patients received out-patient clinical follow-up. Results    Ninety eight patients were successfully occluded by TTE. The occluder was replaced many times in an adult PDA patient, but finally it was successfully plugged. The operation time was 33.2±5.8 min. The lumbar diameter was 12±6 mm. And the postoperative murmur disappeared. Ultrasound showed no shunt between the aorta and the pulmonary artery, and the postoperative hospital stay was 3-4 days. No shunt signal was found in 1, 3, 6, 12 months follow-up. Left atrial anteroposterior diameter (25.8±6.1 mm vs. 30.6±8.4 mm) and left ventricular end diastolic diameter (38.5±9.1 mm vs. 45.2±11.5 mm) were significantly smaller (P < 0.05). Conclusion    TTE-guided transcatheter closure of PDA via femoral artery is a safe and effective method to avoid the damage of X-ray and contrast medium. The prospect of clinical application is good.

Severe right ventricular hypertrophy in a patient with extracardiac and intracardiac shunt.

Cardiac MRI is a complementary and confirmatory modality to a clinical echocardiography in diagnosing patients with complex adult congenital heart disease, especially in presence of great vessel abnormalities. We present a unique case of a patient with pulmonary hypertension (PH), severe right ventricular hypertrophy, Gerbode defect, and a large patent ductus arteriosus (PDA). The diagnosis of PDA was not visualized on prior serial echocardiograms and discovered on a comprehensive cardiac MRI/Chest MR angiogram.

Predictors of transient left ventricular dysfunction following transcatheter patent ductus arteriosus closure in pediatric age.

OBJECTIVES: To evaluate the left ventricular function before and after transcatheter percutaneous patent ductus arteriosus (PDA) closure, and to identify the predictors of myocardial dysfunction post-PDA closure if present. INTERVENTIONS: Transcatheter PDA closure; conventional, Doppler, and tissue Doppler imaging; and speckle tracking echocardiography. OUTCOME MEASURES: To determine the feasibility and reliability of tissue Doppler and myocardial deformation imaging for evaluating myocardial function in children undergoing transcatheter PDA closure. PATIENTS AND METHODS: Forty-two children diagnosed with hemodynamically significant PDA underwent percutaneous PDA closure. Conventional, Doppler, and tissue Doppler imaging, and speckle-derived strain rate echocardiography were performed at preclosure and at 48 hours, 1 month, and 6 months postclosure. Tissue Doppler velocities of the lateral and septal mitral valve annuli were obtained. Global and regional longitudinal peak systolic strain values were determined using two-dimensional speckle tracking echocardiography. RESULTS: The median age of the patients was 2 years and body weight was 15 kg, with the mean PDA diameter of 3.11 ± 0.99 mm. M-mode measurements (left ventricular end diastolic diameter, left atrium diameter to aortic annulus ratio, ejection fraction, and shortening fraction) reduced significantly early after PDA closure (p < 0.001). After 1 month, left ventricular end diastolic diameter and left atrium diameter to aortic annulus ratio continued to decrease, while ejection fraction and fractional shortening improved significantly. All tissue Doppler velocities showed a significant decrease at 48 hours with significant prolongation of global myocardial function (p < 0.001) and then were normalized within 1 month postclosure. Similarly, global longitudinal strain significantly decreased at 48 hours postclosure (p < 0.001), which also recovered at 1 month follow-up. Preclosure global longitudinal strain showed a good correlation with the postclosure prolongation of the myocardial performance index. CONCLUSION: Transcatheter PDA closure causes a significant decrease in left ventricular performance early after PDA closure, which recovers completely within 1 month. Preclosure global longitudinal strain can be a predictor of postclosure myocardial dysfunction.

Transcatheter therapy for congenital heart diseases using the Amplatzer occluder: A report of 30 cases / 中国微创外科杂志

Objective To evaluate the short-term effectiveness of Amplatzer device closure for congenital heart diseases.Methods Under X-ray fluoroscopy or/and transthoracic echocardiography(TTE),percutaneous puncture of the femoral artery or vein was conducted and the Amplatzer occluder was passed through the catheter.Effectiveness evaluation by transthoracic echocardiography,electrocardiography(ECG),and X-ray examination was applied at 24 hours,1 month,6 months,and every 1 year after the procedure.Results In 1 case of perimembranous ventricular septal defect(VSD),the detachment of the Amplatzer occluder to the arch of aorta was due to an inadequate small size.This patient was immediately operated with successful removal of the device through the femoral artery and later underwent a re-deployment of a larger-sized Amplatzer occluder closure successfully.The remaining 29 patients with atrial septal defect(ASD),patent ductus arteriosus(PDA),or perimembranous ventricular septal defect underwent a successful deployment of the Amplatzer occluder on one session without complications.The operation time was 20~90 min (38?16 min),the X-ray exposure time was 5~45 min(18?10 min),and the length of hospital stay was 3~7 days(4?2 days).Conclusions Amplatzer occluder transcatheter closure of congenital heart diseases has advantages of simplicity of deployment,good safety,and high success rate.This procedure is suitable for patients with secundum ASD,membranous VSD,and PDA.

Discussion of hemodynamics and treatment of silent patent ductus arteriosus / 中国介入心脏病学杂志

Objective To discuss the hemodynamics and treatment of silent patent ductus arteriosus (PDA) Methods The heart catheterizations were performed in seven silent PDA patients Results The mean pulmonary artery pressure of seven patients was (16?2 4) mm?Hg The mean Qp/Qs was 1 08?0 02 The mean size of the left right shunt was (0 32?0 08) L/min The proportion of left right shunt size in pulmonary blood flow was 0 098?0 024 on average The mean PDA at its narrowest segment was (0 9?0 2) mm We performed neither surgery nor interventional treatment in all patients In 9 5 months follow up (clinical findings, electrocardiography, echocardiography), no atrioventricular chambers enlargement, pulmonary hypertension, infective endoarteritis and infective endocarditis happened Conclusion In silent PDA patients, there is less size of left right shunt and smaller effect on hemodynamics Its treatment with surgical and interventional closure is under discussion