fellow University of Toronto Hospital For Sick Children Toronto, Ontario, Canada
Background: Hemodynamically significant patent ductus arteriosus (hsPDA) has been associated with increased risk of mortality and morbidities in preterm infants. Randomized controlled trials (RCTs) have failed to show a benefit of active (pharmacologic/ligation) treatment (AT) of hsPDA with regards to reduction of morbidities and mortality and improvement of long term neurodevelopmental outcome. Few studies have shown that conservative treatment (CT) could be an alternative option for hsPDA management in preterm infants.
Objective: To systematically review and meta-analyze the incidence of morbidities and mortality in CT versus AT group of preterm infants with hsPDA.
Design/Methods: PubMed, Embase, CINAHL and Cochrane CENTRAL were searched for relevant studies in December 2019. Studies comparing CT versus AT of hsPDA in preterm infants were included. The primary outcome was mortality prior to discharge. Secondary outcomes included incidence of severe intraventricular hemorrhage (sIVH), pulmonary hemorrhage, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), periventricular leucomalacia (PVL) and severe retinopathy of prematurity. Sensitivity analysis was conducted for studies comparing no treatment versus active treatment of hsPDA for all outcomes. Quality assessment of the included studies was done by using the Newcastle–Ottawa scale. Data was meta-analyzed using a random-effects model with assessment of quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Results: Five observational studies [N = 1379] with good quality were included (Figure 1). Pooled analyses showed that CT didn’t increase the risk of mortality in preterm infants with hsPDA [Risk ratio (RR):0.83 95% Confidence Interval (CI) 0.60 to 1.16, p = 0.28, I2 = 0%, 5 studies, N= 1379, GRADE: Low] (Figure 2). All pre-specified secondary outcomes didn’t differ significantly between the two groups (Figure 3). In comparison to AT, infants with hsPDA with no treatment had significantly lower incidence of BPD [RR: 0.67, 95% CI 0.50, 0.91, p = 0.009, I2 = 0%, 2 studies, N = 821, GRADE: Low]. (Figure 4) Conclusion(s): Compared to AT, CT is a safe alternative management strategy for preterm infants with hsPDA. Adequately powered multicentre RCTs are warranted to further evaluate conservative treatment startegies in preterm infants with hsPDA.
Authors/Institutions: Aida Al-Sabahi, Hospital For Sick Children, Toronto, Ontario, Canada; Bonny Jasani, Hospital for Sick children, Toronto, Ontario, Canada; Marwa S. Al Balushi, University of Toronto, Toronto, Ontario, Canada; Dany Weisz, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada