title: Therapeutic strategies, including a high surgical ligation rate, for patent ductus arteriosus closure in extremely premature infants in a North American centre.
abstract: OBJECTIVE
  To document the rate of surgical ligation of a patent ductus arteriosus (PDA) in extremely premature infants who had received more than one course of indomethacin. Outcomes were compared among three subgroups (ligation, further indomethacin and no further treatment) of infants who received at least one course of indomethacin, and between two subgroups (one course of indomethacin and more than one course) among infants who underwent ligation.
  
  
  METHODS
  A retrospective chart review of all 23 weeks+0 days to 26 weeks+6 days' gestational age infants with a PDA born between 1994 and 2005 was performed. Secondary outcomes were compared among the subgroups.
  
  
  RESULTS
  The final study population consisted of 196 extremely premature infants with a PDA. The rate of surgical ligation in the 88 infants who received more than one course of indomethacin was 64%. The ligation subgroup, in comparison with the no further treatment subgroup, spent a greater median time on mechanical ventilation (39 versus 29 days, P<0.001) and in hospital (115 versus 92 days P=0.002), while trending toward lower mortality (18% versus 40%, P=0.07). The PDA closed following the first course of indomethacin in only 20% of infants.
  
  
  CONCLUSIONS
  A majority of extremely premature infants receiving more than one course of indomethacin underwent surgical ligation. Repeated indomethacin courses were generally well tolerated, but were mostly unsuccessful. Ligation appears to have potential risks and benefits. A randomized trial should be performed after studies define a hemodynamically significant PDA that will result in morbidity and/or mortality unless treated.
authors.affiliation: Department of Pediatrics, Division of Neonatology, Children's Hospital of Eastern Ontario; ; Department of Obstetrics and Gynecology, Division of Newborn Care, The Ottawa Hospital, General Campus;
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Moore
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Lawrence
authors.forename: Gyaandeo
authors.initials: G
authors.lastname: Maharajh
authors.forename: Amanda
authors.initials: A
authors.lastname: Sumner
authors.forename: Isabelle
authors.initials: I
authors.lastname: Gaboury
authors.forename: Nick
authors.initials: N
authors.lastname: Barrowman
authors.forename: Brigitte
authors.initials: B
authors.lastname: Lemyre
keywords: Ductus arteriosus, patent; Indomethacin; Infant, premature; Ligation
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