Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study

Abdulaziz Homedi; Andrea De La Hoz; Michael R. Miller; Renjini Lalitha; Marisha McClean; Soume Bhattacharya

doi:10.1055/s-0043-1774313

American Journal of Perinatology, Table of Contents

Am J Perinatol 2024; 41(S 01): e2703-e2709
DOI: 10.1055/s-0043-1774313

Original Article

Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study

Abdulaziz Homedi

¹Department of Pediatrics, Western University, London, Ontario, Canada

,

Andrea De La Hoz

²Department of Lawson Research – Medicine, London Health Sciences Centre, London, Ontario, Canada

,

Michael R. Miller

¹Department of Pediatrics, Western University, London, Ontario, Canada

²Department of Lawson Research – Medicine, London Health Sciences Centre, London, Ontario, Canada

,

Renjini Lalitha

¹Department of Pediatrics, Western University, London, Ontario, Canada

,

Marisha McClean

¹Department of Pediatrics, Western University, London, Ontario, Canada

,

Soume Bhattacharya

¹Department of Pediatrics, Western University, London, Ontario, Canada

› Author Affiliations

Abstract

Objective Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service.

Study Design This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013–2016) versus Epoch-2 (TNE 2018–2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related)

Results A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2.

Conclusion With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era.

Key Points

TNE allows comprehensive hemodynamic assessment of PDA.
Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.
Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need.

Keywords

targeted neonatal echocardiography - patent ductus arteriosus - premature - neonates

Full Text

References

References
1 Mertens L, Seri I, Marek J. et al; Writing Group of the American Society of Echocardiography, European Association of Echocardiography, Association for European Pediatric Cardiologists. Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. Writing Group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). J Am Soc Echocardiogr 2011; 24 (10) 1057-1078
2 Sinha B, Mirochnick MH, Kumar S, Fujii AM. Targeted echocardiography in the neonatal intensive care unit. J Am Soc Echocardiogr 2012; 25 (03) 361 , author reply 361–362
3 Singh Y. Use of echocardiography in the neonatal intensive care unit. Paediatr Child Health 2022; 32 (09) 351-356
4 Mertens L, Seri I, Marek J. et al; Writing Group of the American Society of Echocardiography (ASE), European Association of Echocardiography (EAE), Association for European Pediatric Cardiologists (AEPC). Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. Eur J Echocardiogr 2011; 12 (10) 715-736
5 Giesinger RE, Hobson AA, Bischoff AR, Klein JM, McNamara PJ. Impact of early screening echocardiography and targeted PDA treatment on neonatal outcomes in “22-23” week and “24-26” infants. Semin Perinatol 2023; 47 (02) 151721
6 Van Overmeire B, Van de Broek H, Van Laer P, Weyler J, Vanhaesebrouck P. Early versus late indomethacin treatment for patent ductus arteriosus in premature infants with respiratory distress syndrome. J Pediatr 2001; 138 (02) 205-211
7 Fanaroff AA, Stoll BJ, Wright LL. et al; NICHD Neonatal Research Network. Trends in neonatal morbidity and mortality for very low birthweight infants. Am J Obstet Gynecol 2007; 196 (02) 147.e1-147.e8
8 Clyman RI. Mechanisms regulating the ductus arteriosus. Biol Neonate 2006; 89 (04) 330-335
9 El-Khuffash AF, McNamara PJ. Neonatologist-performed functional echocardiography in the neonatal intensive care unit. Semin Fetal Neonatal Med 2011; 16 (01) 50-60
10 Schindler T, Smyth J, Bolisetty S. et al. Early PARacetamol (EPAR) trial: a randomized controlled trial of early paracetamol to promote closure of the ductus arteriosus in preterm infants. Neonatology 2021; 118 (03) 274-281
11 Singh Y, Gupta S, Groves AM. et al. Expert consensus statement ‘neonatologist-performed echocardiography (NoPE)’-training and accreditation in UK. Eur J Pediatr 2016; 175 (02) 281-287
12 Singh Y, Katheria A, Tissot C. Functional echocardiography in the neonatal intensive care unit. Indian Pediatr 2018; 55 (05) 417-424
13 Paudel G, Joshi V. Echocardiography of the patent ductus arteriosus in premature infant. Congenit Heart Dis 2019; 14 (01) 42-45
14 Babla K, Duffy D, Dumitru R, Richards J, Kulkarni A. Repeatability of PDA diameter measurements on echocardiography. Eur J Pediatr 2022; 181 (01) 403-406
15 Harabor A, Soraisham AS. Utility of targeted neonatal echocardiography in the management of neonatal illness. J Ultrasound Med 2015; 34 (07) 1259-1263
16 Hébert A, Lavoie PM, Giesinger RE. et al. Evolution of training guidelines for echocardiography performed by the neonatologist: toward hemodynamic consultation. J Am Soc Echocardiogr 2019; 32 (06) 785-790
17 Evans N. Echocardiography on neonatal intensive care units in Australia and New Zealand. J Paediatr Child Health 2000; 36 (02) 169-171
18 Kluckow M, Seri I, Evans N. Echocardiography and the neonatologist. Pediatr Cardiol 2008; 29 (06) 1043-1047
19 Cabral NC, Figueira SANN, Zamith MM. et al. Neonatal performed echocardiography course: can we face it?. J Perinatol 2023; 1-6
20 Corsini I, Ficial B, Fiocchi S. et al; Study Group of Neonatal Cardiology of the Italian Society of Neonatology. Neonatologist performed echocardiography (NPE) in Italian neonatal intensive care units: a national survey. Ital J Pediatr 2019; 45 (01) 131
21 Papadhima I, Louis D, Purna J. et al. Targeted neonatal echocardiography (TNE) consult service in a large tertiary perinatal center in Canada. J Perinatol 2018; 38 (08) 1039-1045
22 Corredera A, Rodríguez MJ, Arévalo P, Llorente B, Moro M, Arruza L. . [Functional echocardiography in neonatal intensive care: 1 year experience in a unit in Spain] Ann Pediatr (Paris) 2014; 81 (03) 167-173
23 Giesinger RE, Rios DR, Chatmethakul T. et al. Impact of early hemodynamic screening on extremely preterm outcomes in a high-performance center. Am J Respir Crit Care Med 2023; 208 (03) 290-300
24 Pereira SS. Comparison of PDA diameter measurements using color and 2D echocardiography in newborn infants. J Neonatal Perinatal Med 2023; 16 (01) 137-140
25 Negreiros Figueira SA, de Oliveira AC, Zamith MM. et al. Echocardiography performed by the neonatologist: the impact on the clinical management. Pediatr Res 2023; 94 (02) 724-729
26 Kharrat A, McNamara PJ, Weisz D, Jain A. Merits and perils of targeted neonatal echocardiography-based hemodynamic research: a position statement. Can J Physiol Pharmacol 2019; 97 (03) 183-186
27 van Laere D, van Overmeire B, Gupta S. et al; European Special Interest Group ‘Neonatologist Performed Echocardiography’ (NPE). Application of NPE in the assessment of a patent ductus arteriosus. Pediatr Res 2018; 84 (Suppl. 01) 46-56
28 McNamara PJ, Sehgal A. Towards rational management of the patent ductus arteriosus: the need for disease staging. Arch Dis Child Fetal Neonatal Ed 2007; 92 (06) F424-F427
29 Conrad C, Newberry D. Understanding the pathophysiology, implications, and treatment options of patent ductus arteriosus in the neonatal population. Adv Neonatal Care 2019; 19 (03) 179-187