Management of the preterm patient with persistent ductus arteriosus
Manejo del paciente pretérmino con ductus arterioso persistente
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Romero, H., & Peña, J. P. (2014). Management of the preterm patient with persistent ductus arteriosus. Journal of Medicine and Surgery Repertoire, 23(3), 168–176. https://doi.org/10.31260/RepertMedCir.v23.n3.2014.705
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Abstract
Persistent ductus arteriosus is considered the most frequent heart disease in neonates weighing less than 1,500 g and with respiratory distress syndrome. Increased morbidity increases the incidence of bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, cholestasis due to increased time of parenteral nutrition, osteopenia and malnutrition. As the management presents a lot of controversy, this literature review of the databases LILACS, EMBASE, PUBMED, MDCONSULT, COCHRANE, SCOPUS, clinicaltrials.gov and internet search engines is carried out. The definition, identification, diagnosis and management are analyzed, updating the subject in order to answer questions of daily practice and propose strategies for the initiation of studies that may be useful in the neonatal intensive care unit. Abbreviations: DAP, persistent ductus arteriosus; RN, newborn (s); NEC, necrotizing enterocolitis; NP, parenteral nutrition.
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1. Mosalli R, Paes B. Patent ductus arteriosus: optimal fluid requirements in preterm infants. NeoReviews. 2010;11(9):e495-e502.
2. Golombek SG, Sola A, Baquero H, Borbonet D, Cabañas F, Fajardo C, et al, editors. Primer consenso clínico de SIBEN: enfoque diagnóstico y terapéutico del ductus arterioso permeable en recién nacidos pretérmino. An Pediatr. 2008; 69(5): 454-81.
3. Mezu-Ndubuisi OJ, Agarwal G, Raghavan A, Pham JT, Ohler KH, Maheshwari A. Patent ductus arteriosus in premature neonates. Drugs. 2012; 72(7): 907-16.
4. Philips III JB, Garcia-Prats JA, Kim MS. Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants [monografía en Internet]. Massachusetts: UpToDate; 2013 [citado 7 Jul 2014]. Disponible en: http://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-patent-ductus-arteriosus-in-premature-infants
5. Rojas MX, Rojas MA, Lozano JM, Rondón MA, Charry LP. Regional variation on rates of bronchopulmonary dysplasia and associated risk factors. ISRN Pediatr. 2012; 2012:685151.
6. Tamayo Pérez ME, Arango Rivera MV, Tamayo Múnera C. Fisiopatología y factores de riesgo para el desarrollo de enterocolitis necrosante en neonatos menores de 1.500 g. Iatreia. 2006;19(4): 356-67.
7. Evans N. Preterm patent ductus arteriosus: Should we treat it?. J Paediatr Child Health. 2012; 48(9):753-8.
8. De Buyst J, Rakza T, Pennaforte T, Johansson AB, Storme L. Hemodynamic effects of fluid restriction in preterm infants with significant patent ductus arteriosus. J Pediatr. 2012;161(3):404-8.
9. Anabrees J, Alfaleh K. Fluid restriction and prophylactic indomethacin versus prophylactic indomethacin alone for prevention of morbidity and mortality in extremely low birth weight infants. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007604.
10. Foo A. North Trent Neonatal Network clinical guideline: patent ductus arteriosus [monografía en Internet]. Londres: North Trent Neonatal Network; 2013 [citado 9 Jul 2014]. Disponible en: http://www.northtrentneonatal.nhs.uk/UserFiles/File/Guidelines/PDA%20-%202012.pdf.
11. Ohlsson A, Walia R, Shah S. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003481.
12. Meißner U, Chakrabarty R, Topf H-G, Rascher W, Schroth M. Improved closure of patent ductus arteriosus with high doses of ibuprofen. Pediatr Cardiol. 2012;33(4):586-90.
13. Colombia. Ministerio de la Protección Social. Guía metodológica para la elaboración de guías de práctica clínica basadas en la evidencia, de evaluaciones económicas y de evaluación del impacto de la implementación de las guías en el POS y en la unidad de pago por capitación del Sistema General de Seguridad Social en Salud Colombiano. Bogotá: El Ministerio; 2009.
14. Hajj H, Dagle JM. Genetics of patent ductus arteriosus susceptibility and treatment. Semin Perinatol. 2012 Apr; 36(2):98-104.
15. San Luis-Miranda R, Arias-Monroy LG, Peralta-Pedrero ML, Lázaro-Castillo JL, León-Ávila JL, Benítez-Aréchiga ZM, et al. Guía de práctica clínica. Persistencia del conducto arterioso. Rev Med Inst Mex Seguro Soc. 2012; 50 (4): 453-63.
16. Tejera Ramírez C, Suárez Cabrera P, Antúnez Jiménez M, Falcón González H. Ductus arterioso persistente en el prematuro. Protocolos diagnósticos y terapéuticos en cardiología pediátrica [monografía en Internet]. Madrid: Telecardiologo; 2009 [citado 9 Jul 2014]. Disponible en: http://telecardiologo.com/descargas/37697.pdf.
17. Tauzin L, Joubert C, Noel AC, Bouissou A, Moulies ME. Effect of persistent patent ductus arteriosus on mortality and morbidity in very low‐birthweight infants. Acta Paediatr. 2012;101(4):419-23.
18. Connuck D, Sun JP, Super DM, Kirchner HL, Fradley LG, Harcar-Sevcik RA, et al. Incidence of patent ductus arteriosus and patent foramen ovale in normal infants. Am J Cardiol. 2002; 89(2), 244-247.
19. Acosta JC, Castaño Castrillón JJ, Álvarez C, Gaitán LF, León Tufiño AM, Mariño I, et al. Prevalencia de las cardiopatias congenitas en un hospital de la ciudad de Manizales, Colombia, años 2000 y 2008. Arch Med Manizales. 2009;9(2):99-109.
20. Popat H, Kapoor V, Travadi J. Patent ductus arteriosus in infants <29 weeks gestation—outcomes and factors affecting closure. Indian Pediatr. 2012;49(8):615-20.
21. Forsey JT, Elmasry OA, Martin RP. Patent arterial duct. Orphanet J Rare Dis. 2009;4(1):17.
22. Evans N. Diagnosis of the preterm patent ductus arteriosus: clinical signs, biomarkers, or ultrasound?. Semin Perinatol. 2012 Apr; 36(2):114-22.
23. Pilling E, Bustani P. North Trent Neonatal Network clinical guideline: feeding the preterm infant [monografía en Internet]. Londres: North Trent Neonatal Network; 2011 [citado 9 Jul 2014]. Disponible en: http://www.northtrentneonatal.nhs.uk/UserFiles/File/Feeding%20COMPLETED.pdf
24. Trefz M, Wilson N, Acton R, Hess DJ, Bass JL. Echocardiographic assessment of ductal anatomy in premature infants—lessons for device design. Echocardiography. 2010;27(5):575-9.
25. Kluckow M, Evans N. Early echocardiographic prediction of symptomatic patent ductus arteriosus in preterm infants undergoing mechanical ventilation. J Pediatr. 1995;127(5):774-9.
26. Murase M, Ishida A, Momota T. Serial pulsed Doppler assessment of early left ventricular output in critically ill very low-birth-weight infants. Pediatr Cardiol. 2002;23(4):442-8.
27. Ruiz González MD, Gómez Guzmán E, Párraga Quiles MJ, Tejero MA, Guzmán Cabañas JM. Protocolos diagnóstico terapeúticos de la AEP (Neonatología): ductus arterioso persistente [monografía en Internet]. Madrid: AEP; 2008 [citado 9 Jul 2014]. Disponible en: http://www.aeped.es/sites/default/files/documentos/36.pdf
28. Choi BM, Lee KH, Eun BL, Yoo KH, Hong YS, Son CS, Lee JW. Utility of rapid B-type natriuretic peptide assay for diagnosis of symptomatic patent ductus arteriosus in preterm infants. Pediatrics. 2005;115(3):e255-e61.
29. Flynn PA, da Graca RL, Auld PA, Nesin M, Kleinman CS. The use of a bedside assay for plasma B-type natriuretic peptide as a biomarker in the management of patent ductus arteriosus in premature neonates. J Pediatr. 2005;147(1):38-42.
30. Chen S, Tacy T, Clyman R. How useful are B-type natriuretic peptide measurements for monitoring changes in patent ductus arteriosus shunt magnitude. J Perinatol. 2010;30(12):780-5.
31. Sanjeev S, Pettersen M, Lua J, Thomas R, Shankaran S, L’Ecuyer T. Role of plasma B-type natriuretic peptide in screening for hemodynamically significant patent ductus arteriosus in preterm neonates. J Perinatol. 2005;25(11):709-13.
32. Lorenz JM, Kleinman LI, Kotagal UR, Reller MD. Water balance in very lowbirth-weight infants: relationship to water and sodium intake and effect on outcome. J Pediatr.1982;101(3):423-32.
33. Tammela O, Lanning F, Koivisto M. The relationship of fluid restriction during the 1st month of life to the occurrence and severity of bronchopulmonary dysplasia in low birth weight infants: a 1-year radiological follow up. Eur J Pediatr. 1992;151(4):295-9.
34. Von Stockhausen H, Struve M. Effects of highly varying parenteral fluid intakes in premature and newborn infants during the first three days of life (author’s transl)]. Klin Padiatr. 1980;192(6):539.
35. Bell E, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2001;(3):CD000503.
36. Ekici F, Atasay B, Gunlemez A. Management of patent ductus arteriosus in preterm infants. Anadolu Kardiyol Derg. 2006;6(1):28-33.
37. Clyman R, Wickremasinghe A, Jhaveri N, Hassinger DC, Attridge JT, Sanocka U, et al. Enteral Feeding during Indomethacin and Ibuprofen Treatment of a Patent Ductus Arteriosus. J Pediatr. J Pediatr. 2013 Aug; 163(2):406-11.
38. Philips III JB, Garcia-Prats JA, Fulton DR, Kim MS. Management of patent ductus arteriosus in premature infants. [monografía en Internet]. Massachusetts: UpToDate; 2013 [citado 7 Jul 2014]. Disponible en: http://www.uptodate.com/contents/management-of-patent-ductus-arteriosus-in-premature-infants
39. Maruyama K, Fujiu T. Effects of prophylactic indomethacin on renal and intestinal blood flows in premature infants. Pediatr Int. 2012;54(4):480-5.
40. van der Lugt NM, Lopriore E, Bökenkamp R, Smits-Wintjens VE, Steggerda SJ, Walther FJ. Repeated courses of ibuprofen are effective in closure of a patent ductus arteriosus. Eur J Pediatr. 2012;171(11):1673-7.
41. Bhatt M, Petrova A, Mehta R. Does treatment of patent ductus arteriosus with cyclooxygenase inhibitors affect neonatal regional tissue oxygenation?. Pediatr Cardiol. 2012;33(8):1307-14.
42. Cooke L, Steer P, Woodgate P. Indomethacin for asymptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. 2003;(2):CD003745.
43. Brunner B, Hoeck M, Schermer E, Streif W, Kiechl-Kohlendorfer U. Patent Ductus Arteriosus, Low Platelets, Cyclooxygenase Inhibitors, and Intraventricular Hemorrhage in Very Low Birth Weight Preterm Infants. J Pediatr. 2013 Jul; 163(1):23-8.
44. Brion L, Campbell D. Furosemide for prevention of morbidity in indomethacin-treated infants with patent ductus arteriosus. Cochrane Database Syst Rev. 2008; (3).
45. Desandes R, Jellimann JM, Rouabah M, Haddad F, Desandes E, Boubred F, et al. Echocardiography as a guide for patent ductus arteriosus ibuprofen treatment and efficacy prediction. Pediatr Crit Care Med. 2012;13(3):324-7.
46. Keller RL, Clyman RI. Persistent Doppler flow predicts lack of response to multiple courses of indomethacin in premature infants with recurrent patent ductus arteriosus. Pediatrics. 2003;112(3):583-7.
47. Desfrere L, Thibaut C, Kibleur Y, Barbier A, Bordarier C, Moriette G. Unbound bilirubin does not increase during ibuprofen treatment of patent ductus arteriosus in preterm infants. J Pediatr. 2012;160(2):258-64.
48. Katakam LI, Cotten CM, Goldberg RN, Dang CN, Smith PB. Safety and effectiveness of indomethacin versus ibuprofen for treatment of the patent ductus arteriosus. Am J Perinatol. 2010;27(5):425.
49. Mirea L, Sankaran K, Seshia M, Ohlsson A, Allen AC, Aziz K, et al. Treatment of patent ductus arteriosus and neonatal mortality/morbidities: adjustment for treatment selection bias. J Pediatr. 2012;161(4):689-94.
50. El-Khuffash AF, Jain A, Dragulescu A, McNamara PJ, Mertens L. Acute changes in myocardial systolic function in preterm infants undergoing patent ductus arteriosus ligation: a tissue Doppler and myocardial deformation study. J Am Soc Echocardiogr. 2012 Oct; 25(10):1058-67
2. Golombek SG, Sola A, Baquero H, Borbonet D, Cabañas F, Fajardo C, et al, editors. Primer consenso clínico de SIBEN: enfoque diagnóstico y terapéutico del ductus arterioso permeable en recién nacidos pretérmino. An Pediatr. 2008; 69(5): 454-81.
3. Mezu-Ndubuisi OJ, Agarwal G, Raghavan A, Pham JT, Ohler KH, Maheshwari A. Patent ductus arteriosus in premature neonates. Drugs. 2012; 72(7): 907-16.
4. Philips III JB, Garcia-Prats JA, Kim MS. Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants [monografía en Internet]. Massachusetts: UpToDate; 2013 [citado 7 Jul 2014]. Disponible en: http://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-patent-ductus-arteriosus-in-premature-infants
5. Rojas MX, Rojas MA, Lozano JM, Rondón MA, Charry LP. Regional variation on rates of bronchopulmonary dysplasia and associated risk factors. ISRN Pediatr. 2012; 2012:685151.
6. Tamayo Pérez ME, Arango Rivera MV, Tamayo Múnera C. Fisiopatología y factores de riesgo para el desarrollo de enterocolitis necrosante en neonatos menores de 1.500 g. Iatreia. 2006;19(4): 356-67.
7. Evans N. Preterm patent ductus arteriosus: Should we treat it?. J Paediatr Child Health. 2012; 48(9):753-8.
8. De Buyst J, Rakza T, Pennaforte T, Johansson AB, Storme L. Hemodynamic effects of fluid restriction in preterm infants with significant patent ductus arteriosus. J Pediatr. 2012;161(3):404-8.
9. Anabrees J, Alfaleh K. Fluid restriction and prophylactic indomethacin versus prophylactic indomethacin alone for prevention of morbidity and mortality in extremely low birth weight infants. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007604.
10. Foo A. North Trent Neonatal Network clinical guideline: patent ductus arteriosus [monografía en Internet]. Londres: North Trent Neonatal Network; 2013 [citado 9 Jul 2014]. Disponible en: http://www.northtrentneonatal.nhs.uk/UserFiles/File/Guidelines/PDA%20-%202012.pdf.
11. Ohlsson A, Walia R, Shah S. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003481.
12. Meißner U, Chakrabarty R, Topf H-G, Rascher W, Schroth M. Improved closure of patent ductus arteriosus with high doses of ibuprofen. Pediatr Cardiol. 2012;33(4):586-90.
13. Colombia. Ministerio de la Protección Social. Guía metodológica para la elaboración de guías de práctica clínica basadas en la evidencia, de evaluaciones económicas y de evaluación del impacto de la implementación de las guías en el POS y en la unidad de pago por capitación del Sistema General de Seguridad Social en Salud Colombiano. Bogotá: El Ministerio; 2009.
14. Hajj H, Dagle JM. Genetics of patent ductus arteriosus susceptibility and treatment. Semin Perinatol. 2012 Apr; 36(2):98-104.
15. San Luis-Miranda R, Arias-Monroy LG, Peralta-Pedrero ML, Lázaro-Castillo JL, León-Ávila JL, Benítez-Aréchiga ZM, et al. Guía de práctica clínica. Persistencia del conducto arterioso. Rev Med Inst Mex Seguro Soc. 2012; 50 (4): 453-63.
16. Tejera Ramírez C, Suárez Cabrera P, Antúnez Jiménez M, Falcón González H. Ductus arterioso persistente en el prematuro. Protocolos diagnósticos y terapéuticos en cardiología pediátrica [monografía en Internet]. Madrid: Telecardiologo; 2009 [citado 9 Jul 2014]. Disponible en: http://telecardiologo.com/descargas/37697.pdf.
17. Tauzin L, Joubert C, Noel AC, Bouissou A, Moulies ME. Effect of persistent patent ductus arteriosus on mortality and morbidity in very low‐birthweight infants. Acta Paediatr. 2012;101(4):419-23.
18. Connuck D, Sun JP, Super DM, Kirchner HL, Fradley LG, Harcar-Sevcik RA, et al. Incidence of patent ductus arteriosus and patent foramen ovale in normal infants. Am J Cardiol. 2002; 89(2), 244-247.
19. Acosta JC, Castaño Castrillón JJ, Álvarez C, Gaitán LF, León Tufiño AM, Mariño I, et al. Prevalencia de las cardiopatias congenitas en un hospital de la ciudad de Manizales, Colombia, años 2000 y 2008. Arch Med Manizales. 2009;9(2):99-109.
20. Popat H, Kapoor V, Travadi J. Patent ductus arteriosus in infants <29 weeks gestation—outcomes and factors affecting closure. Indian Pediatr. 2012;49(8):615-20.
21. Forsey JT, Elmasry OA, Martin RP. Patent arterial duct. Orphanet J Rare Dis. 2009;4(1):17.
22. Evans N. Diagnosis of the preterm patent ductus arteriosus: clinical signs, biomarkers, or ultrasound?. Semin Perinatol. 2012 Apr; 36(2):114-22.
23. Pilling E, Bustani P. North Trent Neonatal Network clinical guideline: feeding the preterm infant [monografía en Internet]. Londres: North Trent Neonatal Network; 2011 [citado 9 Jul 2014]. Disponible en: http://www.northtrentneonatal.nhs.uk/UserFiles/File/Feeding%20COMPLETED.pdf
24. Trefz M, Wilson N, Acton R, Hess DJ, Bass JL. Echocardiographic assessment of ductal anatomy in premature infants—lessons for device design. Echocardiography. 2010;27(5):575-9.
25. Kluckow M, Evans N. Early echocardiographic prediction of symptomatic patent ductus arteriosus in preterm infants undergoing mechanical ventilation. J Pediatr. 1995;127(5):774-9.
26. Murase M, Ishida A, Momota T. Serial pulsed Doppler assessment of early left ventricular output in critically ill very low-birth-weight infants. Pediatr Cardiol. 2002;23(4):442-8.
27. Ruiz González MD, Gómez Guzmán E, Párraga Quiles MJ, Tejero MA, Guzmán Cabañas JM. Protocolos diagnóstico terapeúticos de la AEP (Neonatología): ductus arterioso persistente [monografía en Internet]. Madrid: AEP; 2008 [citado 9 Jul 2014]. Disponible en: http://www.aeped.es/sites/default/files/documentos/36.pdf
28. Choi BM, Lee KH, Eun BL, Yoo KH, Hong YS, Son CS, Lee JW. Utility of rapid B-type natriuretic peptide assay for diagnosis of symptomatic patent ductus arteriosus in preterm infants. Pediatrics. 2005;115(3):e255-e61.
29. Flynn PA, da Graca RL, Auld PA, Nesin M, Kleinman CS. The use of a bedside assay for plasma B-type natriuretic peptide as a biomarker in the management of patent ductus arteriosus in premature neonates. J Pediatr. 2005;147(1):38-42.
30. Chen S, Tacy T, Clyman R. How useful are B-type natriuretic peptide measurements for monitoring changes in patent ductus arteriosus shunt magnitude. J Perinatol. 2010;30(12):780-5.
31. Sanjeev S, Pettersen M, Lua J, Thomas R, Shankaran S, L’Ecuyer T. Role of plasma B-type natriuretic peptide in screening for hemodynamically significant patent ductus arteriosus in preterm neonates. J Perinatol. 2005;25(11):709-13.
32. Lorenz JM, Kleinman LI, Kotagal UR, Reller MD. Water balance in very lowbirth-weight infants: relationship to water and sodium intake and effect on outcome. J Pediatr.1982;101(3):423-32.
33. Tammela O, Lanning F, Koivisto M. The relationship of fluid restriction during the 1st month of life to the occurrence and severity of bronchopulmonary dysplasia in low birth weight infants: a 1-year radiological follow up. Eur J Pediatr. 1992;151(4):295-9.
34. Von Stockhausen H, Struve M. Effects of highly varying parenteral fluid intakes in premature and newborn infants during the first three days of life (author’s transl)]. Klin Padiatr. 1980;192(6):539.
35. Bell E, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2001;(3):CD000503.
36. Ekici F, Atasay B, Gunlemez A. Management of patent ductus arteriosus in preterm infants. Anadolu Kardiyol Derg. 2006;6(1):28-33.
37. Clyman R, Wickremasinghe A, Jhaveri N, Hassinger DC, Attridge JT, Sanocka U, et al. Enteral Feeding during Indomethacin and Ibuprofen Treatment of a Patent Ductus Arteriosus. J Pediatr. J Pediatr. 2013 Aug; 163(2):406-11.
38. Philips III JB, Garcia-Prats JA, Fulton DR, Kim MS. Management of patent ductus arteriosus in premature infants. [monografía en Internet]. Massachusetts: UpToDate; 2013 [citado 7 Jul 2014]. Disponible en: http://www.uptodate.com/contents/management-of-patent-ductus-arteriosus-in-premature-infants
39. Maruyama K, Fujiu T. Effects of prophylactic indomethacin on renal and intestinal blood flows in premature infants. Pediatr Int. 2012;54(4):480-5.
40. van der Lugt NM, Lopriore E, Bökenkamp R, Smits-Wintjens VE, Steggerda SJ, Walther FJ. Repeated courses of ibuprofen are effective in closure of a patent ductus arteriosus. Eur J Pediatr. 2012;171(11):1673-7.
41. Bhatt M, Petrova A, Mehta R. Does treatment of patent ductus arteriosus with cyclooxygenase inhibitors affect neonatal regional tissue oxygenation?. Pediatr Cardiol. 2012;33(8):1307-14.
42. Cooke L, Steer P, Woodgate P. Indomethacin for asymptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. 2003;(2):CD003745.
43. Brunner B, Hoeck M, Schermer E, Streif W, Kiechl-Kohlendorfer U. Patent Ductus Arteriosus, Low Platelets, Cyclooxygenase Inhibitors, and Intraventricular Hemorrhage in Very Low Birth Weight Preterm Infants. J Pediatr. 2013 Jul; 163(1):23-8.
44. Brion L, Campbell D. Furosemide for prevention of morbidity in indomethacin-treated infants with patent ductus arteriosus. Cochrane Database Syst Rev. 2008; (3).
45. Desandes R, Jellimann JM, Rouabah M, Haddad F, Desandes E, Boubred F, et al. Echocardiography as a guide for patent ductus arteriosus ibuprofen treatment and efficacy prediction. Pediatr Crit Care Med. 2012;13(3):324-7.
46. Keller RL, Clyman RI. Persistent Doppler flow predicts lack of response to multiple courses of indomethacin in premature infants with recurrent patent ductus arteriosus. Pediatrics. 2003;112(3):583-7.
47. Desfrere L, Thibaut C, Kibleur Y, Barbier A, Bordarier C, Moriette G. Unbound bilirubin does not increase during ibuprofen treatment of patent ductus arteriosus in preterm infants. J Pediatr. 2012;160(2):258-64.
48. Katakam LI, Cotten CM, Goldberg RN, Dang CN, Smith PB. Safety and effectiveness of indomethacin versus ibuprofen for treatment of the patent ductus arteriosus. Am J Perinatol. 2010;27(5):425.
49. Mirea L, Sankaran K, Seshia M, Ohlsson A, Allen AC, Aziz K, et al. Treatment of patent ductus arteriosus and neonatal mortality/morbidities: adjustment for treatment selection bias. J Pediatr. 2012;161(4):689-94.
50. El-Khuffash AF, Jain A, Dragulescu A, McNamara PJ, Mertens L. Acute changes in myocardial systolic function in preterm infants undergoing patent ductus arteriosus ligation: a tissue Doppler and myocardial deformation study. J Am Soc Echocardiogr. 2012 Oct; 25(10):1058-67