PDA ligation and regional blood flow

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It may come as a surprise that the controversy about how to manage patent ductus arteriosis (PDA) in preterm infants has heated up in recent years. The majority of clinicians attempt to close a significant PDA with indomethacin or ibuprofen, although the definition of “significant” is unclear. If the PDA does not close (how many courses, what doses, and at what age?) or reopens, then surgical closure is considered by some clinicians. The decision to surgically close a “significant” PDA is complicated by recent experiences indicating that surgery of any kind in newborns is associated with poor neurodevelopmental outcomes and some preterm infants seem to not tolerate a PDA ligation, perhaps because of acute physiological changes that are imposed on a cardiovascular system that has adapted to the PDA. The new information reported in this issue of The Journal by Hoodbhoy et al will contribute to the discussion. They used ultrasound to evaluate hemodynamics in middle cerebral, celiac, and superior mesenteric arteries before and after PDA ligation. They found regional and interval after PDA ligation specific alterations in hemodynamics. The best management for a preterm infant with a PDA remains unclear.