Towards rational management of the patent ductus arteriosus: the need for disease staging

Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis?

“…This should prompt continued development and evaluation of objective measures of the hemodynamic consequences of ductal patency, such as the clinical and echocardiographic staging system proposed by McNamara and Sehgal. 136 New technologies that enable direct measurement of tissue perfusion or oxygenation also may prove valuable. Such measures may identify particular subgroups of infants at special risk for adverse outcomes.…”

Spectral Doppler waveforms in systemic arteries and physiological significance of a patent ductus arteriosus

“…12 Our group has recently proposed a 'PDA-staging' system which recognizes the HSDA as a physiological continuum with heterogeneity of clinical and echocardiography significance. 18 The PDA-staging system classifies ductal illness severity according to incremental clinical and echocardiography characteristics, which are direct consequences of pulmonary overcirculation and/or systemic hypoperfusion. In the echocardiography component (stages I to IV) of the staging system, decreased or absent end-diastolic flow in the systemic arteries (such as the celiac or middle cerebral artery) is staged as E3, whereas reversal of flow signifies greater magnitude of shunt and steal and is classified as E4.…”

Reply to McNamara and Jain

“…1 On the whole, my coauthors and I agree with their salient points: (1) deleterious effects of a PDA are likely related to the magnitude and duration of the left-to-right shunt, and these data are generally not documented in PDA publications (including ours, although we made some progress in this regard), (2) small restrictive PDAs likely have been overtreated in past years (and our study specifically avoided this pitfall), (3) standardizing the definition of hemodynamic significance is paramount to refining rational PDA therapy.…”