465 - Evaluation of Post-Ligation Cardiac Syndrome Following Surgical or Transcatheter PDA Closure in Premature Infants

Publication Number: 3450.465

Kevin M. Blum, Duke University School of Medicine, Durham, NC, United States; Yasmeen A. Midgette, Duke University School of Medicine, Durham, NC, United States; Rick Pittman, Duke University School of Medicine, Durham, NC, United States; Rachel G. Greenberg, Duke Clinical Research Institute, Durham, NC, United States; Michael Cotten, Duke University School of Medicine, Durham, NC, United States; Lakshmi Katakam, Duke University School of Medicine, Durham, NC, United States

Background: Patent ductus arteriosus (PDA) is a common condition in preterm infants and is associated with increased risk of bronchopulmonary dysplasia (BPD), heart failure, and pulmonary hypertension (PH). Pharmacologic PDA closure often fails leading to surgical ligation (SL) or transcatheter (TC) device closure. Post-ligation cardiac syndrome (PLCS), marked by cardio-respiratory instability, often involves hypotension but emerging data report underrecognized hypertension (HTN), and will be a primary outcome in the NICHD Neonatal Research Network (NRN) Milrinone for prevention of post-patent Ductus Arteriosus closure Syndrome (MIDAS) trial, highlighting a key target for quality improvement efforts for tertiary NICUs.

Objective: To assess incidence of PLCS, hypotension, and HTN after PDA closure in preterm infants, and to identify targets for NICU quality improvement.

Design/Methods: Retrospective review of inborn infants < 28 weeks gestation admitted to the Duke NICU (Jan 2018-Jul 2025) who underwent SL or TC PDA closure within 90 postnatal days. Exclusions included major cardiac anomalies and immediate pre-closure pressor use. Primary outcomes, like those described for the MIDAS trial, were death within 7 days or PLCS within 1 day, defined by respiratory escalation or oxygenation failure (≥20% increase in FiO₂ or MAP) with hypo- ( < 3%ile) or hyper-tension (>95%ile). Secondary outcomes included post-closure recovery time, PH, and BPD.

Results: Among 41 infants who underwent PDA closure (18 SL, 23 TC), more male and Hispanic patients were in SL group and more black patients in TC group (Table 1). The majority of patients in both groups had Medicaid insurance. SL patients were of lower gestational age, weighed less at closure, and more often intubated prior to intervention. Closure occurred earlier in SL patients. Pharmacotherapy attempts were similar between groups (3±1 vs. 2±1 courses), with comparable use of acetaminophen and indomethacin (Figure 1).
Post-closure, SL patients had higher rates of respiratory escalation / oxygenation failure (72% vs. 43%) and PLCS (44% vs. 19%). HTN PLCS was more common in SL (39% vs. 19%). Hypotension PLCS occurred only in SL (11%). HTN was frequent in both groups (50% SL vs. 43% TC) and required longer to recover than hypotension. PH was more common in TC patients (29% vs. 10%). No deaths occurred (Table 2).

Conclusion(s): Hypertension is common after SL and TC PDA closure and may be an underrecognized component of PLCS. Findings support standardized post-closure monitoring and studies such as MIDAS to identify optimal strategies for treatment post-PDA closure.

Patient Demographics
Demographics and pre-intervention characteristics for patients undergoing SL or TC PDA closure

Pharmacologic Courses
Number of pharmacologic treatment courses attempted prior to PDA closure. Bars represent the distribution of patients undergoing 0 to 5 courses of medical therapy (e.g., acetaminophen, indomethacin) before proceeding to surgical ligation (SL) or transcatheter (TC) closure.

Patient Outcomes
Post-intervention outcomes and complications following SL or TC PDA closure