Surgical ligation of patent ductus arteriosus in pre-term infants: a narrative review

Background and Objective: Patent ductus arteriosus (PDA) in preterm neonates is common. Despite most of them would close spontaneously, some of them could lead to significant deleterious haemodynamic consequences. Surgical ligation used to be the main stay of therapy; however, cyclooxygenase inhibitors and catheter-based techniques have been gaining ground. A head-to-head comparison of these modalities is confounded by the presence of multiple factors that prevent a clear consensus. We attempted to look at this aspect with an aim to clarify the role of surgical ligation and its current relevance. Methods: PubMed, Cochrane and Embase databases were reviewed using search keywords. Original articles, meta-analysis and systematic reviews in the English language describing therapy protocols for the PDA in preterm infants were selected. Relevant references in some of these articles were included as well. Key Content and Findings: Multiple factors play a role in the modality-of-choice for closing a haemodynamically significant PDA. Decision-making and treatment protocols remain controversial and often represent team experience and preferences. Surgical ligation is seldom the first option in the management. When surgery is chosen to treat ductus arteriosus, these infants had often been trialled with other forms of management including conservative or medical therapy. Comparison of patient groups, specific closing methods and outcomes remains difficult. Conclusions: Patency of the arterial duct is more prevalent among lower birth weight (BW) and lower gestational age (GA) infants. PDA is often considered an isolated entity; however, it participates in a 'continuum' of morbidities. Although many studies note higher incidence of mortality, necrotizing enterocolitis, chronic lung disease (CLD) and neuro-developmental impairment (NDI) after surgical ligation, most of these studies may represent selection bias since surgical ligation was the last line of therapy. NDI and CLD, two conditions of a strong association with PDA, require further clarification of pathogenesis and their relationship with the therapeutic methods.