Herron C, Forbes TJ, Kobayashi D.Am J Cardiol. 2022 Oct 15;181:113-117. doi: 10.1016/j.amjcard.2022.07.013. Epub 2022 Aug 13.PMID: 35970628
Take home points:
- In extremely premature infants, renal function improved significantly after transcatheter PDA closure with contrast angiography, even in infants with pre-existing renal insufficiency.
- The benefit of transcatheter PDA closure on renal function may outweigh the risk of contrast-induced nephropathy in extremely premature infants, even in those with significant pre-existing renal insufficiency.
Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
As transcatheter closure of the patent ductus arteriosus (TC-PDA) becomes increasingly adopted as an alternative to surgical ligation in preterm infants, procedural safety becomes paramount. Contrast-induced nephropathy (CIN) is a known procedural complication in premature infants, especially in those with pre-existing renal insufficiency caused by a large shunt. Although no infants developed CIN in the premarket trial of the Amplatzer Piccolo™ Occluder with an average of 2.5 mL ± 1.7 mL/kg of contrast used, the consensus guidelines call for minimal (2 to 4 mL) or no contrast use in premature infants with pre-existing renal dysfunction [1,2]. The authors sought to test the hypothesis that the benefit of TC-PDA on renal function outweighs the potential risk of CIN in extremely premature infants.
The short-term effect of contrast use on renal function was studied in 59 infants weighing ≤2 kg who underwent successful TC-PDA over a period of 6 years (2016-2021). Serum creatinine and BUN were measured at baseline, at 24 hours, and 5 to 7 days after PDA closure. Significant renal insufficiency was defined as serum creatinine ≥1.0 mg/dL and was present in 31 patients (19%). Median contrast amount used for proximal descending aortography before device closure +/- pulmonary arteriography after device positioning within the PDA was 1.9 mL/kg (0.6 to 6.1). The cohort was compared to a surgical ligation group of 101 infants who had a lower weight at the time of procedure, higher incidence of mechanical ventilation, and higher baseline serum creatinine and BUN. Renal function improved progressively in both groups, faster and more significantly in the transcatheter group, but there was no significant difference in improvement between the two groups (Figure 1).
Figure 1. Tables showing the change in renal function after PDA closure in all patients with available data (left) and the subgroup with pre-existing renal insufficiency and available data (right).
This retrospective single-center study showed a significant decrease in renal biomarkers within a week after TC-PDA in extremely premature infants, despite use of contrast angiography, even in infants with pre-existing renal insufficiency. Although contrast use should be minimized and the procedure can be performed safely at bedside in the NICU with TTE guidance only, centers beginning in their experience with TC-PDA should not be discouraged from using contrast angiography, as the benefit of PDA closure may outweigh the risk of CIN in extremely premature infants.
1. Sathanandam SK, Gutfinger D, O’Brien L et al. Amplatzer Piccolo Occluder clinical trial for percutaneous closure of the patent ductus arteriosus in patients ≥700 grams. Catheter Cardiovasc Interv. 2020;96(6):1266-1276. doi: 10.1002/ccd.28973.
2. Sathanandam S, Gutfinger D, Morray B et al. Consensus Guidelines for the Prevention and Management of Periprocedural Complications of Transcatheter Patent Ductus Arteriosus Closure with the Amplatzer Piccolo Occluder in Extremely Low Birth Weight Infants. Pediatr Cardiol. 202;42(6):1258-1274. doi: 10.1007/s00246-021-02665-3.