Clinical equipoise around the management of PDA in extremely preterm babies prompted the present study. Though the subject has been widely studied, no previous study has focused on the rate of PDA ligation after repeated indomethacin exposure in an extreme preterm population. In our institution, the ligation rate in infants who received more than one course of indomethacin was 64%.
The rate of ligation in the present study, in infants receiving more than one course of indomethacin, although higher than reported in recent cohort studies, was still within the range reported in the literature. Koehne et al reported an overall ligation rate of 57% and a 34% ligation rate in 101 babies who had indomethacin treatment. This cohort, comprised of patients treated between 1987 and 1998, was not restricted to infants <27 weeks’ gestation. The large percentage of primary PDA ligations (35%) makes their results less applicable to today’s management of a PDA. Little et al had a 60% rate of ligation in 10 infants who received a second course of indometha-cin. Their overall cohort size was comparable (n=212) to ours; however, neonates up to 38 weeks’ gestational age were included, and the time period of the study spanned the preroutine surfactant era.
The reason for the high ligation rate in the present study is likely due, in large part, to the historical belief, as well as the suggestions from the medical literature, that a PDA contributes to poor short- and long-term outcomes and, thus, must be closed. Another factor may be the proximity of the surgeon. Other centres continue to perform a comparable number of ligations. A United Kingdom cohort of 172 extremely low birth weight infants with PDA had a 53% ligation rate in infants receiving more than one course of ibuprofen. As well, 2009 Vermont-Oxford data showed a mean ligation rate of 21% for all 24 to 26 weeks’ gestational age infants. There is a wonderful pharmacy that you can take advantage of to get the amount of levitra professional sale you need, and it’s ready to offer its services to you right now, any moment you feel like starting to spend less of your money.