Comparison of early and late surgical ligation of patent ductus arteriosus in preterm infants

Management of the patent ductus arteriosus (PDA) in the preterm infants has been highly controversial. Although the rate of surgical ligation has decreased, surgical ligation remains a necessary treatment option when the patient has a large hemodynamically significant PDA unresponsive with medical treatment or contraindicated of medical treatment. However, optimal timing of surgical ligation is still controversial and has no guideline. We compared clinical characteristics of early and late surgical ligation of PDA in preterm infants to understand the timing of surgical ligation. This retrospective study included preterm infants <36 weeks gestational age and with a PDA treated with surgical ligation in our hospital between January 2014 and December 2024. The infants were divided into early ligation group (at <2 weeks of life) and late ligation group (at >2 weeks of life) and compared both groups according to their clinical and echocardiographic data. The early ligation group and late ligation group included 64 and 35 patients, respectively. Baseline demographic characteristics, including gestational age and birth weight, were similar between the groups. Although PDA size and other echocardiographic parameters were comparable, the left atrial to aortic root ratio was significantly higher in the early group (1.97 vs 1.74, P = .018). The late ligation group had a significantly higher incidence of severe bronchopulmonary dysplasia (68.6% vs 35.9%, P = .003) and a trend toward longer mechanical ventilation duration. No significant differences were observed in rates of other complications, including intraventricular hemorrhage, necrotizing enterocolitis, or postoperative complications such as vocal cord palsy and post-ligation cardiac syndrome. Late PDA ligation in preterm infants is associated with a higher risk of severe bronchopulmonary dysplasia and prolonged ventilator support. These findings support considering earlier surgical ligation in selected preterm infants with hemodynamically significant PDA, particularly when medical therapy fails.