Outcomes associated with surgical ligation versus medical treatment for patent ductus arteriosus in extremely preterm infants

The association between surgical ligation of patent ductus arteriosus (PDA) and outcomes in extremely preterm infants remains uncertain because of treatment-selection and survival biases. Using data from the Taiwan Premature Infant Follow-up Network (1997–2017), we conducted a propensity score–matched cohort study of infants born at < 28 weeks’ gestation. Among 4071 infants with hemodynamically significant PDA, 1211 matched pairs were analyzed. Surgical ligation was associated with an increased risk of neurodevelopmental impairment (NDI) (adjusted risk ratio [ARR], 1.18; 95% CI 1.01–1.38) and lower mortality before discharge (ARR, 0.53; 95% CI 0.43–0.64), but not with the composite outcome of NDI or death (ARR, 0.96; 95% CI 0.86–1.08). Among infants surviving beyond 36 weeks’ postmenstrual age, associations with NDI (ARR, 1.15; 95% CI 0.97–1.36), mortality (ARR, 1.08; 95% CI 0.68–1.74), and the composite outcome (ARR, 1.14; 95% CI 0.97–1.34) were not statistically significant. Mediation analyses identified significant indirect associations through bronchopulmonary dysplasia and retinopathy of prematurity. These findings highlight the potential influence of treatment selection, survival-related bias, and postnatal morbidities on the observed associations between surgical ligation and subsequent outcomes and underscore the challenges of attributing adverse neurodevelopmental outcomes directly to surgical ligation.