In the world of neonatal intensive care, few topics stir as much quiet controversy as the patent ductus arteriosus, a small blood vessel that every fetus needs but that can cause serious trouble when it refuses to close after birth. A new cross-sectional survey of more than 400 American specialists, published in the Journal of Perinatology, has now put hard numbers on just how divided the medical community remains over when and how to treat the so-called hemodynamically significant patent ductus arteriosus, or hsPDA, in premature infants. The findings reveal a field in flux, where two specialties that care for the same tiny patients look at the same ultrasound images and draw strikingly different conclusions about what matters and what does not.

The ductus arteriosus is a fetal shortcut that connects the pulmonary artery to the aorta, allowing blood to bypass the fluid-filled, non-functioning lungs before birth. In most babies, the vessel seals itself within the first days of life. In premature infants, however, closure often fails. The problem is remarkably common: an estimated 66 to 79 percent of neonates born weighing less than 1000 grams still have a patent ductus at seven days of age. Whether that open vessel is merely a lingering remnant or a genuine threat to fragile organs depends on its hemodynamic significance, meaning the degree to which it steals blood from the systemic circulation and floods the lungs. And that, precisely, is where consensus collapses, because no universally accepted standard exists for defining when a ductus has crossed the line from benign to dangerous.

The new study, led by Paige E. Condit and John S. Hokanson of the University of Wisconsin-Madison, set out to map this contested terrain. Between February and April 2024, the researchers distributed an anonymous Qualtrics survey to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the Section on Cardiology and Cardiac Surgery, and the Pediheart.net online community. Roughly 504 providers began the survey and 422 completed it, yielding an overall response rate of about 8 percent. The analytic sample included 315 neonatologists and 107 pediatric cardiologists. Importantly, the neonatology group was stratified by whether the respondent’s institution offered in-house catheter-based ductal closure, a proxy for the highest-acuity Level IV neonatal intensive care units, allowing the investigators to probe whether access to advanced procedural capability shapes clinical judgment.

The headline result is a portrait of deep disagreement over echocardiography, the ultrasound technique on which virtually all modern ductal assessment rests. Respondents were asked to rank the clinical utility of 14 echocardiographic parameters on a three-point importance scale; the analysis focused on the nine parameters most commonly included in published scores and guidelines. Of those nine, the specialists agreed on the importance of only two: retrograde flow in the post-ductal aorta and the diameter of the ductus itself. For the remaining seven, including measures of left ventricular output, left atrial to aortic root ratio, and end-diastolic flow velocity in the branch pulmonary arteries, neonatologists and cardiologists assigned statistically different levels of both familiarity and importance. The largest familiarity gaps appeared for pulmonary artery end-diastolic flow velocity and left ventricular outflow, with effect sizes reaching the large range, a signal that the two specialties are not merely quibbling over fine points but diverging on fundamental diagnostic building blocks.

One intriguing pattern emerged from the stratification: neonatologists working at centers with in-house catheter closure capability tended to answer more like cardiologists than did their colleagues at centers without such programs. The authors attribute this to daily collaboration, noting that proximity to interventional cardiology likely exposes neonatologists to the same imaging vocabulary and interpretive habits. The implication is sobering for the field, because it suggests that even within a single specialty, the perceived meaning of an echocardiographic image may depend less on the image itself than on the institutional culture surrounding it. When two subspecialties disagree on which markers define hemodynamic significance, confusion can ripple through clinical handoffs, treatment decisions, and even the design of research studies, since cardiology-led and neonatology-led investigations may prioritize different aspects of ductal evaluation.

Formal scoring systems, which were developed precisely to resolve this ambiguity, remain strikingly underused. Only a minority of respondents reported employing any echocardiographic or clinical scoring system, with routine use ranging from 7.8 percent among neonatologists without catheter programs to 19.4 percent among those with them. The survey was conducted before the American Academy of Pediatrics released its recent clinical practice guideline, which recommends a combined echocardiographic and clinical approach with specific criteria required from each domain, so adoption may shift. But the authors point to a deeper problem: several validated scores exist, including the El-Khuffash score, which incorporates gestational age, ductal diameter, flow velocity, and left ventricular measures and has shown strong prediction of chronic lung disease or death with an area under the curve of 0.92, yet none has been proven in a randomized trial to improve outcomes when used to guide treatment compared with clinical judgment alone. A small feasibility trial of score-guided therapy did not demonstrate a statistically significant benefit, and the Iowa score’s reported reductions in severe bronchopulmonary dysplasia cannot be cleanly attributed to the score because the protocol bundled early screening echocardiography and other care changes together.

The survey also documented a quiet revolution in treatment delivery. Medical therapy was available to 99 percent of respondents, but prophylactic treatment was rare, reported by just 12.3 percent. Among first-line agents, acetaminophen narrowly led at 32.8 percent, followed by ibuprofen at 30.5 percent and the older indomethacin at 23.9 percent, with significant differences between specialties, partly because nearly half of cardiologists reported not making these pharmacologic recommendations at all. Most providers, 59 percent, said they would attempt medication-based closure twice before recommending a procedure, while about a quarter would try three times. When it came to procedural closure, the landscape has flipped: 72.1 percent of respondents said they rarely recommend surgical ligation, while catheter-based occlusion, recommended often by 65.1 percent of cardiologists and 48.1 percent of catheter-equipped neonatologists, has been rapidly adopted. An overwhelming 89 percent of respondents named the Amplatzer Piccolo device as their preferred occlusion device, a preference that did not differ by specialty. This shift follows studies suggesting better respiratory outcomes and lower mortality with transcatheter closure compared with surgery, even though no definitive trial has yet shown transcatheter closure to be superior to expectant management.

Screening practices added another layer of variation. Only 13.5 percent of respondents reported that their facility used routine screening echocardiograms for ductal evaluation. Among those who did, the average timing was 28.3 weeks’ gestation, but the spread was wide: neonatologists with in-house catheter programs screened earliest at a mean of 27.5 weeks, those without screened at 27.8 weeks, and cardiologists reported a mean of 31.0 weeks, a statistically significant difference with a medium effect size. The authors caution, however, that the question about screening echocardiography may have been interpreted differently across specialties, a reminder that survey-based comparisons of practice carry their own measurement hazards.

Indeed, the study’s limitations deserve as much attention as its findings. With an 8 percent response rate, non-response bias is a real concern; respondents may be more interested or experienced in ductal management than their silent colleagues, so the results reflect an engaged subset rather than a nationally representative sample. The survey did not capture practice setting, patient volume, or how often respondents actually manage hsPDA, all of which could confound the specialty comparisons. Membership overlap between the cardiology organizations means some cardiologists may have received duplicate invitations and potentially responded more than once, and multiple responses from the same institution could have skewed resource-availability estimates. The survey instrument lacked formal psychometric validation, multiple statistical comparisons were performed without correction for multiplicity, and respondents averaged 18 years in practice, which may not capture the habits of newer generations of clinicians.

Still, the big picture is hard to escape. A vessel present in most extremely premature infants is being diagnosed, scored, medicated, and closed in wildly different ways across the country, by specialists who cannot agree on which ultrasound measurements matter most. The authors call for studies that correlate echocardiographic findings with clinical outcomes and with hemodynamic data from cardiac catheterization, the gold standard of direct measurement, to finally anchor the definition of hemodynamic significance in physiology rather than tradition. Until that evidence arrives, the treatment of the premature ductus will remain what this survey reveals it to be: a high-stakes judgment call, made at the bedside of the smallest patients, under rules that two specialties are still writing separately.

Subject of Research: Diagnosis and management of hemodynamically significant patent ductus arteriosus in premature infants

Article Title: Current practices in the management of hemodynamically significant patent ductus arteriosus

Article References: Condit, P. E., Erdmann, A. A., Zhang, X., Ndukwe, E., Fernandez, J., & Hokanson, J. S. (2026). Current practices in the management of hemodynamically significant patent ductus arteriosus. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02914-4

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02914-4

Keywords: patent ductus arteriosus, premature infants, echocardiography, neonatology, pediatric cardiology, catheter closure, scoring systems, survey, neonatal intensive care, acetaminophen, ibuprofen, surgical ligation