PDA Scoring Systems App

Importance to read before use: This scoring app is provided solely as an educational and research-oriented tool to compare published echocardiographic and clinical frameworks for PDA significance in preterm infants. It is not intended to provide treatment recommendations, direct patient management, or determine eligibility for pharmacologic or procedural intervention. The outputs should always be interpreted within the full clinical context by qualified clinicians and must not replace bedside assessment, comprehensive echocardiographic review, multidisciplinary discussion, or clinical judgment. This tool should not override local practice standards, institutional protocols, or specialist recommendations, and any management decisions must remain based on the treating team’s independent evaluation of the individual patient.

1. Strictly "Early" Screening Protocols (First 72 Hours)

These systems were specifically designed to predict downstream morbidity using early transitional hemodynamics to guide prophylactic or early targeted treatment.

• SMART-PDA (Mitra et al. 2024): Strictly studied in the ≤72 hours of life. The protocol requires the screening echo to be performed between 12 and 72 hours of age. The treatment matrix is specifically designed to identify which infants benefit from early medical treatment before significant left-to-right shunting establishes chronic volume overload.

• Iowa Protocol (Rios 2021 / Giesinger 2023): Heavily focused on the first 18–24 hours of life. The protocol was built around screening the highest-risk group (22–26 weeks) very early to initiate acetaminophen or indomethacin before day 2.

• El-Khuffash Severity Score (2015): The original prospective cohort derived this score specifically from echoes performed at 48 hours of life (median 2 days). Its later use in the PDA-RCT also focused on early screening to trigger treatment.

2. Descriptive / Mid-to-Late Frameworks (Not time-restricted)

These frameworks evaluate the "current state" of the ductus and are typically applied whenever clinical deterioration prompts an evaluation, often spanning from the end of the transitional period through several weeks of life.

• Chock Echo Score (2014): Derived from a retrospective cohort where echoes were done on a clinical basis. The median age at echo was 5 days, but ranged anywhere from 1 to 42 days. It evaluates the established burden of the shunt rather than early transitional prediction.

• McNamara Disease Staging (2007) & Teaching Manual (2014): These are conceptual physiological staging systems designed to evaluate the degree of left-heart loading and systemic steal at any point in the neonatal course.

• Jain-Shah Cut-offs (2015) & NPE Parameter Map (2018): These represent consensus thresholds for what constitutes a "large" or "moderate" shunt. They are not time-locked, but because they rely heavily on markers of severe volume overload (e.g., LA:Ao > 1.5, LVO > 300), they are most accurate after PVR has dropped sufficiently to allow maximal left-to-right shunting (typically >72 hours).

• AAP 2025 Definition & Backes Contemporary Perspective (2022): Broad consensus definitions meant to identify a hemodynamically significant PDA at any age when intervention or diagnostic labeling is being considered.

3. Chronological Age-Adjusted Frameworks

• Shepherd-Noori (2019): This is the only framework that explicitly builds chronological age into its conceptual model. They argue that a specific set of parameters at day 3 requires a different interpretation than those same parameters at day 21, acknowledging that the preterm infant's vulnerability to volume overload versus systemic steal shifts over time.

Takeaway for the Application: If a user inputs data from a Day 14 echo, the Iowa, El-Khuffash, and SMART scores will technically calculate, but they are being applied outside their tested windows. The descriptive frameworks (Chock, NPE, McNamara) are possibly more studied for evaluating the established hemodynamic burden in the second or third week of life.

References - Scoring Systems

El-Khuffash A, James AT, Corcoran JD, Dicker P, Franklin O, Elsayed YN, Ting JY, Sehgal A, Malikiwi A, Harabor A, Soraisham AS, McNamara PJ. A Patent Ductus Arteriosus Severity Score Predicts Chronic Lung Disease or Death before Discharge. J Pediatr. 2015 Dec;167(6):1354-1361.e2. doi: 10.1016/j.jpeds.2015.09.028. Epub 2015 Oct 21. PMID: 26474706.

PDA risk score = (Gestation in weeks × −1.304) + (PDA diameter in mm × 0.781) + (Left ventricular output in mL/kg/min × 0.008) + (maximum PDA velocity in m/s × −1.065) + (left ventricular a' wave in cm/s × −0.470) + 41.

Score ranges between 0 (low risk) and 13 (high risk).

References:

• El-Khuffash A, James AT, Corcoran JD, Dicker P, Franklin O, Elsayed YN, Ting JY, Sehgal A, Malikiwi A, Harabor A, Soraisham AS, McNamara PJ. A Patent Ductus Arteriosus Severity Score Predicts Chronic Lung Disease or Death before Discharge. J Pediatr. 2015 Dec;167(6):1354-1361.e2. doi: 10.1016/j.jpeds.2015.09.028. Epub 2015 Oct 21. PMID: 26474706.

  • Narrowest PDA diameter (mm) by 2D at pulmonary end 

  • Max velocity across PDA ( in m/s); 

  • LV output (in mL/kg/min); 

  • Tissue Doppler imaging was obtained at apical 4-chamber view. Late diastolic (a′) velocities used at the level of the lateral mitral valve annulus. If the e′ and a′ waves were fused, they measured the single wave as an a′ wave.

• El-Khuffash A, Bussmann N, Breatnach CR, Smith A, Tully E, Griffin J, McCallion N, Corcoran JD, Fernandez E, Looi C, Cleary B, Franklin O, McNamara PJ. A Pilot Randomized Controlled Trial of Early Targeted Patent Ductus Arteriosus Treatment Using a Risk Based Severity Score (The PDA RCT). J Pediatr. 2021 Feb;229:127-133. doi: 10.1016/j.jpeds.2020.10.024. Epub 2020 Oct 16. PMID: 33069668.

  • <29 weeks: echo at 36 to 48 hours of life.

  •  In RCT, infants with risk score of ≥5.0 deemed at high risk for chronic lung disease or death and were randomized

Conservative Approach - NeoCardioLab / MCH