Early Human Development 149 (2020) 105142

Contents lists available at ScienceDirect

Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Cardiovascular biomarkers in the evaluation of patent ductus arteriosus in T

very preterm neonates: A cohort study
Anna Sellmera,b, , Vibeke E. Hjortdala, Jesper V. Bjerrec, Michael R. Schmidtd, Bodil H. Beche,
⁎

Tine B. Henriksenb,c
a
Department of Cardiothoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
b
Perinatal Epidemiology Research Unit, Department of Pediatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
c
Department of Pediatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
d
Department of Cardiology, Rishospitalet Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
e
Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark

ARTICLE INFO ABSTRACT

Keywords: Background: The evaluation of the patent ductus arteriosus (PDA) in the very premature neonate is a challenge.
Patent ductus arteriosus Echocardiography provides an interpretation of the hemodynamic condition. It is however, only a snapshot.
Copeptin Biomarkers may represent a physiological response to the hemodynamic alterations brought on by the PDA and
Natriuretic peptides may add to the identification of the clinical significant PDA.
Endothelin-1
Aim: To investigate the association between mid regional proadrenomodulin (MR-proADM), N-terminal pro b-
Adrenomodulin
type natriuretic peptide (NT-proBNP), mid regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro
Preterm neonate
endothelin-1 (CT-proET1) and copeptin and echocardiographic measures of PDA.
Study design: Cohort study with echocardiography performed on day 3 and 6. Blood samples from day 3.
Subject: 139 consecutive neonates born at a gestational age < 32 weeks.
Outcome measures: The main outcomes were presence of a PDA day 3 and 6, PDA diameter, left atrium to aorta
ratio (LA:Ao-ratio), and descending aorta diastolic flow (DADF).
Results: Adjusted plasma levels of all investigated biomarkers, except CT-proET1, were found to be associated
with both PDA diameter and LA:Ao-ratio, and also the presence of a large PDA. CT-proET1 and copeptin was
found to be associated with abnormal DADF. Using pre-specified cut-off values NT-proBNP and MR-proANP day
3 seemed to be of value in identifying a large PDA day 3 and 6 in very preterm neonates.
Conclusion: Among the investigated biomarkers NT-proBNP and MR-proANP performed best in relation to
echocardiographic markers of PDA severity in very preterm neonates.

1. Introduction
The assessment of the clinical significance of the patent ductus ar­
teriosus (PDA) in the preterm neonate is a challenge [1]. Echocardio­
graphy is considered the gold standard for diagnosis of PDA, despite the
lack of consensus on what echocardiographic measures should be used
to define ductal significance. PDA diameter, LA:Ao-ratio, and des­
cending aorta diastolic flow (DADF) are considered important measures
[2] However, echocardiography only provides information valid at the
time of the investigation, while the changing hemodynamics during the
transitional period, may not be captured unless frequent serial in­
vestigations are carried out. Also, echocardiography is not always
available, it is costly, a stress factor for the newly born preterm neonate,
and the investigation is prone to inter observer variability underlining
the need for other diagnostic tools in the evaluation of the PDA [3].
Biomarkers in plasma may represent a way to evaluate the changes
brought on by the PDA, reflecting both the degree of shunting, the
impact on perfusion, and the neonate's ability to cope with these
challenges. Among plasma biomarkers, BNP and NT-proBNP are the
most studied in both adult and neonatal population. They do only

Abbreviations: LA:Ao-ratio, left atrium to aorta ratio; MR-proADM, mid regional proadrenomodulin; NT-proBNP, N-terminal pro b-type natriuretic peptide; MR-
proANP, mid regional pro-atrial natriuretic peptide; CT-proET1, C-terminal pro endothelin-1; PDA, patent ductus arteriosus; GA, gestational age; NICU, neonatal
intensive care unit; BPD, broncho pulmonary dysplasia; DADF, descending aorta diastolic flow
⁎
Corresponding author at: Department of Cardiothoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
E-mail addresses: anna.sellmer@clin.au.dk (A. Sellmer), vibeke.hjortdal@regionh.dk (V.E. Hjortdal), jesper.bjerre@skejby.rm.dk (J.V. Bjerre),
michael.rahbek.schmidt@regionh.dk (M.R. Schmidt), bhb@ph.au.dk (B.H. Bech), tine.brink.henriksen@clin.au.dk (T.B. Henriksen).

https://doi.org/10.1016/j.earlhumdev.2020.105142
Received 6 February 2020; Received in revised form 8 July 2020; Accepted 27 July 2020
0378-3782/ © 2020 Elsevier B.V. All rights reserved.

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al. Early Human Development 149 (2020) 105142

represent a single pathophysiologic pathway and several other bio­

markers reflecting alternative pathways have been found to be asso­
ciated with cardiac and pulmonary status in adults. Very little is known
about the actions of these markers in the very preterm neonates. We
speculate, that they are associated with echocardiographic markers of
PDA significance.
The heart exerts an endocrine function by expressing polypeptide
hormones and their receptors including adrenomodulin (ADM) and en­
dothelin-1 (ET-1) and the natriuretic peptides; brain natriuretic peptide
(BNP) and atrium natriuretic peptide (ANP). The natriuretic peptide fa­
mily and adrenomodulin-related peptides have hypotensive, natriuretic
and diuretic properties [21,17,33]. On the other hand, ET-1 has hy­
pertensive and volume retentive properties [45]. Copeptin is released
together with vasopressin and has potent vasoactive properties and it is
involved in the regulation of renal water and sodium reabsorption [50].
The aim of the study was to evaluate the association between these
5 biomarkers day 3 and echocardiographic measures of PDA day 3 and
6 of life in a cohort of very preterm neonates.

2. Methods

2.1. Study population

The study population has previously been described [4,5]. From

June 1, 2010 to February 28, 2012 all very preterm newborns with a
gestational age (GA) < 32 completed weeks at birth admitted to our
level three neonatal intensive care unit (NICU) were eligible for in­
clusion into this study (n = 184). Neonates born with GA < 24 com­
pleted weeks and neonates with chromosomal abnormalities or con­
genital heart malformations other than atrial septum defects were
excluded from the study (Fig. 1).

2.2. Data collection and definitions

All very preterm neonates were assessed by echocardiography on
postnatal days 3 and 6 as part of their routine care. Blood samples were
collected together with routine blood samples on day 3. They were
centrifuged and plasma samples were stored at −80 °C until analysis in
2014 [6].
The following clinical information was obtained from the patients'
medical records; maternal preeclampsia, antenatal steroid administra­
tion, mode of delivery, multiple birth, birth weight and gestational age
at birth (based on early ultrasound scanning), Apgar score at 1 and
5 min, surfactant administration, packed red blood cell transfusion
within the first 3 days of life, inotropes within the first 3 days of life,
early onset sepsis defined as 7 days of antibiotics initiated before day 3,
and use of mechanical ventilation day 3.
2.3. Echocardiography measurements
A complete echocardiography was performed to confirm normal
anatomy of the heart. The examination was performed by two senior
pediatric echocardiographers (JB and MRS) using two-dimensional, B-
mode, and color Doppler in standard neonatal windows [7]. Using a
Philips IE33 Ultrasound machine with a 12-MHz cardiology probe
(Philips Healthcare, Andover, Massachusetts, USA). A PDA was defined
as present if flow could be visualized by color Doppler. The PDA dia­
meter was measured in B mode at the most narrow point and defined as
large if the diameter was above 1.5 mm and a small PDA if the diameter
of the PDA was 1.5 mm or below [8,9]. The ratio of the left atrium to
the aorta (LA:Ao-ratio) was determined in the parasternal long axis
view by M-mode using the leading edge to leading edge method. A large
LA:Ao-ratio was defined as a ratio above 1.5 and a small LA:Ao-ratio if
1.5 or below. Descending aorta diastolic flow (DADF) was evaluated by
Doppler flow patterns in the descending aorta obtained from the su­
prasternal view.
Fig. 1. Study population from the 184 neonates admitted to Aarhus University
Hospital (AUH) from June 2010 to February 2012.
2.4. Biomarkers
NT-proBNP was measured as previously described by routine im­
mune-assay analysis on the Cobas e601 platform (Roche Diagnostics,
Basel, Switzerland) at the Department of Clinical Biochemistry, Aarhus
University Hospital, Denmark [5]. MR-proADM, MR-proANP, CT-pro-
ET1 and copeptin were measured on the Kryptor Compact Plus platform
according to the manufacturer protocol (BRAHMS, Henningsdorf,
Germany) also at the Department of Clinical Biochemistry, Aarhus
University Hospital, Denmark. Samples were diluted 1: 3 with fetal
bovine serum. Limits of detection as described by the manufacturer was
0.05 nmol/L for MR-proADM, 2.1 pmol/L for MR-proANP, 2.94 pmol/L
for CT-proET1, and 0.69 pmol/L for copeptin.
2.5. Clinical guidelines
The management of a PDA was according to our local guideline.
According to this guideline, all neonates born with a gestational age
below 32 weeks have an echocardiography day 3 in order to evaluate
whether there is a PDA. Treatment with Ibuprofen (Pedea, Orphan
Europe SARL Puteaux, France) was initiated based on detection of a
PDA by echocardiography alone if the gestational age at birth was <
28 weeks (8 neonates were not treated accordingly due to contra­
indications). Neonates with a gestational age at or above 28 weeks at
birth only received Ibuprofen if they had specific echocardiographic
findings and also specific clinical signs (only 2 neonates were treated).
None of the neonates received Ibuprofen or had surgical closure before
day 3.

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al. Early Human Development 149 (2020) 105142

2.6. Statistical analysis Table 1

Characteristics of 139 neonates born before 32 weeks of gestation by presence
Perinatal characteristics were described by number (percentage) or of PDA postnatal day 3.
median values (inter quartiles or range). Medians were compared using No PDA (n = 81) PDA (n = 58)
Mann–Whitney Univariate and U test and proportions using Fisher's
exact test. The distribution of MR-proADM, NT-proBNP, MR-proANP, Preeclampsia, number (%) 25 (31) 5 (9)⁎
Antenatal steroids, number (%) 78 (96) 50 (86)⁎
CT-proET1, and copeptin concentrations were skewed, and therefore
Multiple pregnancy 22 (27) 29 (50)⁎
natural logarithm transformation was applied [10]. Multivariate log- Cesarean delivery, number (%) 59 (72) 37 (64)
linear regression was performed in order to examine the association Gestational age weeks, median (range) 30 (24;31) 27 (24;31)⁎⁎
between the biomarkers and PDA. We then exponentiated the differ­ Birthweight, median (range) 1202 (545; 2090) 928 (570; 1840)⁎⁎
Males, number (%) 54 (67) 33 (57)
ences estimated on the natural log scale to obtain ratio of the medians,
Apgar at 1 min, median (IQR) 8 (6; 10) 6 (5; 8)⁎
hence, for a log-transformed Y and an untransformed X, an additive Apgar at 5 min, median (IQR) 10 (9; 10) 10 (8;10)⁎
change in X results in a relative change in the median or geometric Early onset sepsis, number (%) 11 (14) 12 (21)
mean of Y. The formula (eβ − 1) ∗ 100% was used to express the Surfactant, number (%) 30 (37) 32 (55)⁎
percent change. We present the percent change as crude and adjusted PRCB transfusion, number (%) 7 (9) 13 (22)⁎
Inotropes, number (%) 5 (6) 6 (10)
percent change per unit of explanatory variable or difference from re­
ference group with 95% confidence interval (CI) [11]. Estimates were Early onset sepsis defined as 7 days of antibiotics initiated before days 3 of life.
adjusted for gestational age, early onset sepsis and mechanical venti­ PRBC transfusion, packed red blood cell transfusion within the first 3 days of
lation. Receiver operator characteristic (ROC) analysis was performed life. Inotropes within the first 3 days of life.
to determine the discriminatory ability of the investigated hormones by ⁎
P value < 0.05.
the natural log continuous measure and their ability to recognize a large ⁎⁎
P value < 0.001.
PDA, a large LA:Ao-ratio or retrograde DADF. Cut-off values for NT-
proBNP and MR-proANP were decided upon a priori based on existing 108% (CI: 76; 147) and MR-proANP and copeptin with 64% and 39%
literature [12–14]. Robust cluster standard errors were used in order to respectively. Whereas, MR-proADM levels increased by only 9% (CI: 4;
take into account the correlation between twins. STATA special edition 15). Also plasma levels of MR-proADM, NT-proBNP, MR-proANP, and
version 16 (College Station, Texas, USA) was used for analyses. All tests copeptin were higher in neonates with an LA:Ao-ratio > 1.5 compared
were two-sided. Two sided P values of < 0.05 were considered statis­ to neonates with a LA:Ao-ratio ≤ 1.5. In neonates with retrograde
tically significant. DADF we found that adjusted median levels of CT-proET1 and copeptin
were higher compared to neonates with normal DADF, surprisingly we
2.7. Ethics found no difference in NT-proBNP nor in MR-proANP levels (Table 2).
Also adjusted plasma levels of all the biomarkers day 3, except CT-
All parents gave informed, written consent for their child to parti­ proET1, were higher in neonates with a PDA day 6 and also a large PDA
cipate in the study. The study was approved by the Central Denmark day 6, irrespective of whether the PDA was treated (Table 2). Plasma
Region Committee on Health Research Ethics (journal number M- levels of all biomarkers, except CT-proET1 were higher in neonates with
20090243), the Danish Data Protection Agency, and the National Board a large LA:Ao-ratio compared to neonates with a small LA:Ao-ratio. We
of Health. found that plasma levels of all five investigated biomarkers were higher
(from 32 to 731%) in neonates with retrograde DADF. We found that
3. Results neonates that changed status from PDA to no PDA from day 3 to 6 had a
50% lower plasma levels of both NT-proBNP and MR-proANP on day 3
We consecutively enrolled 184 neonates born at a gestational age compared to neonates that did not close their PDA (Table 2).
below 32 weeks. We acquired plasma values of NT-proBNP and the In the receiver operating characteristic (ROC) analysis distribution
other four other investigated markers in a total of 119 and 139 very of plasma MR-proADM, NT-proBNP, MR-proANP, and copeptin in
preterm neonates, respectively (Fig. 1). A PDA was found in 58 (42%) identifying a large PDA was found to have acceptable discriminatory
neonates on day 3 and the majority was diagnosed with a large PDA ability (Table 3). AUC was larger for MRproANP compared to
(59%). Among neonates born at a gestational age below 28 weeks 35 NTproBNP (0.89 (CI: 0.82; 0.95) vs 0.86 (CI: 0.79; 0.94), p < 0.05) in
out of 57 neonates had a PDA day 3 (61%). Neonates with a PDA day 3 identifying a large PDA day 3. No difference in AUC was found on day 6
were born at a lower gestational age, had lower birth weight and had (Fig. 3). The discriminatory ability in identifying a large LA:Ao-ratio or
more unfavorable characteristics (Table 1). On day 6 a PDA was present retrograde DADF on day 3 was found not to be acceptable, except for
in 41 neonates, however 4 of these neonates did not have a PDA on day copeptin (AUC 0.90, CI 0.82; 0.97). However, NT-proBNP and MR-
3. A total of 19 neonates changed status from open to closed PDA be­ proANP was acceptable in predicting a large LA:Ao-ratio and also ret­
tween day 3 and 6. In 7 neonates the second echocardiography was not rograde DADF on day 6.
performed as they died (n = 1) or were transferred to another hospital Using the a priori defined cut-off value for NT-proBNP of
(n = 6) before day 6. 5000 pmol/L yielded a sensitivity of 86% (CI: 67; 96) and a specificity
Plasma levels of the 5 markers are shown in Fig. 2. When adjusted of 70% (CI: 60; 79) in detecting a large PDA among all neonates day 3.
for GA, early onset sepsis, and mechanical ventilation median NT- And a cut-off value of 850 pmol/L for MR-proANP to detect a large PDA
proBNP levels were 195% (CI: 76; 394) higher in neonates with a PDA day 3, yielded a sensitivity of 83% (CI: 65; 93) and a specificity of 74%
compared to neonates with no PDA. Also median MR-proANP, and (CI: 64; 82). Using plasma NT-proBNP day 3 to predict a large PDA day
copeptin levels were higher on day 3 in neonates with a PDA compared 6 with the same cut-off values as on day 3 resulted in a slightly higher
to neonates with no PDA (Table 2). Furthermore, on day 3, MR- sensitivity for both NT-proBNP and MR-proANP (Table 4). Differences
proADM, NT-proBNP, MR-proANP, and copeptin adjusted levels were in diagnostic ability between NT-proBNP and MR-proANP was found in
higher in neonates with a large PDA compared to no PDA and compared relation to LA:Ao-ratio. None of them performed well in diagnosing
to neonates with no PDA or a small PDA. In contrast, CT-proET1 levels retrograde DADF day 3.
were similar regardless of presence or size of a PDA (Table 2).
Adjusted plasma levels of all the biomarkers, except CT-proET1, 4. Discussion
were associated with PDA diameter and LA:Ao-ratio. For every one
1 mm increase in PDA diameter median NT-proBNP levels increased by In the present study we have investigated the association between

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al. Early Human Development 149 (2020) 105142

A
** *

B
* ** ** *

C
**
**

*
*

* *

E **

** *

(caption on next page)

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al. Early Human Development 149 (2020) 105142

Fig. 2. Plasma concentrations of MR-proADM, MR-proANP, NT-proBNP, CT-proET1, and copeptin day 3 of life according to PDA diameter, LA:Ao-ratio and des­
cending aorta diastolic flow in 139 neonates born before 32 weeks of gestation at Aarhus University Hospital.
Large PDA (diameter > 1.5 mm) vs. no PDA, small PDA (PDA diameter ≤ 1.5 mm) vs. no PDA. Large LA:Ao-ratio (> 1.5) vs small LA:Ao-ratio (≤1.5). Retrograde
DADF (descending aorta diastolic flow) vs antegrade DADF. *P value < 0.05 **P value < 0.001.

five cardiovascular biomarkers and the three most often used echo­
cardiographic markers of PDA; PDA diameter > 1.5 mm, LA:Ao-
ratio > 1.5, and retrograde DADF [2]. We found that all the in­
vestigated biomarkers on day 3, except CT-proET1, were associated
with increased median values in neonates with a large PDA day 3 and 6
and neonates with a large LA:Ao-ratio day 3 and 6, also when adjusted.
We also found that all the investigated biomarkers were associated with
increased median values in neonates with retrograde DADF on day 6,
on day 3 this was only found for CT-proET1 and copeptin. Further the
discriminatory ability was best for NT-proBNP and MR-proANP.
We are the first to describe that there is an association between MR-
proADM and echocardiographic measures of PDA in very preterm
neonates. MR-proADM levels day 3 were 20% higher in neonates with a
large PDA day 3 or day 6 compared to neonates with no PDA. We also
found an association between MR-proADM and LA:Ao-ratio day 3 and
6. There is little evidence on the site of production, biological actions
and metabolism of ADM in preterm neonates [15,16]. In adults adre­
nomodulin is produced by vascular endothelial cells and is widely
distributed in the cardiovascular system, including the heart, blood
vessels, and kidneys. ADM causes vasodilation and hypotension, and is
part of the inflammatory process [17]. Adrenomodulin has recently
been found to be a prognostic marker in sepsis [18] and heart failure
[19] in the adult population.
The B-type natriuretic peptide (BNP) is released as a pro-hormone
and then cleaved into the physiologically active BNP and the inert NT-
proBNP. The biological actions described in adults include natriuresis,
diuresis, vasodilation, and direct suppression of volume-retaining, va­
soconstricting systems including the renin–angiotensin–aldosterone and
sympathetic nervous systems [21]. BNP and NT-proBNP have proven to
be sensitive markers of cardiac dysfunction and are being used to
screen, diagnose and monitor response to treatment in a variety of
clinical situations primarily in the adult populations [23–25,63].
NT-proBNP has been found to be associated with PDA in preterm
neonates in numerous studies [14,26–31], but has gained limited
clinical usage. Previous studies are difficult to compare as they vary by
patient characteristics, assay method, units reported, timing of testing,
adjustment for confounders and cut-off investigated [12,32]. We used
the commercially available assay and the analysis was part of their
routine at the Department of clinical biochemistry. We used a cut-off for
NT-proBNP at 5000 pmol/l in concordance with a previous studies
[12,14] and confirm that NT-proBNP day 3 had good sensitivity and
specificity in identifying a large PDA both day 3 and 6 in very preterm
neonates. The sensitivity in identifying a large LA:Ao-ratio and retro­
grade DADF was good, however, the specificity was not impressive.
The A-type natriuretic peptide (ANP) is in adults primarily released
from the atrium and has several biological roles including natriuresis,
diuresis, vasodilatation, and inhibition of the renin-angiotensin-aldos­
terone axis and the sympathetic nervous system [33]. However, in
preterm neonates, place of release, receptors and their localization and
the biological actions have not been described. Plasma ANP levels are
higher in neonates with PDA compared to neonates without a PDA
[34,35]. MR-proANP is the mid regional and very stable fragment of the
precursor hormone that is released in equimolar ratio to ANP. MR-
proANP has been found to be associated with cardiovascular disease
and infections in children and adults [20,33,36–38].
Our study confirms that MR-proANP day 3 is associated with the
size of the PDA [39,40] we further found it to be associated with LA:Ao-
ratio and retrograde DADF both on day 3 and 6. We demonstrated that
MR-proANP levels day 3 were not only able to identify a large PDA the
same day but also able to predict a large PDA 3 days later [39]. Findings
resemble that of NT-proBNP. Despite MR-proANP and NT-proBNP ex­
hibit very similar properties, and levels seem to be closely correlated in

Table 2
Plasma MR-proADM, NT-proBNP, MR-proANP, CT-proET1, and copeptin day 3 in neonates born before 32 weeks of gestation at Aarhus University Hospital.
MR-proADM NT-proBNP MR-proANP CT-proET1 Copeptin
n = 139 n = 119 n = 139 n = 139 n = 139

Crude Adjusteda Crude Adjusteda Crude Adjusteda Crude Adjusteda Crude Adjusteda

PDA diameter 14 9 (4; 15)⁎⁎ 124 108 (76; 147)⁎⁎ 72 64 (47; 83)⁎⁎ 10 3 (−4; 12) 55 39 (23; 58)⁎⁎
LA:AO-ratio 52 40 (9; 80)⁎ 1642 1161 (451; 2948)⁎⁎ 362 295 (138; 555)⁎⁎ 28 16 (−20; 70) 210 156 (45; 351)⁎
Day 3
PDA vs no PDA 25 9 (−2; 22) 289 195 (76; 394)⁎⁎ 152 119 (62; 196)⁎⁎ 20 3(−14; 23) 135 79 (38; 132)⁎⁎
Small vs no PDA 11 −0.1 (−20; 6) 85 32 (−28; 140) 57 32 (−4; 81) 20 0.2 (−20; 26) 100 49 (6; 108)⁎
Large vs no PDA 35 21 (8; 37)⁎ 583 456 (246; 793)⁎⁎ 246 204 (125; 310)⁎⁎ 20 4 (−15;38) 161 101 (47; 176)⁎⁎
Large vs small/no PDA 31 24 (10; 40)⁎ 472 382 (191; 694)⁎⁎ 212 176 (133; 316)⁎⁎ 15 2 (−15; 23) 132 83 (34; 152)⁎⁎⁎
LAAo > 1.5 vs < 1.5 22 23 (4; 45)⁎ 352 330 (164; 600)⁎⁎ 128 121 (65; 214)⁎⁎ 7 6 (−16; 37) 49 42 (4; 95)⁎
DADF retrograde vs antegrade 21 8 (−19; 45) 234 110 (−45; 702) 110 56 (−22; 210) 70 41 (7; 88)⁎ 254 148 (63; 278)⁎⁎
Day 6
PDA vs no PDA 26 15 (1; 30)⁎ 300 234 (97;467)⁎⁎ 162 131 (71; 213)⁎⁎ 29 12 (−5; 31) 129 88 (39; 154)⁎⁎
Small vs no PDA 0.5 −6 (−20; 10) 82 39 (−30; 174) 63 32 (−11; 97) 18 4 (−15; 28) 118 76 (14; 171)⁎
Large vs no PDA 36 20 (5; 37)⁎ 368 266 (117; 517)⁎⁎ 147 119 (59; 201)⁎⁎ 28 14 (−4; 36) 71 53 (12; 110)⁎
Large vs small/no PDA 48 32 (16; 50)⁎⁎ 626 466 (342; 836)⁎⁎ 240 196 (120; 297)⁎⁎ 33 17 (−2; 39) 101 67 (20; 133)⁎
LAAo > 1.5 vs < 1.5 22 25 (6; 47)⁎ 383 371 (194; 653)⁎⁎ 132 130 (69; 211)⁎⁎ 4 5 (−18; 33) 53 46 (6; 101)⁎
DADF retrograde vs antegrade 33 32 (15; 50)⁎⁎ 707 731 (177; 2394)⁎⁎ 489 479 (134; 1331)⁎⁎ 44 36 (17; 58)⁎⁎ 65 76 (36; 127)⁎⁎
PDA closure −13 −16 (−30; 0.2) −57 −56 (−78; −10)⁎ −57 −56 (−78; −11)⁎ −17 −10 (−30; 16) −29 −27 (−51; 9)

Percent change in concentration of MR-proADM, NT-proBNP, MR-proANP, CTproET1 or copeptin respectively by a) one unit increase in PDA diameter or LA:Ao-ratio
or b) between groups (PDA vs. no PDA, small PDA vs no PDA, large PDA vs no PDA, large PDA vs. no or small PDA, LA:Ao-ratio > 1.5 vs. LA:Ao-ratio ≤ 1.5,
retrograde flow vs antegrade DADF, PDA closed from day 3 to 6 vs. remained open). LA:Ao-ratio left atrium to aorta ratio. Small PDA if diameter ≤ 1.5 mm. Large
PDA if diameter > 1.5 mm. DADF descending aorta diastolic flow.
a
Adjusted for gestational age, early onset sepsis defined as 7 days of antibiotics initiated before day 3, and mechanical ventilation day 3. In 7 neonates an
echocardiography was not performed day 6.
⁎
P value < 0.05.
⁎⁎
P value < 0.001.

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al. Early Human Development 149 (2020) 105142

Table 3
Area under the curve AUC (CI) for MR-proADM, NT-proBNP, MR-proANP, CT-proET1, and copeptin day 3 in relation to echocardiographic markers of PDA in 139
very preterm neonates, Aarhus University Hospital.
Echocardiography day 3 Echocardiography day 6

PDA diameter > 1.5 mm LAAO-ratio > 1.5 DADF retrograde PDA diameter > 1.5 mm LAAO-ratio > 1.5 DADF retrograde

MR-proADM 0.72 (0.62; 0.82) 0.67 (0.54; 0.79) 0.70 (0.37; 1.00) 0.83 (0.74; 0.92) 0.82 (0.74; 0.92) 0.81 (0.69; 0.94)
NT-proBNP 0.86 (0.79; 0.94) 0.81 (0.71; 0.91) 0.72 (0.40; 1.00) 0.90 (0.84; 0.96) 0.90 (0.84; 0.96) 0.91 (0.82; 1.00)
MR-proANP 0.89 (0.82; 0.95) 0.79 (0.69; 0.89) 0.79 (0.51; 1.00) 0.92 (0.87; 0.97) 0.92 (0.87; 0.97) 0.97 (0.92; 1.00)
CT-proET1 0.59 (0.47; 0.71) 0.57 (0.43; 0.71) 0.82 (0.62; 1.00) 0.67 (0.55; 0.79) 0.67 (0.55; 0.79) 0.70 (0.46; 0.95)
Copeptin 0.78 (0.69; 0.87) 0.63 (0.50; 0.77) 0.90 (0.82; 0.97) 0.75 (0.64; 0.85) 0.75 (0.64; 0.85) 0.75 (0.62; 0.88)

very preterm neonates [40]. However, there are indications, that they
differ in ways not yet fully described. Plasma levels of both MR-proANP
and NT-proBNP rises rapidly after birth and then gradually fall to a
steady state level. The decent of MR-proANP is slower than that for NT-
proBNP reaching a plateau after 4 and 2 days, respectively [31,41,42].
CT-proET1 is the C-terminal of the ET-1 precursor. In adults, the
main site of ET-1 production is considered to be the bronchial epithe­
lium and the endothelium of the pulmonary arteries [43,44]. In adults,
it is released in response to angiotensin II, inflammatory mediators, and
vascular shear stress. A wide spectrum of biological activities of ET-1
has been described in adults, including vasoconstriction, regulation of
other hormones, bronchoconstriction, natriuresis, and diuresis [45].
CT-proET1 has been found to be associated with heart failure in an
adult population [46]. CT-proET1 is thought to participate in the cir­
culatory adaption in the fetal-to-neonatal transition period. Animal
studies have found endothelin-1 to be involved in the closure of the
PDA immediately after birth [47,48].
In a study of 52 neonates with a gestational age below 32 weeks CT-
proET1 was not associated with significant PDA. Earlier results from the
same research group found an association between CT-proET1 and
LA:Ao-ratio [13,40]. Our study supported the finding, that CT-proET1 is
not a marker of PDA size nor LA:Ao-ratio in very preterm neonates.
Interestingly, we found that neonates with retrograde DADF on day 3 as
well as 6 had higher levels of CT-proET-1. The endothelin system is
complex, and the action of ET-1 depends on concentration, but also on
the type of receptors, their localization, and present physiological si­
tuation [48]. A high level of ET-1 may be an adaptive mechanism that
protects the pulmonary circulation by vasoconstriction from the hyper-
perfusion state reflected by the retrograde flow in the descending aorta.
However, the high level of ET-1 may also just be an epiphenomenon.
CT-proAVP also known as copeptin is the C-terminal portion of
prepro-vasopressin. Copeptin is co-released with arginine-vasopressin
(AVP) in equimolar quantities. In adults, AVP has been shown to have
potent vasoactive properties, increase renal water reabsorption and act
on the renin-angiotensin-aldosterone system and the sympathetic ner­
vous system [49]. In preterm neonates the physiological effects of AVP
may also be important, however, it is not as well characterized as in the
adult population [50]. The physiologic effects of copeptin remain to be
identified [51].
The value of copeptin as a marker of cardiovascular disease in adults
is being studied with increasing interest [22,49,52]. To our knowledge
we are the first to study the association between copeptin and PDA in
very preterm neonates. Although we found that copeptin levels day 3
were associated with PDA presence, PDA diameter and LA:Ao-ratio
both day 3 and 6 copeptin did have limited diagnostic value. The as­
sociation between copeptin and retrograde DADF was present day 3 and
6. CT-proET1 and copeptin both known vasoconstrictors provide im­
portant information on the hemodynamic alterations brought on by the
PDA that complement the information obtained from the vasodilators in
particularly NT-proBNP and MR-proANP. We speculate if a bedside
PDA biomarker test ought to include two biomarkers; both a vasodilator
and a vasoconstrictor.
There is sparse evidence on the regulation, affinity and localization
of receptors, metabolism, and the biological effects of these 5 markers
in the neonatal population. And it remains to be clarified if these
markers are not only important in relation to the hemodynamic changes
that take place after birth, but if they in fact also contribute in a ne­
gative feed forward mechanism to maintain a PDA [53]. Animal studies
have demonstrated that BNP has not only vasodilatory but also anti-
remodeling effects on the ductus arteriosus, hence elevated plasma le­
vels may delay PDA closure [54]. Studies have found, that some of these
biomarkers are also independently related to morbidity known to be
associated with PDA [5,55,56].
Echocardiography is currently considered the most important tool
in the evaluation of PDA in preterm neonates [57,58]. Ultrasound is
widely used in the care of preterm neonates e.g. to diagnose pneu­
mothorax, confirm placement of central catheters, and evaluate treat­
ment response when hemodynamics are challenged. The approach to

Fig. 3. NTproBNP and MRproANP levels day 3 as markers of large PDA on day 3 and 6 in 119 very preterm neonates.
The Area under the curve (AUC) is larger for MRproANP (○) compared to NTproBNP (+) in identifying a large PDA day 3 (A). No difference in AUC was found on
day 6 (B).

Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
A. Sellmer, et al.
Table 4
Diagnostic and predictive value of NT-proBNP and MR-proANP day 3 in relation to echocardiographic markers of PDA 139 very preterm neonates, Aarhus University
Hospital.
Echocardiography day 3
PDA diameter > 1.5 mm LAAO-ratio > 1.5
n = 34 n = 22
NT-proBNP cutoff 5000 pmol/L
Sensitivity 86% (67; 96) 81% (59; 94)
Specificity 70% (60; 79) 54% (45; 63)
MR-proANP cutoff 850 pmol/L
Sensitivity 83% (65; 93) 68% (45; 86)
Specificity 74% (64; 82) 70% (60; 78)
assessment of the PDA is moving in the direction of not only identifying
PDA patency, need of treatment, or quantification of hemodynamic
effects but also to identify neonates at increased risk of PDA related
morbidity and mortality [4,59]. Biomarkers may turn out to be very
important tools in this risk assessment. Biomarkers provide a compre­
hensive evaluation as they should represent a measure of the challenges
posed on the neonates over time by the PDA and also the neonate's
ability to cope with this. Future studies will have to demonstrate if the
use of biomarkers can guide our management of PDA in the preterm
neonates to improve outcome.
4.1. Strengths and limitations
We consecutively included and performed echocardiography in a
total of 139 very preterm neonates making this a very large study
within this population. None of the neonates were treated with
Ibuprofen before plasma samples were collected. This is important be­
cause prostaglandins are involved in synthesis and release of both ANP
[60] and AVP [61].
It is a strength that we were able to use pre-specified cut points for
the evaluation of biomarkers NT-proBNP and MR-proANP. As it has
been shown that use of data-driven cut points tend to exaggerates test
performance [62].
Neonates that were diagnosed with a PDA were born at a lower
gestational age compared to neonates with no PDA. To make groups
more comparable we made sub-analysis including only neonates born
before 28 gestational weeks and found that this slightly changed point
estimates and CI (hence a lower number of patients) but the conclusions
made on the association between the investigated biomarkers and
echocardiographic markers were unchanged.
We only included neonates with plasma values of all five in­
vestigated markers. As plasma analysis for NT-proBNP and the 4 other
markers were not made on the same platform we experienced that
analysis of plasma values did not fail in the same neonates on the two
platform, therefore we had to exclude neonates with valid values from
one platform as it did not have a value from the other platform. Also
missing samples were related to blood samples not being collected,
samples being incorrectly handled, and samples that coagulated. One
could speculate that the neonates doing worse were more likely not to
have extra blood samples taken, thereby introducing sampling bias.
However, we did supplementary analysis (not shown) and found that
neonates with missing plasma values of the biomarkers were not dif­
ferent from neonates with all values present with respect to perinatal
characteristics and morbidity e.g. presence of PDA, BPD or death.
5. Conclusion
We found that particularly NT-proBNP and MR-proANP were asso­
ciated with echocardiographic markers of PDA severity. Several of the
investigated peptides may represent biomarkers that could potentially
add to the detection and characterization of the PDA and support
Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
Early Human Development 149 (2020) 105142
Echocardiography day 6
DADF retrograde PDA diameter > 1.5 mm LAAO-ratio > 1.5 DADF retrograde
n=5 n = 24 n = 21 n=3
80% (28; 99) 95% (74; 82) 86% (63; 97) 100% (29; 100)
50% (41; 59) 66% (56; 76) 54% (44; 63) 48% (40; 58)
80% (28; 99) 95% (79; 99) 71% (47; 89) 100% (29; 100)
65% (56; 73) 76% (66; 83) 69% (59; 77) 64% (55; 72)
treatment strategies. Future studies must investigate their association to
PDA related morbidity in the neonatal population.
Contributions
Anna Sellmer: Conceptualization, Methodology, Formal analysis,
Investigation, Writing - Original Draft, Funding acquisition. Final ap­
proval of the version to be submitted.
Vibeke E. Hjortdal: Conceptualization, Methodology, Formal ana­
lysis, Writing - Review & Editing, Supervision, Funding acquisition,
Final approval of the version to be submitted.
Jesper V. Bjerre: Methodology, Investigation, Writing - Review &
Editing, Final approval of the version to be submitted.
Michael R. Schmidt: Investigation, Writing - Review & Editing,
Final approval of the version to be submitted.
Bodil H. Bech: Methodology, Formal analysis, Writing - Review &
Editing, Supervision, Final approval of the version to be submitted.
Tine B. Henriksen: Conceptualization, Methodology, Formal ana­
lysis, Investigation, Writing - Review & Editing, Supervision, Funding
acquisition, Final approval of the version to be submitted.
Funding
Funding for this study was obtained from Novo Nordisk Foundation
grant nr. NFF17SA0030576, Aarhus University Faculty of Health, and
The Aase and Ejnar Danielsen's Foundation. The funders had no role in
the study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Declaration of competing interest
The authors of this manuscript have none.
Acknowledgements
The authors would like to thank the parents of the infants enrolled,
the staff at the neonatal intensive care unit at Aarhus University
Hospital, Aarhus, and laboratory technician Jane Knudsen for handling
plasma samples. Also a special thanks to the Department of Clinical
Biochemistry for their great effort in making this study possible.
References
[1] M. Kluckow, P. Lemmers, Hemodynamic assessment of the patent ductus arteriosus:
beyond ultrasound, Semin. Fetal Neonatal Med. 23 (2018) 239–244.
[2] A. Jain, P.S. Shah, Diagnosis, evaluation, and management of patent ductus arter­
iosus in preterm neonates, JAMA Pediatr. 169 (2015) 863.
[3] C.E. Schwarz, A. Preusche, W. Baden, C.F. Poets, A.R. Franz, Repeatability of
echocardiographic parameters to evaluate the hemodynamic relevance of patent
ductus arteriosus in preterm infants: a prospective observational study, BMC
Pediatr. 16 (2016) 18.
[4] A. Sellmer, J.V. Bjerre, M.R. Schmidt, P.J. McNamara, V.E. Hjortdal, B. Host, et al.,
Morbidity and mortality in preterm neonates with patent ductus arteriosus on day
3, Arch. Dis. Child. Fetal Neonatal Ed. 98 (2013) F505–F510.
A. Sellmer, et al.
[5] A. Sellmer, V.E. Hjortdal, J.V. Bjerre, M.R. Schmidt, P.J. McNamara, B.H. Bech,
et al., N-terminal pro-B type natriuretic peptide as a marker of bronchopulmonary
dysplasia or death in very preterm neonates: a cohort study, PLoS One 10 (2015)
e0140079.
[6] A. Wagner-Golbs, S. Neuber, B. Kamlage, N. Christiansen, B. Bethan, U. Rennefahrt,
et al., Effects of long-term storage at −80 °C on the human plasma metabolome,
Metabolites 9 (2019).
[7] W.W. Lai, T. Geva, G.S. Shirali, P.C. Frommelt, R.A. Humes, M.M. Brook, et al.,
Guidelines and standards for performance of a pediatric echocardiogram: a report
from the Task Force of the Pediatric Council of the American Society of
Echocardiography, J. Am. Soc. Echocardiogr. 19 (2006) 1413–1430.
[8] M. El Hajjar, G. Vaksmann, T. Rakza, G. Kongolo, L. Storme, Severity of the ductal
shunt: a comparison of different markers, Arch. Dis. Child. Fetal Neonatal Ed. 90
(2005) F419–F422.
[9] A. Sehgal, P.J. McNamara, Does echocardiography facilitate determination of he­
modynamic significance attributable to the ductus arteriosus? Eur. J. Pediatr. 168
(8) (2009) 907–914.
[10] A. Nir, A. Lindinger, M. Rauh, B. Bar-Oz, S. Laer, L. Schwachtgen, et al., NT-pro-B-
type natriuretic peptide in infants and children: reference values based on combined
data from four studies, Pediatr. Cardiol. 30 (2009) 3–8.
[11] J. Barrera-Gómez, X. Basagaña, Models With Transformed Variables, vol. 26,
(2015), pp. e16–e17.
[12] M. Kulkarni, G. Gokulakrishnan, J. Price, C.J. Fernandes, M. Leeflang, M. Pammi,
Diagnosing significant PDA using natriuretic peptides in preterm neonates: a sys­
tematic review, Pediatrics 135 (2015) e510–e525.
[13] B. Grass, P. Baumann, R. Arlettaz, S. Fouzas, P. Meyer, K. Spanaus, et al.,
Cardiovascular biomarkers pro-atrial natriuretic peptide and pro-endothelin-1 to
monitor ductus arteriosus evolution in very preterm infants, Early Hum. Dev. 90
(2014) 293–298.
[14] A.F. El-Khuffash, M. Amoruso, M. Culliton, E.J. Molloy, N-terminal pro-B-type na­
triuretic peptide as a marker of ductal haemodynamic significance in preterm in­
fants: a prospective observational study, Arch. Dis. Child. Fetal Neonatal Ed. 92
(2007) F421–F422.
[15] Y. Cao, Q. Xia, C. Chen, Y. Yang, Precursors of adrenomedullin, endothelin and
atrial natriuretic peptide as diagnostic markers of neonatal infection, Acta Paediatr.
101 (2012) 242–246.
[16] D. Admaty, J. Benzing, T. Burkhardt, O. Lapaire, L. Hegi, G. Szinnai, et al., Plasma
midregional proadrenomedullin in newborn infants: impact of prematurity and
perinatal infection, Pediatr. Res. 72 (2012) 70–76.
[17] N.E. Ibrahim, J.L. Januzzi Jr., Beyond natriuretic peptides for diagnosis and man­
agement of heart failure, Clin. Chem. 63 (2017) 211–222.
[18] U. Onal, F. Valenzuela-Sanchez, K.E. Vandana, J. Rello, Mid-regional pro-adreno­
medullin (MR-pro ADM) as a biomarker for sepsis and septic shock: narrative re­
view, Healthcare 6 (2018).
[19] T. Nishikimi, Y. Nakagawa, Adrenomedullin as a biomarker of heart failure, Heart
Fail. Clin. 14 (2018) 49.
[20] S. von Haehling, E.A. Jankowska, N.G. Morgenthaler, C. Vassanelli, L. Zanolla,
P. Rozentryt, et al., Comparison of midregional pro-atrial natriuretic peptide with
N-terminal pro-B-type natriuretic peptide in predicting survival in patients with
chronic heart failure, J. Am. Coll. Cardiol. 50 (2007) 1973–1980.
[21] E.A. Espiner, A.M. Richards, Atrial natriuretic peptide, Lancet 333 (1989) 707–710.
[22] A. Maisel, Y. Xue, K. Shah, C. Mueller, R. Nowak, W.F. Peacock, et al., Increased 90-
Day Mortality in Patients With Acute Heart Failure With Elevated Copeptin:
Secondary Results From the Biomarkers in Acute Heart Failure (BACH) Study, vol.
4, (2011), pp. 613–620.
[23] S.M. Amdani, M.U.M. Mian, R.L. Thomas, R.D. Ross, NT-pro BNP-A marker for
worsening respiratory status and mortality in infants and young children with
pulmonary hypertension, Congenit. Heart Dis. 13 (2018) 499–505.
[24] J.Y. Jung, E.M. Ham, H. Kwon, Y.H. Kwak, D.K. Kim, J.H. Lee, et al., N-terminal
pro-brain natriuretic peptide and prediction of coronary artery dilatation in hy­
peracute phase of Kawasaki disease, Am. J. Emerg. Med. 37 (2019) 468–471.
[25] K. Dickstein, A. Cohen-Solal, G. Filippatos, J.J.V. McMurray, P. Ponikowski,
P.A. Poole-Wilson, et al., ESC guidelines for the diagnosis and treatment of acute
and chronic heart failure 2008‡, Eur. J. Heart Fail. 10 (2008) 933–989.
[26] I. Farombi-Oghuvbu, T. Matthews, P.D. Mayne, H. Guerin, J.D. Corcoran, N-term­
inal pro-B-type natriuretic peptide: a measure of significant patent ductus arter­
iosus, Arch. Dis. Child. Fetal Neonatal Ed. 93 (2008) F257–F260.
[27] P.A. Flynn, R.L. da Graca, P.A. Auld, M. Nesin, C.S. Kleinman, The use of a bedside
assay for plasma B-type natriuretic peptide as a biomarker in the management of
patent ductus arteriosus in premature neonates, J. Pediatr. 147 (1) (2005) 38–42.
[28] P. Nuntnarumit, A. Khositseth, P. Thanomsingh, N-terminal probrain natriuretic
peptide and patent ductus arteriosus in preterm infants, J. Perinatol. 29 (2009)
137–142.
[29] S. Rodriguez-Blanco, I. Oulego-Erroz, S. Gautreaux-Minaya, A. Perez-Muñ Uzuri,
M.L. Couce-Pico, Early NT-pro BNP levels as a screening tool for the detection of
hemodynamically significant patent ductus arteriosus during the first week of life in
very low birth weight infants, J. Perinatol. 38 (2018) 881–888.
[30] K. König, K.J. Guy, S.M. Drew, C.P. Barfield, B-type and N-terminal pro-B-type
natriuretic peptides are equally useful in assessing patent ductus arteriosus in very
preterm infants, Acta Paediatr. 104 (2015) e139–e142.
[31] S. Ramakrishnan, Y.M. Heung, J. Round, T.P. Morris, P. Collinson, A.F. Williams,
Early N-terminal pro-brain natriuretic peptide measurements predict clinically
significant ductus arteriosus in preterm infants, Acta Paediatr. 98 (2009)
1254–1259.
[32] D.E. Weisz, P.J. McNamara, A. El-Khuffash, Cardiac biomarkers and haemodyna­
mically significant patent ductus arteriosus in preterm infants, Early Hum. Dev. 105
(2017) 41–47.
Downloaded for Sahniriansa Sahionge (sahniriansa.sahionge@ui.ac.id) at University of Indonesia from ClinicalKey.com by Elsevier on
April 18, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
Early Human Development 149 (2020) 105142
[33] B.B. Das, R. Solinger, Role of natriuretic peptide family in cardiovascular medicine,
Cardiovasc. Hematol. Agents Med. Chem. 7 (2009) 29–42.
[34] F.J. Weir, A. Smith, P. Littleton, N. Carter, P.A. Hamilton, Atrial natriuretic peptide
in the diagnosis of patent ductus arteriosus, Acta Paediatr. 81 (1992) 672–675.
[35] W. Rascher, H.W. Seyberth, Atrial natriuretic peptide and patent ductus arteriosus
in preterm infants, Arch. Dis. Child. 62 (1987) 1165–1167.
[36] F.S. Davidovski, J.P. Goetze, Pro ANP and pro BNP in plasma as biomarkers of heart
failure, Biomark. Med 13 (2019) 1129–1135.
[37] M. Vazquez, K. Jockers, M. Christ-Crain, W. Zimmerli, B. Muller, P. Schuetz, MR-
pro-atrial natriuretic peptide (MR-pro ANP) predicts short- and long-term outcomes
in respiratory tract infections: a prospective validation study, Int. J. Cardiol. 156
(2012) 16–23.
[38] J.A. Hauser, S. Demyanets, K. Rusai, C. Goritschan, M. Weber, D. Panesar, et al.,
Diagnostic performance and reference values of novel biomarkers of paediatric
heart failure, Heart 102 (2016) 1633–1639.
[39] H. Holmstrom, C. Hall, E. Thaulow, Plasma levels of natriuretic peptides and he­
modynamic assessment of patent ductus arteriosus in preterm infants, Acta
Paediatr. 90 (2001) 184–191.
[40] J. Letzner, F. Berger, S. Schwabe, J. Benzing, N.G. Morgenthaler, H.U. Bucher, et al.,
Plasma C-terminal pro-endothelin-1 and the natriuretic pro-peptides NT-pro BNP
and MR-pro ANP in very preterm infants with patent ductus arteriosus,
Neonatology 101 (2012) 116–124.
[41] L. Koch, M.T. Dabek, D. Frommhold, J. Poeschl, Stable precursor fragments of va­
soactive peptides in umbilical cord blood of term and preterm infants, Horm. Res.
Paediatr. 76 (2011) 234–239.
[42] T.S. Mir, R. Laux, H.H. Hellwege, B. Liedke, C. Heinze, B.H. von, et al., Plasma
concentrations of aminoterminal pro atrial natriuretic peptide and aminoterminal
pro brain natriuretic peptide in healthy neonates: marked and rapid increase after
birth, Pediatrics 112 (2003) 896–899.
[43] M. Houde, L. Desbiens, P. D’Orleans-Juste, Endothelin-1: biosynthesis, signaling
and vasoreactivity, Adv. Pharmacol. 77 (2016) 143–175.
[44] T. Ogawa, A.J. de Bold, The heart as an endocrine organ, Endocr. Connect. 3 (2014)
R31–R44.
[45] G.A. Gray, D.J. Webb, The endothelin system and its potential as a therapeutic
target in cardiovascular disease, Pharmacol. Ther. 72 (1996) 109–148.
[46] R. Pacher, B. Stanek, M. Hulsmann, J. Koller-Strametz, R. Berger, M. Schuller, et al.,
Prognostic impact of big endothelin-1 plasma concentrations compared with in­
vasive hemodynamic evaluation in severe heart failure, J. Am. Coll. Cardiol. 27
(1996) 633–641.
[47] T. Taniguchi, H. Azuma, Y. Okada, H. Naiki, M.D. Hollenberg, I. Muramatsu,
Endothelin-1-endothelin receptor type A mediates closure of rat ductus arteriosus at
birth, J. Physiol. 537 (2001) 579–585.
[48] F. Coceani, Y. Liu, E. Seidlitz, L. Kelsey, T. Kuwaki, C. Ackerley, et al., Endothelin A
receptor is necessary for O (2) constriction but not closure of ductus arteriosus, Am.
J. Phys. 277 (1999) H1521–H1531.
[49] S.M. Parizadeh, M. Ghandehari, M.R. Parizadeh, G.A. Ferns, M. Ghayour-Mobarhan,
A. Avan, et al., The diagnostic and prognostic value of copeptin in cardiovascular
disease, current status, and prospective, J. Cell. Biochem. 119 (2018) 7913–7923.
[50] K.S. Evers, S. Wellmann, Arginine vasopressin and copeptin in perinatology, Front.
Pediatr. 4 (2016) 75.
[51] K. Yalta, T. Yalta, N. Sivri, E. Yetkin, Copeptin and cardiovascular disease: a review
of a novel neurohormone, Int. J. Cardiol. 167 (2013) 1750–1759.
[52] I. Tentzeris, R. Jarai, S. Farhan, T. Perkmann, M.A. Schwarz, G. Jakl, et al.,
Complementary role of copeptin and high-sensitivity troponin in predicting out­
come in patients with stable chronic heart failure, Eur. J. Heart Fail. 13 (2011)
726–733.
[53] A. El-Khuffash, E.J. Molloy, Are B-type natriuretic peptide (BNP) and N-terminal-
pro-BNP useful in neonates? Arch. Dis. Child. Fetal Neonatal Ed. 92 (2007)
F320–F324.
[54] J.L. Yeh, J.R. Wu, B.N. Wu, S.F. Yang, Z.K. Dai, S.F. Liou, et al., B-type natriuretic
peptide prevents postnatal closure of ductus arteriosus by both vasodilation and
anti-remodeling in neonatal rats, Clin. Sci. (Lond.) 132 (2018) 2045–2058.
[55] A. El-Khuffash, D. Barry, K. Walsh, P.G. Davis, E.J. Molloy, Biochemical markers
may identify preterm infants with a patent ductus arteriosus at high risk of death or
severe intraventricular haemorrhage, Arch. Dis. Child. Fetal Neonatal Ed. 93 (2008)
1407–1412.
[56] S. Rodríguez-Blanco, I. Oulego-Erroz, P. Alonso-Quintela, S. Terroba-Seara,
A. Jiménez-González, M. Palau-Benavides, N-terminal-probrain natriuretic peptide
as a biomarker of moderate to severe bronchopulmonary dysplasia in preterm in­
fants: a prospective observational study, Pediatr. Pulmonol. 53 (2018) 1073–1081.
[57] D. van Laere, B. van Overmeire, S. Gupta, A. El-Khuffash, M. Savoia,
P.J. McNamara, et al., Application of NPE in the assessment of a patent ductus
arteriosus, Pediatr. Res. 84 (2018) 46–56.
[58] S. Alagarsamy, M. Chhabra, M. Gudavalli, A.M. Nadroo, V.G. Sutija, D. Yugrakh,
Comparison of clinical criteria with echocardiographic findings in diagnosing PDA
in preterm infants, J. Perinat. Med. 33 (2005) 161–164.
[59] J.L. Shepherd, S. Noori, What is a hemodynamically significant PDA in preterm
infants? Congenit. Heart Dis. 14 (2018) 21–26.
[60] D.G. Gardner, H.D. Schultz, Prostaglandins regulate the synthesis and secretion of
the atrial natriuretic peptide, J. Clin. Invest. 86 (1990) 52–59.
[61] J.A. Oliver, R.R. Sciacca, C.G. Le, P.J. Cannon, Modulation by prostaglandins of the
renal vascular action of arginine vasopressin, Prostaglandins 24 (1982) 641–656.
[62] B. Ewald, Post Hoc Choice of Cut Points Introduced Bias to Diagnostic Research, vol.
59, (2006), pp. 798–801.
[63] A.S. Maisel, P. Krishnaswamy, R.M. Nowak, Rapid measurement of B-type na­
triuretic peptide in the emergency diagnosis of heart failure, N. Engl. J. Med 347 (3)
(2002) 161–167.