Narayanan M, Cooper B, Weiss H, Clyman R I
Cardiovascular Research Institute, Department of Pediatrics, University of California, San Francisco, USA.
J Pediatr. 2000 Mar;136(3):330-7. doi: 10.1067/mpd.2000.103414.
Permanent closure of the ductus arteriosus (DA) requires both effective muscular constriction to block luminal blood flow and anatomic remodeling to prevent later reopening.
We examined the role of prophylactic indomethacin in producing permanent DA closure and the mechanism by which this occurs.
We studied 2 separate approaches to managing a patent DA in 257 preterm infants (gestation 24 to 27 weeks): (1) prophylactic indomethacin (all infants treated during the first 15 hours after birth) or (2) symptomatic treatment (infants in this group received indomethacin only if clinical symptoms appeared; infants whose ductus closed spontaneously and never received indomethacin were included in this group). Echocardiography was performed 24 to 36 hours after the last dose of indomethacin was administered or by age 5 days if spontaneous closure occurred. Infants were monitored for the development of ductus reopening.
The prophylactic treatment group had a greater degree of initial ductus constriction, a higher rate of permanent anatomic closure, and a decreased need for surgical ligation than did the symptomatic treatment group. The degree of initial ductus constriction was the most important factor determining the rate of ductus reopening. Post-treatment echocardiography proved to be the best test for predicting eventual reopening.
Prophylactic indomethacin improved the rate of permanent ductus closure by increasing the degree of initial constriction. Prophylactic indomethacin did not affect the remodeling process, nor did it alter the inverse relationship between infant maturity and subsequent reopening. Even when managed with prophylactic indomethacin, the rate of ductus reopening remained unacceptably high in the most immature infants.
动脉导管（DA）的永久性闭合需要有效的肌肉收缩以阻断管腔内血流，以及解剖结构重塑以防止日后重新开放。
我们研究了预防性使用吲哚美辛在实现DA永久性闭合中的作用及其发生机制。
我们研究了257例早产婴儿（孕周24至27周）中处理动脉导管未闭的两种不同方法：（1）预防性使用吲哚美辛（所有婴儿在出生后15小时内接受治疗）或（2）症状性治疗（该组婴儿仅在出现临床症状时接受吲哚美辛治疗；导管自发闭合且从未接受吲哚美辛治疗的婴儿也纳入该组）。在最后一剂吲哚美辛给药后24至36小时或如果发生自发闭合则在5日龄时进行超声心动图检查。监测婴儿动脉导管重新开放的情况。
与症状性治疗组相比，预防性治疗组初始导管收缩程度更大，永久性解剖学闭合率更高，手术结扎需求减少。初始导管收缩程度是决定导管重新开放率的最重要因素。治疗后超声心动图被证明是预测最终重新开放的最佳检查方法。
预防性使用吲哚美辛通过增加初始收缩程度提高了动脉导管永久性闭合率。预防性使用吲哚美辛不影响重塑过程，也未改变婴儿成熟度与随后重新开放之间的反比关系。即使采用预防性吲哚美辛治疗，最不成熟婴儿的动脉导管重新开放率仍然高得令人无法接受。
