Tschuppert Scott, Doell Carsten, Arlettaz-Mieth Romaine, Baenziger Oskar, Rousson Valentin, Balmer Christian, Prêtre René, Dodge-Khatami Ali
Division of Congenital Cardiovascular Surgery, University Children's Hospital, University of Zurich, Zurich, Switzerland.
J Thorac Cardiovasc Surg. 2008 Jan;135(1):78-82. doi: 10.1016/j.jtcvs.2007.07.027.
We sought to analyze the effect of patent ductus arteriosus diameter on treatment success in premature neonates.
Among 537 consecutive neonates born between 1985 and 2005 with a diagnosed patent ductus arteriosus, 201 premature patients (<35 weeks' gestation) treated for a hemodynamically significant patent ductus arteriosus were retrospectively reviewed. Two groups were compared: group MED (n = 154; successful treatment with indomethacin) and group FAIL (n = 47; failure of medication to reduce the patent ductus arteriosus diameter to hemodynamic insignificance).
After unsuccessful medical treatment, 33 patients required surgical patent ductus arteriosus closure, 12 died before further possible treatment, and 2 were discharged home without clinical symptoms but with an open patent ductus arteriosus. Mean patent ductus arteriosus diameter in the FAIL group (2.8 +/- 0.9 mm) was significantly larger than that in the MED group (2.4 +/- 0.6 mm, P < .01). Assisted respiration time (ventilation plus continuous positive airway pressure) before patent ductus arteriosus closure was longer in the FAIL group (20 days) than in the MED group (9 days, P < .001) but was similar after patent ductus arteriosus closure. By using an index of patent ductus arteriosus diameter squared/birth weight (in square millimeters per kilogram), a cutoff value of less than 9 mm2/kg correctly predicts medical patent ductus arteriosus closure in 87.5% of patients. Values of greater than 9 mm2/kg correctly predict medication failure in 41.5% of patients.
In preterm babies requiring surgical patent ductus arteriosus closure, longer respiration times reflect a delay while attempting medical treatment, but respiration time is equally short between groups after shunt elimination. Medical treatment, although a valid first option, is likely to fail with larger patent ductus arteriosus diameters and lower birth weights. Unwarranted assisted respiration and corresponding hospital stay might be shortened by earlier surgical referral for patent ductus arteriosus closure in preterm babies with a patent ductus arteriosus index of greater than 9 mm2/kg.
我们试图分析动脉导管直径对早产儿治疗成功率的影响。
回顾性分析1985年至2005年间连续出生的537例诊断为动脉导管未闭的新生儿，其中201例早产（孕周<35周）且因血流动力学显著的动脉导管未闭接受治疗的患儿。比较两组：MED组（n = 154；吲哚美辛治疗成功）和FAIL组（n = 47；药物治疗未能将动脉导管直径减小至血流动力学无意义）。
药物治疗失败后，33例患者需要手术关闭动脉导管，12例在进一步治疗前死亡，2例出院时无临床症状但动脉导管未闭。FAIL组的平均动脉导管直径（2.8±0.9 mm）显著大于MED组（2.4±0.6 mm，P <.01）。FAIL组动脉导管未闭关闭前的辅助呼吸时间（机械通气加持续气道正压通气）（20天）长于MED组（9天，P <.001），但动脉导管未闭关闭后相似。使用动脉导管直径平方/出生体重指数（每千克平方毫米），小于9 mm2/kg的临界值可正确预测87.5%的患者药物治疗动脉导管未闭关闭成功。大于9 mm2/kg的值可正确预测41.5%的患者药物治疗失败。
在需要手术关闭动脉导管的早产儿中，较长的呼吸时间反映了药物治疗尝试的延迟，但分流消除后两组之间的呼吸时间同样短。药物治疗虽然是有效的首选，但对于较大的动脉导管直径和较低的出生体重可能会失败。对于动脉导管未闭指数大于9 mm2/kg的早产儿，早期手术转诊关闭动脉导管可能会缩短不必要的辅助呼吸时间和相应的住院时间。
