88例早产儿动脉导管未闭的临床分析

目的 对动脉导管未闭(PDA)早产儿的临床资料进行回顾性分析，寻找和确定更适当的治疗方法。方法 88例PDA早产儿中采用消炎痛治疗59例，直接行外科手术结扎29例，对其治疗方法、出生时体重和死亡情况进行比较分析。结果 消炎痛治疗失败率为44．1％，尤其在体重小于l500g的早产儿中偏高(83．3％)，其并发症、呼吸窘迫综合征，死亡例数均较体重大于l500g的早产儿多，机械辅助呼吸时间和住ICU时间等均较长(P＜0．05)。手术患者无与麻醉或手术相关的并发症和死亡。结论 PDA早产儿的治疗应考虑以动脉导管结扎术作为首选治疗方法。     

Analysis of outcome in 298 extremely low-birth-weight infants with patent ductus arteriosus

Purpose

Indomethacin is accepted therapy for patent ductus arteriosus (PDA) in ELBW infants (<1000 g). We hypothesize that surgical ligation may provide comparatively superior outcomes in select ELBW infants.

Methods

Predischarge outcomes of 298 ELBW infants with echocardiography-proven PDA were retrospectively compared by treatment provided: no treatment (group 1, n = 54), indomethacin (group 2, n = 140), ligation (group 3, n = 46), and ligation after indomethacin failure (group 4, n = 58). χ² and Wilcoxon rank sum tests were used to test for significance. Institutional review board approval was obtained (IRB/05-00395).

Results

Group 3 had significantly lower gestational age (P < .001), birth weight (P = .006), and 5-minute Apgar scores (P = .03) compared with group 2. Group 3 and group 1 had a higher rate of pretreatment intraventricular hemorrhage (IVH) compared with group 2 (P < .001). By contrast, posttreatment complications including acute renal failure, necrotizing enterocolitis, thrombocytopenia, and IVH occurred more frequently in groups 2 (P = .004) and 4 (P = .001) compared with group 3. Survival was 57.7% in group 1 compared with groups 2, 3, and 4 (82.4%, 86.0%, and 92.7% respectively; P = .001). Preoperative conditions associated with nonsurvival include gestational age (P = .009), birth weight (P = .002), maternal preeclampsia (P = .015), 5-minute Apgar score (P = .013), and sepsis (P = .018). Posttreatment complications associated with nonsurvival include acute renal failure (P = .002), thrombocytopenia (P = .002), and necrotizing enterocolitis (P = .034). Survival was not influenced by any congenital comorbidity, pre- or posttreatment IVH, diameter of the PDA, or recurrence of the PDA after indomethacin therapy.

Conclusions

(1) Patent ductus arteriosis requires treatment in ELBW infants to maximize survival. (2) Indomethacin and surgical ligation permit equivalent survival in low-risk ELBW infants, but indomethacin results in a high failure and complication rate requiring operative salvage in a number of patients. (3) Surgical ligation permits survival of high-risk ELBW infants with a low complication rate and is preferable to indomethacin in ELBW infants with the above risk factors.     

介入封堵术和外科手术治疗中国大陆人群动脉导管未闭的Meta分析

目的比较介入封堵术和外科手术治疗中国大陆人群动脉导管未闭的价值。方法检索中国生物医学文献、PubMed等数据库,收集公开发表的关于介入封堵术和外科手术治疗动脉导管未闭的文献资料。采用RevMan 5.3软件进行统计分析。结果共纳入12篇文献,采用介入封堵术治疗患者782例,外科手术980例。Meta分析显示介入封堵术成功率低于外科手术(RR=0.98,95%CI 0.97~1.00,P=0.03);介入封堵术并发症发生率低于外科手术(RR=0.32,95%CI 0.11~0.95,P=0.04);介入封堵术即时残余分流率高于外科手术(RR=4.26,95%CI 2.21~8.21,P0.000 01);介入封堵术输血率低于外科手术(RR=0.07,95%CI 0.02~0.21,P0.000 01);介入封堵术操作时间短于外科手术(SMD=-1.21,95%CI-1.72~-0.70,P0.000 01);介入封堵术住院时间短于外科手术(SMD=-2.11,95%CI-3.52~-0.70,P=0.000 3);介入封堵术治疗费用高于外科手术(SMD=9.08,95%CI 5.29~12.86,P0.000 01)。结论介入封堵术手术并发症发生率和手术输血率低,手术时间和住院时间短;在适应证范围内,介入封堵术可为治疗PDA的首选方法。     

Esophageal stethoscope: an old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure

Background

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for closure of a patent ductus arteriosus (PDA), but is associated with a minute rate of residual or recurrent duct patency. This study aims to analyze the efficacy of intraoperative esophageal stethoscopic monitoring in reducing the incidence of residual ductal flow during PDA clipping by VATS.

Methods

Between June 1997 and October 2009, we retrospectively assessed 2000 consecutive patients with PDA who underwent VATS. During the procedure, heart sounds were monitored by the anesthesiologist through an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded before and after the PDA clipping and were confirmed to disappear completely. Color flow Doppler echocardiography was performed immediately before discharge, and patients were followed monthly for 3, 6, and 12 months and then annually to confirm the absence of residual or recurrent shunt.

Results

Mean age was 6.0 years (range, 1 month-35 years), mean weight was 11.1 kg (range, 6-65 kg), and mean PDA diameter was 5.5 mm (range, 3-9 mm). Ninety-two percent of patients showed no ductal flow after a single clipping. In the other 8% of patients, residual flow was detected intraoperatively after a single clipping, but was eliminated by the second clipping. Twelve patients (0.6%) presented with residual ductal flow immediately after the operation (detected by color Doppler echocardiography), which was eliminated by thoracotomy before discharge. All patients left the hospital with echocardiography documenting no evidence of residual PDA. At follow-up, the incidence of residual patency was 0.2% (4 of 2000).

Conclusions

Our results demonstrate that the intraoperative esophageal stethoscope provides a remarkably effective technique for monitoring and evaluating PDA ligation by VATS, thus avoiding reintervention and the complications associated with residual ductal flow in most cases.