目的 探讨极低出生体重儿（very low birth weight infant，VLBWI）动脉导管未闭（patent ductus arteriosus，PDA）手术结扎时机对预后的影响。 方法 回顾性分析2018年6月至2021年5月行经胸PDA手术结扎治疗的VLBWI临床资料。根据结扎时日龄分为早期结扎组（日龄≤21 d）和晚期结扎组（日龄>21 d），比较2组间围术期临床特征、并发症及病死率，并分析早期手术结扎的影响因素。 结果 共纳入72例VLBWI，早期结扎组19例（26%），晚期结扎组53例（74%）。2组间出生体重、胎龄、手术时体重、手术时日龄、术前有创机械通气率、术前无创机械通气率、肺出血及低血压发生率、术前72 h PDA内径/体重、术中PDA外径/体重、手术结扎后心脏综合征发生率及术后有创机械通气时间比较差异有统计学意义（P<0.05）。二元logistic回归分析显示：肺出血宜早期行PDA手术结扎（P<0.05）。早期结扎组和晚期结扎组术后并发症发生率和病死率差异无统计学意义（P>0.05）。 结论 当VLBWI生后出现肺出血并经心脏超声证实存在有血流动力学意义的PDA时，可早期行手术结扎治疗，但应警惕手术结扎后心脏综合征的发生。另外，PDA的早期结扎并未增加手术本身、远期并发症及死亡的风险，是一种安全、可行的治疗方案。 用格式：引用格式:中国当代儿科杂志，2022，24（5）：500-506
Abstract
Objective To study the effect of timing of surgical ligation of patent ductus arteriosus (PDA) on the prognosis of very low birth weight infants (VLBWI). Methods The medical data of VLBWI who underwent transthoracic ligation for PDA from June 2018 to May 2021 were reviewed retrospectively. The infants were divided into early ligation group (≤21 days of age) and late ligation group (>21 days of age) based on the age of ligation. The two groups were compared in terms of perioperative clinical features, complications, and mortality. The risk factors for early surgical ligation were analyzed. Results A total of 72 VLBWI were enrolled, with 19 infants (26%) in the early ligation group and 53 infants (74%) in the late ligation group. There were significant differences in birth weight, gestational age, weight at operation, days of age at operation, rates of preoperative invasive and noninvasive mechanical ventilation, incidence rate of pulmonary hemorrhage, incidence rate of hypotension, preoperative PDA internal diameter (mm/kg), intraoperative PDA external diameter (mm/kg), incidence rate of post-ligation cardiac syndrome, and duration of postoperative invasive mechanical ventilation between the two groups (P<0.05). A binary logistic regression analysis showed that pulmonary hemorrhage was an indication of early surgical ligation of PDA (P<0.05). There were no significant differences in the incidence rates of post-operative complications and the mortality rate between the early ligation and late ligation groups. Conclusions Early surgical ligation may be performed for VLBWI who are experiencing pulmonary hemorrhage and hemodynamically significant PDA confirmed by cardiac ultrasound after birth. However, post-ligation cardiac syndrome should attract enough attention. In addition, early surgical ligation of PDA does not increase the risk of surgery-related and long-term complications or death, indicating that it is a safe and feasible treatment option. Citation:Chinese Journal of Contemporary Pediatrics, 2022, 24(5): 500-506
关键词
动脉导管未闭 /
早期手术结扎 /
极低出生体重儿 /
早产儿
Key words
Patent ductus arteriosus /
Early surgical ligation /
Very low birth weight infant /
Preterm infant
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
1 Deshpande P, Baczynski M, McNamara PJ, et al. Patent ductus arteriosus: the physiology of transition[J]. Semin Fetal Neonatal Med, 2018, 23(4): 225-231. PMID: 29779927. DOI: 10.1016/j.siny.2018.05.001.
2 Ognean ML, Boant? O, Kovacs S, et al. Persistent ductus arteriosus in critically ill preterm infants[J]. J Crit Care Med (Targu Mures), 2016, 2(4): 175-184. PMID: 29967857. PMCID: PMC5953255. DOI: 10.1515/jccm-2016-0026.
3 Abu-Shaweesh JM, Almidani E. PDA: does it matter?[J]. Int J Pediatr Adolesc Med, 2020, 7(1): 9-12. PMID: 32373696. PMCID: PMC7193069. DOI: 10.1016/j.ijpam.2019.12.001.
4 Conrad C, Newberry D. Understanding the pathophysiology, implications, and treatment options of patent ductus arteriosus in the neonatal population[J]. Adv Neonatal Care, 2019, 19(3): 179-187. PMID: 30720481. DOI: 10.1097/ANC.0000000000000590.
5 Hamrick SEG, Sallmon H, Rose AT, et al. Patent ductus arteriosus of the preterm infant[J]. Pediatrics, 2020, 146(5): e20201209. PMID: 33093140. PMCID: PMC7605084. DOI: 10.1542/peds.2020-1209.
6 Liu T, Chen Z, Ma X, et al. Predictive tool for closure of ductus arteriosus with pharmacologic or surgical treatment in preterm infants[J]. Pediatr Cardiol, 2022, 43(2): 373-381. PMID: 34510236. PMCID: PMC8435120. DOI: 10.1007/s00246-021-02731-w.
7 Weisz DE, Giesinger RE. Surgical management of a patent ductus arteriosus: is this still an option?[J]. Semin Fetal Neonatal Med, 2018, 23(4): 255-266. PMID: 29636280. DOI: 10.1016/j.siny.2018.03.003.
8 Weisz DE, More K, McNamara PJ, et al. PDA ligation and health outcomes: a meta-analysis[J]. Pediatrics, 2014, 133(4): e1024-e1046. PMID: 24639268. DOI: 10.1542/peds.2013-3431.
9 Gudmundsdottir A, Brostr?m L, Ski?ld B, et al. The type and timing of patent ductus arteriosus treatment was associated with neurodevelopment when extremely preterm infants reached 6.5 years[J]. Acta Paediatr, 2021, 110(2): 510-520. PMID: 32603514. DOI: 10.1111/apa.15452.
10 Ulrich TJB, Hansen TP, Reid KJ, et al. Post-ligation cardiac syndrome is associated with increased morbidity in preterm infants[J]. J Perinatol, 2018, 38(5): 537-542. PMID: 29453434. DOI: 10.1038/s41372-018-0056-4.
11 Yang MC, Liu HK, Wu HY, et al. Initial experience with patent ductus arteriosus ligation in pre-term infants with bidirectional shunt pattern[J]. Front Pediatr, 2020, 8: 591441. PMID: 33194925. PMCID: PMC7649389. DOI: 10.3389/fped.2020.591441.
12 Su BH, Lin HY, Chiu HY, et al. Therapeutic strategy of patent ductus arteriosus in extremely preterm infants[J]. Pediatr Neonatol, 2020, 61(2): 133-141. PMID: 31740267. DOI: 10.1016/j.pedneo.2019.10.002.
13 Jain A, Shah PS. Diagnosis, evaluation, and management of patent ductus arteriosus in preterm neonates[J]. JAMA Pediatr, 2015, 169(9): 863-872. PMID: 26168357. DOI: 10.1001/jamapediatrics.2015.0987.
14 El-Khuffash AF, Jain A, McNamara PJ. Ligation of the patent ductus arteriosus in preterm infants: understanding the physiology[J]. J Pediatr, 2013, 162(6): 1100-1106. PMID: 23410600. DOI: 10.1016/j.jpeds.2012.12.094.
15 Jhaveri N, Moon-Grady A, Clyman RI. Early surgical ligation versus a conservative approach for management of patent ductus arteriosus that fails to close after indomethacin treatment[J]. J Pediatr, 2010, 157(3): 381-387, 387.e1. PMID: 20434168. PMCID: PMC2926149. DOI: 10.1016/j.jpeds.2010.02.062.
16 Brooks JM, Travadi JN, Patole SK, et al. Is surgical ligation of patent ductus arteriosus necessary? The Western Australian experience of conservative management[J]. Arch Dis Child Fetal Neonatal Ed, 2005, 90(3): F235-F239. PMID: 15846015. PMCID: PMC1721898. DOI: 10.1136/adc.2004.057638.
17 Sung SI, Choi SY, Park JH, et al. The timing of surgical ligation for patent ductus arteriosus is associated with neonatal morbidity in extremely preterm infants born at 23-25 weeks of gestation[J]. J Korean Med Sci, 2014, 29(4): 581-586. PMID: 24753708. PMCID: PMC3991804. DOI: 10.3346/jkms.2014.29.4.581.
18 van Laere D, van Overmeire B, Gupta S, et al. Application of NPE in the assessment of a patent ductus arteriosus[J]. Pediatr Res, 2018, 84(Suppl 1): 46-56. PMID: 30072803. PMCID: PMC6257219. DOI: 10.1038/s41390-018-0077-x.
19 D'Amato G, Errico G, Franco C, et al. Ductal size indexed to weight and body surface area correlates with morbidities in preterm infants ≤32 weeks[J]. J Matern Fetal Neonatal Med, 2021, 34(19): 3133-3139. PMID: 31619099. DOI: 10.1080/14767058.2019.1678134.
20 Kwinta P, Rudziński A, Kruczek P, et al. Can early echocardiographic findings predict patent ductus arteriosus?[J]. Neonatology, 2009, 95(2): 141-148. PMID: 18776728. DOI: 10.1159/000153098.
21 Noori S, Friedlich P, Seri I, et al. Changes in myocardial function and hemodynamics after ligation of the ductus arteriosus in preterm infants[J]. J Pediatr, 2007, 150(6): 597-602. PMID: 17517241. DOI: 10.1016/j.jpeds.2007.01.035.
22 Noori S, Kumar SR. Predicting post-ligation syndrome[J]. J Thorac Cardiovasc Surg, 2017, 154(6): 2060-2061. PMID: 28967417. DOI: 10.1016/j.jtcvs.2017.08.048.
23 Giesinger RE, Bischoff AR, McNamara PJ. Anticipatory perioperative management for patent ductus arteriosus surgery: understanding postligation cardiac syndrome[J]. Congenit Heart Dis, 2019, 14(2): 311-316. PMID: 30945807. DOI: 10.1111/chd.12738.
24 Teixeira LS, Shivananda SP, Stephens D, et al. Postoperative cardiorespiratory instability following ligation of the preterm ductus arteriosus is related to early need for intervention[J]. J Perinatol, 2008, 28(12): 803-810. PMID: 18615091. DOI: 10.1038/jp.2008.101.
25 Harting MT, Blakely ML, Cox CS, et al. Acute hemodynamic decompensation following patent ductus arteriosus ligation in premature infants[J]. J Invest Surg, 2008, 21(3): 133-138. PMID: 18569433. DOI: 10.1080/08941930802046469.
26 Yan H, Ma F, Li Y, et al. The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: a systematic review and meta-analysis[J]. Medicine (Baltimore), 2020, 99(9): e19356. PMID: 32118777. PMCID: PMC7478603. DOI: 10.1097/MD.0000000000019356.
27 Hagadorn JI, Brownell EA, Trzaski JM, et al. Trends and variation in management and outcomes of very low-birth-weight infants with patent ductus arteriosus[J]. Pediatr Res, 2016, 80(6): 785-792. PMID: 27509008. DOI: 10.1038/pr.2016.166.
28 Mashally S, Nield LE, McNamara PJ, et al. Late oral acetaminophen versus immediate surgical ligation in preterm infants with persistent large patent ductus arteriosus[J]. J Thorac Cardiovasc Surg, 2018, 156(5): 1937-1944. PMID: 30007780. DOI: 10.1016/j.jtcvs.2018.05.098.
29 Noori S, McCoy M, Friedlich P, et al. Failure of ductus arteriosus closure is associated with increased mortality in preterm infants[J]. Pediatrics, 2009, 123(1): e138-e144. PMID: 19117835. DOI: 10.1542/peds.2008-2418.
30 Weisz DE, Mirea L, Resende MHF, et al. Outcomes of surgical ligation after unsuccessful pharmacotherapy for patent ductus arteriosus in neonates born extremely preterm[J]. J Pediatr, 2018, 195: 292-296.e3. PMID: 29306492. DOI: 10.1016/j.jpeds.2017.11.029.
PDF(581 KB)
