Fechamento percutâneo do canal arterial em pacientes prematuros abaixo de 2 Kg: experiência inicial Brasileira / Percutaneous closure of ductus arteriosus in preterm babies: the initial Brazilian experience

FUNDAMENTO: A incidência de ductus arteriosus patente (PCA) pode chegar a 50% em pacientes prematuros. Quando hemodinamicamente significativo, pode ser responsável por tempo de ventilação mecânica prolongado, além de importante fator de risco para o aparecimento de enterocolite necrotizante, hemorragia intraventricular e displasia broncopulmonar nessa população. OBJETIVO: O objetivo deste estudo é descrever a experiência inicial do fechamento percutâneo de canal arterial em prematuros pesando menos de 2 kg. MÉTODOS: Trata-se de estudo prospectivo que compreendeu 14 pacientes consecutivos submetidos a fechamento percutâneo de canal arterial de março de 2020 a fevereiro de 2021 em 6 instituições no Brasil. RESULTADOS: A idade gestacional média ao nascimento foi de 28,45 ±3,14 semanas, a idade média no momento do procedimento foi de 38,85 ±17,35 dias e o peso médio de 1,41±0,41 kg. Dentre os prematuros, 79% necessitavam de ventilação mecânica e 79% tinham feito uso de, em média, 1,5 ciclos de anti-inflamatórios não esteroides. A maioria dos pacientes teve melhora dos parâmetros ventilatórios e o tempo médio de extubação foi de 12,6 ±7,24 dias. A taxa de sucesso foi de 100%. Não houve mortalidade relacionada ao procedimento. CONCLUSÃO: Este estudo concluiu que o fechamento percutâneo do canal arterial em prematuros é uma realidade no Brasil, com resultados satisfatórios e baixa taxa de complicações.

BACKGROUND: The presence of patent ductus arteriosus can be as high as 50% in preterm babies. Hemodynamically significant patent ductus arteriosus is a common cause of delayed weaning of respiratory support and an important risk factor of necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia in this population. OBJECTIVE: The aim of this study is to describe an initial experience of percutaneous closure of the ductus arteriosus in preterm infants weighing less than 2 kg. METHODS: This was a prospective study, comprised of 14 consecutive patients submitted to percutaneous closure of ductus arteriosus between March 2020 and February 2021 in 6 institutions in Brazil. RESULTS: Mean gestational age was 28.45±3.14 weeks, mean age at the procedure was 38.85±17.35 days and mean weight was 1.41 ±0.41 kg; 79% of the patients were under mechanical ventilation, and 79% had been submitted, on average, to a 1.5 cycle of non-steroidal anti-inflammatory drugs. Most patients were weaned off of mechanical ventilation in a mean of 12.6 ±7.24 days after the procedure. Success rate was 100%. No procedure-related mortality was observed. CONCLUSION: This study concluded that percutaneous closure of ductus arteriosus in premature babies below 2 kg has satisfactory results and a low complication rate in this study sample.

Unusual presentation of patent ductus arteriosus in elderly patient

Abstract We presented a case of a 56-year-old man with giant pulmonary artery aneurysm caused by a misdiagnosed patent ductus arteriosus, severe multivalvular disease and active aortic valve endocarditis successfully treated by surgery. The correct diagnosis was missed despite preoperative diagnostics because the small patent ductus arteriosus was located at the distal part of common pulmonary trunk and a huge regurgitant signal overlapped its Doppler signal. Thorough evaluation of every patient, regardless of age, is necessary to recognize and treat this congenital anomaly.

Aspectos desconocidos de la relación entre el sistema de grupo sanguíneo ABO y las morbilidades en prematuros / Unknown aspects of the relationship between ABO blood group system and preterm morbidities

Objetivos. Se ha demostrado, en diversos estudios llevados a cabo en adultos, que los grupos sanguíneos desempeñan un papel importante en muchas enfermedades. El objetivo fue investigar si hay una relación entre las morbilidades y el sistema de grupos sanguíneos ABO en lactantes prematuros.Metodología. En este estudio de cohorte retrospectivo, se incluyó a recién nacidos prematuros que habían nacido con menos de 32 semanas de gestación y con un peso al nacer inferior a 1500 g. Se los agrupó por grupo sanguíneo (0, A, B, AB) y por morbilidades de la prematurez y se los comparó.Resultados. Se analizaron los datos de 1785 recién nacidos prematuros de muy bajo peso al nacer. La comparación entre los grupos sanguíneos A y no A reveló que los lactantes de grupo sanguíneo A tenían una incidencia más alta de conducto arterial persistente (CAP) (48,7 % frente a 39,7 %, p = 0,005) y displasia broncopulmonar (DBP) (27 % frente a 20,8 %, p = 0,04), mientras que la incidencia de la hemorragia intraventricular de grado ≥3 era más baja (5,1 % frente a 10,1 %, p = 0,006).Conclusión. Este estudio es la primera y más grande investigación sobre la relación entre los grupos sanguíneos y las morbilidades en los prematuros. Con estos resultados se demuestra que el grupo sanguíneo A podría ser un factor de riesgo de CAP y DBP

Objectives. Blood groups have been shown to play an important role in a lot of diseases in various studies conducted in adults. The objective was to investigate whether there is a relationship between morbidities and ABO blood groups system in preterm infants.Methodology. This retrospective cohort study included preterm neonates born at < 32 weeks of gestation with a birth weight < 1500 g. Neonates were grouped by blood type (O, A, B, AB) and morbidities of prematurity were compared among these groups. Results. Data pertaining to 1785 very low birth weight preterm neonates were analyzed. Comparison of the A and non-A blood groups revealed that infants with blood group A had significantly higher incidence of patent ductus arteriosus (PDA) (48.7 % vs. 39.7 %, p = 0.005) and bronchopulmonary dysplasia (BPD) (27 % vs. 20.8 %, p = 0.04), while the incidence of grade ≥ 3 intraventricular hemorrhage was lower (5.1 % vs. 10.1 %, p = 0.006).Conclusion. This study represents the first and biggest series examination of the relationship between blood groups and preterm morbidities. Our results show that blood group A may be a risk factor for PDA and BPD.

Factores predisponentes para administrar un segundo ciclo de paracetamol o el cierre quirúrgico del ductus arterioso persistente en los recién nacidos pretérmino / Predisposing factors for administering a second paracetamol cycle or surgical closure of the persistent arterial ductus in preterm infants

Contexto: el conducto arterioso es una estructura que forma parte de la circulación fetal normal; en condiciones normales, se cierra espontáneamente en las primeras 24 a 36 horas de vida. En algunas condiciones patológicas, como la prematuridad, sigue siendo permeable. El tratamiento incluye terapia farmacológica y, en casos extremos, asistencia quirúrgica. Propósito: determinar si los factores demográficos, la edad en el momento del diagnóstico, los parámetros antropométricos, las patologías asociadas, la sobrehidratación, la fototerapia, las transfusiones sanguíneas, el uso de drogas inotrópicas y la ventilación mecánica influyen en la respuesta del tratamiento farmacológico con un ciclo de paracetamol en los pacientes con conducto arterioso persistente y en aquellos que requieren un segundo ciclo o el cierre quirúrgico. Sujetos y métodos: Este es un estudio descriptivo, analítico, epidemiológico, transversal, retrospectivo. Muestra: 205 pacientes pretérminos, nacidos en Quito entre noviembre del 2016 y noviembre del 2018 que tuvieron ductus arterioso persistente. Resultados: 103 casos de ducto arterioso persistente con respuesta al tratamiento con un solo ciclo de paracetamol y 102 que no cerraron el ductus; en el momento del diagnóstico la edad fue menor o igual a 72 horas (n = 110; 53,73 %); predominó el sexo masculino (n = 111; 54,14 %), así como la raza mestiza (200; 97.73 %); los diagnósticos al ingreso fueron: riesgo metabólico (n = 147; 71.7 %) y riesgo de sepsis (n = 108; 52.9 %); la edad gestacional promedio fue de 32-37 semanas ; la mayoría de los pacientes presentaron perímetro cefálico, talla y temperatura adecuados; y no requirieron inotrópicos (n = 132; 64,39 %); la mayoría recibió antibióticos (n = 170; 82,71 %); muchos no recibieron alimentación (n = 126; 61,76 %); algunos requirieron Ventilación Mecánica Intermitente (n = 131; 63,7 %). Las patologías asociadas más frecuentes fueron las respiratorias (n = 179; 87.31 %), las metabólicas (n = 160; 78,36 %) y las infecciosas (n = 152; 74,63 %); en cuanto a los hallazgos ecocardiográficos, se encontró un tamaño del ductus mayor a 1,4mm/kg (n = 110; 53,62 %), un patrón de flujo en cierre (n = 99; 48,55 %), sin inversión de flujo (n = 157; 76,81 %), una fracción de acortamiento mayor o igual a 35 % (n = 162; 78.99 %), sin dilatación de las cavidades izquierdas (n = 184; 89,86 %); los cofactores asociados fueron: fototerapia (n = 113; 55,07 %), transfusión sanguínea (n = 83; 40,58 %), uso de furosemida (n = 58; 28,26 %) y sobrehidratación (n = 55; 26,81 %). Conclusiones: las variables asociadas a una no respuesta a un solo ciclo de paracetamol fueron la edad en el momento del diagnóstico, mayor a 72 horas; la temperatura al nacer menor a 36,5° C; las transfusiones, el uso de furosemida y la sobrehidratación.

Context: The ductus arteriosus is part of the normal fetal circulation, that normally closes spontaneously in the first 24 to 36 hours of life. In some pathological conditions, such as prematurity, it continues to be permeable. Treatment includes pharmacological therapy and in extreme cases surgical assistance. Purpose: To determine if demographic factors, age of diagnosis, anthropometric parameters, associated pathologies, overhydration, phototherapy, blood transfusions, use of inotropic drugs, mechanical ventilation influence the response of pharmacological treatment with a paracetamol cycle in patients with persistent ductus arteriosus and those that require a second cycle or surgical closure. Subjects and methods: This is a descriptive, analytical, epidemiological, cross-sectional, retrospective study. Sample: 205 preterm patients born from November 2016 to November 2018 in Quito with persistent ductus arteriosus. Results: 103 patients responded to treatment with a single cycle of paracetamol and 102 did not, age at diagnosis less than or equal to 72 hours (n = 110, 53.73%), male sex (n = 111 54.14%), mestizo (200, 97.73%), diagnosis at admission: metabolic risk (n = 147, 71.7%), risk of sepsis (n = 108, 52.9%), gestational age 32-37 SG (n = 85, 41.67%), the majority of the patients presented adequate head circunference, height and temperature, did not require inotropics (n = 132, 64.39), used antibiotics (n = 170, 82.71%), did not receive food (n = 126, 61.76%), required Intermittent Mandatory Ventilation(n = 131, 63.7%), among the associated pathologies the most frequent were: respiratory (n = 179, 87.31%), metabolic (n = 160, 78.36%), infectious (n = 152, 74.63%), echocardiographic findings: ductus size greater than 1.4mm / kg (n = 110, 53.62%), flow pattern at closure ( n = 99; 48.55%), without flow reversal (n = 157; 76.81%), shortening fraction greater than or equal to 35% ( n = 162; 78.99%), without dilatation of left cavities (n = 184; 89.86%), associated cofactors: phototherapy (n = 113, 55.07%), blood transfusion (n = 83, 40.58%), use of furosemide (n = 58, 28.26%) and overhydration ( n = 55, 26.81%) Conclusions: The variables associated with non-response to a single cycle of paracetamol were age at diagnosis greater than 72 hours, temperature at birth less than 36.5 ° C, transfusions, use of furosemide and overhydration.

Prevalência de persistência do canal arterial em neonatos em um hospital público / Prevalence of persistence of the arterial canal in newborns in a public hospital

Resumo Objetivo: Identificar a prevalência de persistência do canal arterial (PCA) em neonatos em um hospital público. Metodologia: Trata-se de um estudo quantitativo, observacional e de caráter descritivo. Foram coletados dados de 313 prontuários de recém-nascidos, observando a ocorrência do diagnóstico de PCA em uma amostra de neonatos internados em um hospital público do norte de Minas Gerais no período de agosto de 2015 a agosto de 2016, até o 7° dia de vida. As seguintes variáveis foram analisadas: idade gestacional, peso ao nascer, Apgar 1' e 5', desconforto respiratório, uso de equipamentos de suporte ventilatório e utilização de medicamentos para a função respiratória. Os dados coletados foram processados estatisticamente através do programa Minitab. Resultados: Neste estudo, percebe-se que a incidência da PCA é maior em prematuro quando a relação idade gestacional e peso ao nascer são inversamente proporcionais à PCA. A prevalência neste estudo foi de 2,6 % de recém nascidos com a cardiopatia, sendo que destes foi observado o desconforto respiratório em 43 % de neonatos. Conclusão: A prevalência do canal arterial na amostra foi relativamente baixa, dentre os fatores associados ao aparecimento da cardiopatia, mas as alterações no quinto minuto de Apgar mostraram ser estatisticamente significantes. Sendo assim, identificar a ocorrência do diagnóstico da PCA e conhecer as repercussões respiratórias, assim como proposto nesse estudo, pode auxiliar na programação da assistência e, em especial, favorecer a melhoria da conduta de enfermagem.

Resumen Objetivo: Identificar la prevalencia de persistencia del canal arterial (PCA) en neonatos en un hospital público. Metodología: Se trata de un estudio cuantitativo, observacional y de carácter descriptivo. Se recogieron datos de 313 prontuarios de recién nacidos, observando la ocurrencia del diagnóstico de PCA en una muestra de neonatos internos en un hospital público del norte de Minas Gerais en el período de agosto de 2015 a agosto de 2016, hasta el 7° día de vida, analizando las variables: edad gestacional, peso al nacer, Apgar 1' y 5', malestar respiratorio, uso de equipos de soporte ventilatorio y utilización de medicamentos para la función respiratoria. Los datos recolectados fueron procesados estadísticamente a través del programa Minitab. Resultados: En este estudio se percibe que la incidencia de la PCA es mayor en prematuros, donde la relación edad gestacional y peso al nacer son inversamente proporcionales a la PCA. La prevalencia en este estudio fue de 2,6 % recién nacidos con la cardiopatía, siendo que de estos se observó la incomodidad respiratoria en el 4,3 % de neonatos. Conclusión: La prevalencia del canal arterial en la muestra fue relativamente baja, entre los factores asociados a la aparición de la cardiopatía, las alteraciones en el quinto minuto de Apgar mostraron ser estadísticamente significantes. Siendo así, identificar la ocurrencia del diagnóstico de la PCA y conocer las repercusiones respiratorias, así como es propuesto en ese estudio, puede auxiliar en la programación de la asistencia y, en particular, favorecer la mejora de la conducta de enfermería.

Abstract Objective: To identify the prevalence of persistence of the arterial canal (PAC) in newborns in a public hospital. Methodology: This is a quantitative, observational and descriptive study. Data from 313 compendiums of newborns were collected, noting the occurrence of the diagnosis of PAC in a sample of inmate newborns at a public hospital in the north of Minas Gerais, Brazil, in the period between August 2015 and August 2016, up to the 7th day of life. The following variables were analyzed: gestational age, birth weight, Apgar 1' and 5', respiratory discomfort, use of ventilation support equipment and use of medication for respiratory function. The collected data were statistically processed through the Minitab program. Results: The incidence of the PAC is higher in premature infants, where the relationship of gestational age and birth weight are inversely proportional to the PAC. The prevalence in this study was 2,6 % of newborns with heart disease, and it was observed respiratory discomfort in 43 % of them. Conclusion: The prevalence of arterial canal in the sample was relatively low; among the factors associated with the occurrence of heart disease, alterations in the fifth minute of Apgar were statistically significant. Being so, identifying the occurrence of the diagnosis of PAC and knowing the respiratory impact can aid in the programming of assistance and, in particular, favor the improvement of the conduct of nursing.

Descripción anatómica, clínica y sobrevida de los pacientes con atresia pulmonar que han sido llevados a angioplastia con stent en el ductus arterioso persistente en el periodo 2009-2014 / Anatomical and clinical description and survival of patients with pulmonary atresia subjected to angioplasty with ductal stent in the period 2009-2014

Resumen Objetivo: describir las características anatómicas, la evolución clínica y la sobrevida de los pacientes con atresia pulmonar que han sido llevados a angioplastia con stent en ductus arterioso persistente y determinar si existen diferencias significativas en la saturación al inicio y final del procedimiento y a las 6, 12 y 24 horas posprocedimiento. Materiales y métodos: estudio analítico, descriptivo tipo cohorte. La población de estudio se tomó de las bases de datos del servicio de Cardiología pediátrica de una institución especializada en la ciudad de Bogotá, Colombia. Se incluyeron pacientes con diagnóstico de atresia pulmonar sometidos a angioplastia, en tanto que se excluyeron aquellos con cirugía cardiovascular previa. El análisis estadístico se realizó en STATA® 12,0, mediante estadística descriptiva, curvas de Kaplan-Meier y ANOVA de medidas repetidas. Resultados: se identificaron 237 pacientes con atresia pulmonar. Se seleccionaron 30 de los cuales se excluyeron 5. En total se construyó una cohorte de 25 pacientes que fueron llevados a angioplastia, 52% con atresia pulmonar con comunicación interventricular. Edad promedio 12,2 días, peso 2.698 g, diámetro del DAP 3,8 mm (DE = 1,1), índice de McGoon media 1,35. El implante del stent fue exitoso en todos los pacientes; sin embargo 2 fallecieron en la sala de procedimientos y uno durante las 6 horas siguientes. Las complicaciones más frecuentes fueron paro cardiorrespiratorio (n = 2), trombosis del stent (n = 2) y bacteriemia (n = 2). La mortalidad a 30 días fue del 28% (n = 7); durante el tiempo total fue del 36% (n = 9). Por medio del ANOVA no se encontraron diferencias significativas en los promedios de saturación en los cinco tiempos de interés. Conclusiones: la atresia pulmonar es una patología compleja que requiere intervención invasiva para el mantenimiento de la capacidad circulatoria de los pacientes. Este estudio muestra que a pesar de una intervención efectiva, la mortalidad a los 30 días es elevada. No se encontraron diferencias en los tiempos de saturación, lo que sugiere que mantiene la saturación de los pacientes de una forma no distinta que con la prostaglandina E (PGE1) pero garantiza la permeabilidad del ductus.

Abstract Objective: the aim of this study is to describe the anatomical characteristics, the clinical progression, and survival of patients with pulmonary atresia subjected to angioplasty with a stent in patent ductus arteriosus (PDA), and to determine if there are significant difference in the saturation at the beginning and the end of the procedure, and at 6, 12, and 24 hours after the procedure. Materials and methods: An analytical and descriptive cohort study was conducted on a population taken from the database of a Paediatric Cardiology Department of a specialised institution in the city of Bogota, Colombia. Patients with pulmonary atresia subjected to angioplasty were included, and those with previous cardiovascular were excluded. The statistical analysis was performed using STATA® 12.0, by means of descriptive statistics, Kaplan-Meier curves and repeated measurements ANOVA. Results: A total of 237 patients with pulmonary atresia were identified. Of the 30 that were selected, 5 were excluded, leaving a total of 25 patients that were subjected to angioplasty. Interventricular communication was observed in 52%. The mean age was 12.2 days, with a mean weight of 2.698 g, a mean PDA diameter of 3.8 mm (SD = 1.1), and a mean McGoon index of 1.35. Although the stent implant was successful in all patients, two died in the procedures room, and another one during the following 6 hours. The most common complications were, cardiorespiratory arrest in 2 patients, thrombosis of the stent in 2, and bacteraemia in two patients. The mortality at 30 days was 28% (7), and 36% (9) during the total time. Using ANOVA, no significant differences were found in the saturation means at the five times of interest. Conclusions: Pulmonary atresia is a complicated condition that requires invasive intervention in order to maintain the circulatory capacity of the patients. This study shows that, despite an effective intervention, the 30-day mortality is elevated. No differences were, found in the saturation times, which suggest that saturation is maintained in the patients in a way not unlike that with prostaglandin E (PGE1), but ensures the patency of the ductus.

Trombosis antenatal de aneurisma espontáneo de conducto arterial / Antenatal thrombosis of arterial ductus spontaneous aneurysm

Los aneurismas espontáneos del conducto arterial se detectan inusualmente de forma prenatal. Su incidencia varía entre 1,5 por ciento y 8 por ciento de los embarazos. Usualmente se solucionan espontáneamente; sin embargo, pueden presentarse complicaciones letales como trombosis, embolia y ruptura. Los casos fatales descritos son escasos, la mayoría después del nacimiento. El objetivo es presentar el reporte de autopsia de un mortinato cuya causa de muerte fue la trombosis de aneurisma del conducto arterial. La madre fue una primigesta de 22 años de edad, con embarazo de 40 semanas sin antecedentes de importancia, atendida en un hospital de tercer nivel de Bucaramanga, Santander. Le realizamos una cesárea emergente por perfil biofísico fetal alterado y bradicardia fetal. Se obtuvo un mortinato masculino sin esfuerzo respiratorio, hipotónico, cianótico, que no respondió a maniobras de reanimación. Los hallazgos de autopsia relevantes fueron: dilatación auricular derecha y dilatación preductal con trombosis del conducto cuya luz estaba completamente ocluida por un coágulo. Los aneurismas ductales prenatales son una entidad que merece más estudio para determinar estrategias de diagnóstico precoz y seguimiento, y así disminuir el riesgo de desenlaces fatales(AU)

Introduction: Spontaneous ductus arteriosus aneurysm is a condition rarely diagnosed on prenatal imaging. Literature reveals 1,5 to 8 percent incidence on pregnancies. Most cases have spontaneous resolution, nonetheless, life-threatening complications such thrombosis, embolism and rupture can occur. Fatal cases reports are scarce, most of them presenting on newborns, days to months after birth. Objective: To present the autopsy report of a stillbirth whose cause of death was thrombosis of the arterial duct aneurysm. Methods: A 22-year healthy prime mother with 40-week pregnancy was assisted at a tertiary hospital in Bucaramanga, Santander. She required emergency cesarean section due to low biophysical profile and fetal bradycardia. The newborn had no respiratory effort, was floppy, cyanotic and did not respond to resuscitation maneuvers. The relevant autopsy findings were right atrial dilatation and preductal dilation with thrombosis of the duct whose lumen was completely occluded by a clot. Conclusions: The prenatal ductal aneurysm is an entity that deserves more study to determine strategies for early diagnosis and follow-up thus decrease the risk of fatal outcomes(AU)

La hipertensión pulmonar en el recién nacido con cierre del ductus arterioso en el útero y secuencia de la perfusión arterial reversa en el embarazo gemelar / Pulmonary hypertension of the newborn with in utero closure of the ductus arteriosus and twin reversed arterial perfusion sequence

Resumen Introducción: La hipertensión pulmonar del recién nacido secundario con cierre en el útero del ductus arterioso es una complicación frecuente en las pacientes gestantes que usan analgésicos no esteroideos durante el embarazo. Se presenta un caso de secuencia de la perfusión arterial reversa en el embarazo gemelar con evidencia de supervivencia del gemelo acárdico con el flujo sanguíneo del gemelo bomba. El tratamiento es la cirugía con fetocoagulación láser al gemelo acárdico, previniendo complicaciones mayores para el gemelo sano. Caso clínico: Gemelo con secuencia twin reversed arterial perfusion. A las 22 semanas de gestación se le practicó fotocoagulación con láser al feto acárdico. La madre recibió por dos días acetaminofén y analgésicos no esteroideos para manejo del dolor. Se le realizó ecocardiograma fetal a las 31 semanas de gestación, con evidencia de disfunción diastólica del ventrículo derecho y cierre del ductus arterioso. Se le realizó cesárea de urgencia obteniendo recién nacido que presentó hipertensión pulmonar en el período neonatal, quien con manejo médico tiene resolución de la misma. Conclusión: La hipertensión pulmonar del recién nacido secundario a cierre del ductus arterioso en el útero por ingesta de medicamentos, es una entidad que pone en riesgo la vida del feto, por lo cual su diagnóstico y tratamiento oportuno es indispensable para mejorar la sobrevida de nuestros pacientes.

Abstract Introduction: Pulmonary hypertension of the newborn secondary to in utero closure of the ductus arteriosus is a frequent complication in pregnant patients taking non-steroidal antiinflammatory drugs during pregnancy. We present a case of reversed arterial perfusion sequence in a twin pregnancy with evidence of survival of the acardiac twin with the blood flow of the pump twin. The treatment of choice is surgery with intrafetal laser coagulation on the acardiac twin, to prevent further complications on the healthy twin. Clinical case: Twin with reversed arterial perfusion sequence. At 22 weeks gestation intrafetal laser coagulation on the acardiac twin was performed. The mother received acetaminophen for two days and non-steroidal anti-inflammatory drugs for the management of pain. Fetal echocardiogram was conducted at 31 weeks gestation, evidencing diastolic dysfunction of the right ventricle and ductus arteriosus closure. She underwent an emergency c-section; the newborn had pulmonary hypertension during the neonatal period that was solved with medical management. Conclusion: Pulmonary hypertension of the newborn secondary to in utero closure of the ductus arteriosus due to drug consumption is an entity that poses a risk to the fetus, so a timely diagnosis and treatment is essential to improve survival of our patients.

Modified hybrid procedure in hypoplastic left heart syndrome: initial experience of a center in northeastern Brazil

Abstract Introduction: Although it only corresponds to 2.5% of congenital heart defects, hypoplastic left heart syndrome (HLHS) is responsible for more than 25% of cardiac deaths in the first week of life. Palliative surgery performed after the second week of life is considered an important risk factor in the treatment of HLHS. Objective: The aim of this study is to describe the initial experience of a medical center in Northeastern Brazil with a modified off-pump hybrid approach for palliation of HLHS. Methods: From November 2012 through November 2015, the medical records of 8 patients with HLHS undergoing hybrid procedure were retrospectively evaluated in a tertiary private hospital in Northeastern Brazil. The modified off-pump hybrid palliation consisted of stenting of the ductus arteriosus guided by fluoroscopy without contrast and banding of the main pulmonary artery branches. Demographic and clinical variables were recorded for descriptive analysis. Results: Eight patients were included in this study, of whom 37.5% were female. The median age and weight at the time of the procedure was 2 days (p25% and p75% = 2 and 4.5 days, respectively) and 3150 g (p25% and p75% = 3077.5 g and 3400 g, respectively), respectively. The median length in intensive care unit stay was 6 days (p25% and p75% = 3.5% and 8 days, respectively). There were no in-hospital deaths. Four patients have undergone to the second stage of the surgical treatment of HLHS. Conclusion: In this series, the initial experience with the modified off-pump hybrid procedure showed to be safe, allowing a low early mortality rate among children presenting HLHS.

Restricción del ductus arterioso fetal en gestante de tercer trimestre por consumo de paracetamol / Fetal Ductus Arteriosus Restriction in the Final Third of Pregnancy Due To Acetaminophen Consumption

Se presenta el caso de una paciente que desde la semana 20 de gestación fue diagnosticada de cólico renal con la necesidad de varios ingresos y colocación de catéter doble J por parte de Urología. La paciente recibió tratamiento con paracetamol intravenoso y oral. Los controles ecográficos obstétricos -a los largo de la gestación- fueron normales hasta que en la semana 32, cuando ingresó de nuevo por cuadro sospechoso de cólico renal tratado con Paracetamol. Se objetivan en ecografía con hallazgos compatibles con restricción precoz del ductus arterioso. Se indicó la suspensión del paracetamol y los cambios se redujeron en las 48 horas posteriores y casi desaparecieron por completo una semana tras la retirada de la medicación. La gestación llegó a término y el recién nacido presentó un ecocardiograma posnatal normal. Recomendamos la restricción de los analgésicos no opiáceos en el tercer trimestre y el seguimiento con Doppler del conducto arterioso en los casos en que se requiriera usarlos(AU)

A case is reported of a pregnant woman who was diagnosed with renal colic at 20 weeks of gestation. She needed various admissions in hospital and double J stent placement by Urology Service and she was treated with acetaminophen by both intravenous and oral ways. Obstetric ultrasound scans were normal throughout gestation until week 32, when she was admitted to hospital again for suspected renal colic. She was treated with acetaminophen. In that moment, ultrasound findings are consisted with early ductus arteriosus constriction. Acetaminophen was decided to be stopped and changes reduced in the first 48 hours and they almost disappeared after one week of medication withdrawal. Pregnancy came to term and the child was born normal. Restricting non-opioid analgesics was recommended in the third quarter, as well as following up with ductus arteriosus doppler in cases in which it is required to use them(AU)

Co-morbilidades secundarias a ductus arterioso persistente en pacientes menores de 5 años previo reparo quirúrgico en el Hospital Nacional de Niños Benjamín Bloom en el periodo de enero de 2014 a diciembre de 2015 / Co-morbidities secondary to patent ductus arteriosus in patients under 5 years of age previous surgical repair at the Benjamín Bloom National Children's Hospital in the period from January 2014 to December 2015

El ductus arterioso es una estructura vascular que conecta la aorta descendente proximal con la arteria pulmonar principal cerca del origen de la rama pulmonar izquierda. Si no se da el cierre espontáneo del ductus arterioso en la vida extrauterina suceden una serie de eventos que se convierten en complicaciones, debido a que el flujo sanguíneo se deriva de izquierda a derecha. Se revisaron 53 expedientes clínicos de pacientes menores de 5 años que fueron operados en Hospital Nacional de Niños Benjamín Bloom en el periodo de enero del 2014 a diciembre del 2015 y se hizo una caracterización clínica de los pacientes junto a las morbilidades que presentaron previo al reparo quirúrgico. Se reportaron 53 casos con una relación (M/F) 1:1, de estos un 81% de pacientes presentaron Desnutrición, el 66% de pacientes presentaron Hipertensión pulmonar, el 34% de pacientes presentaron Insuficiencia Renal Aguda y el 33% de pacientes presentaron Neumonía, siendo estas las morbilidades más frecuentes. Las consecuencias clínicas del ductus arterioso persistente se relacionan con el descenso del gasto cardíaco secundario al cortocircuito de izquierda a derecha. La distribución del flujo sistémico está alterada dando como resultado una reducción de la perfusión, que contribuye a la aparición de algunas morbilidades que se asocian con el ductus arterioso persistente. Las cuáles forman parte del cuadro clínico y de la historia natural de la enfermedad siendo de gran impacto la reparación quirúrgica, para mejorar la esperanza de vida

Restricción del ductus arterioso fetal en gestante del tercer trimestre por consumo de paracetamol / Fetal ductus arteriosus constriction in the final third of pregnancy due to paracetamol comsumption

El ductus arterioso es una derivación que conecta la arteria pulmonar con el arco aórtico el que permite la descarga del ventrículo derecho sin pasar por la alta resistencia de los pulmones. La permeabilidad del conducto arterioso se mantiene durante la gestación por las prostaglandinas producidas especialmente PGE2, que circulan a nivel local, especialmente PGE2, y la baja saturación de oxígeno fetal. Se trata de una paciente que desde la semana 20 de gestación es diagnosticada de cólico renal con la necesidad de varios ingresos y colocación de catéter doble J por parte de Urología y la cual recibió tratamiento con paracetamol intravenoso y oral. Los controles ecográficos obstétricos a los largo de la gestación fueron normales hasta que en semana 32, cuando ingresa de nuevo por cuadro sospechoso de cólico renal tratado con Paracetamol, se objetivan en ecografía hallazgos compatibles con restricción precoz del ductus arterioso. Se indicó suspender el paracetamol y los cambios se redujeron en las 48 horas posteriores y casi desaparecieron por completo una semana tras la retirada de la medicación. La gestación llegó a término y el recién nacido presentó un ecocardiograma postnatal normal. Recomendamos la restricción de los analgésicos no opiáceos en el tercer trimestre y el seguimiento con Doppler del conducto arterioso en los casos en que se requiriera usarlos(AU)

Ductus arteriosus is a derivation that connects the pulmonary artery with the aortic arch and allows the discharge from the right ventricle without passing the high resistance of lungs. Permeability of the ductus arteriosus is kept during gestation because of the production of prostaglandins, particularly PGE2, which circulates locally, and the low fetal oxygen saturation. Here is a pregnant woman who, since her 20th week of gestation was diagnosed as a renal colic case. She required several admissions to hospital and placement of double J stent in the urology service and she was treated with intravenous and oral paracetamol. Obstetric ultrasound scans throughout gestation were normal until week 32, when she was admitted to hospital again for suspected renal colic and treated again with paracetamol. At that moment, findings compatible with early ductus arteriosus constriction were observed in ultrasound. It was then decided to stop the paracetamol treatment, the changes declined in the following 48 hours and they almost disappeared completely after one week after the medication withdrawal. It was finally a term pregnancy and the postnatal echocardiogram of the newborn was normal. Restricting non-opioid analgesics in the third pregnancy trimester and the follow up of the ductus arteriosus with Doppler technique when required(AU)

Acetaminofén intravenoso en el cierre del conducto arterioso permeable en prematuros / Intravenous acetaminophen in closure of patent ductus arteriosus in preterm infants

Reportamos el caso de tres recién nacidos de 26, 29 y 32 semanas de edad gestacional, con pesos de 810, 1.300 y 1.670 gr, respectivamente. A quienes se les diagnosticó clínicamente conducto arterioso permeable con repercusión hemodinámica. Se confirmó con ecocardiograma transtorácico, mostrando conducto arterioso de 1.5, 3,2 y 3.9 mm. Por sus condiciones clínicas inestables que contraindicaban cierre farmacológico convencional con antiinflamatorios no esteroideos (AINES), y alto riesgo quirúrgico. Se optó por cierre farmacológico con acetaminofén intravenoso a 15 mg/kg una dosis cada 6 horas. Control ecocardiográfico cada 24 horas, se corroboró el cierre total del conducto arterioso a los 3, 5 y 7 días de tratamiento, respectivamente. Se les realizó enzimas hepáticas 24 horas antes y 48 horas posteriores a la administración del acetaminofén. Todos tuvieron seguimiento clínico y ecocardiográfico al mes, 3 y 6 meses. Descartando la reapertura del conducto arterioso.

We report the case of three 26, 29 and 32 week-old newborns, with a birthweight of 810, 1,300 and 1,670 g respectively, who were clinically diagnosed with patent ductus arteriosus with hemodynamic repercussion. It was confirmed by means of a transthoracic echocardiogram that showed a ductus arteriosus of 1.5, 3.2 and 3.9 mm. Due to their unstable clinical condition, which contraindicated conventional pharmacological closure with nonsteroidal anti-inflammatory medications (NSAIDs) and posed a high surgical risk, it was decided to perform pharmacological closure with intravenous acetaminophen at 15 mg/kg, one dose every 6 hours. Echocardiographic control every 24 hours confirmed total closure of tha ductus arteriosus after 3, 5 and 7 treatment days respectively. Liver enzymes were analysed 24 hours before and 48 hours after administering acetaminophen. All of them had clinical and echocardiographic follow-ups after one, 3 and 6 months which ruled out any reopening of the ductus arteriosus.

Papel da ecocardiografia na avaliação das alterações cardiovasculares em recém-nascidos prematuros de muito baixo peso, com ênfase na presença do canal arterial / Echocardiography role in assessing cardiovascular changes in very low birth weight babies, with emphasis on the presence of the ductus arteriosus

O trabalho consistiu em uma revisão bibliográfica sobre as alterações cardiovasculares em neonatos prematuros. Tais alterações têm elevada prevalência nas unidades de terapiaintensiva neonatal, bem como há necessidade frequente de tratamento específico e implicações prognósticas. A revisão foi realizada de forma não sistematizada, a partir das seguintesfontes de pesquisas: PubMed, BVS e Medline. Foram definidas as causas de tais alterações hemodinâmicas,os métodos frequentemente utilizados para sua detecção e propostas alternativas mais objetivas e eficientes nesta avaliação, enfatizando-se diferentes parâmetros ecocardiográficos bem como as limitações de cada método.

Tratamento intervencionista das cardiopatias congênitas: estado da arte / Interventionist treatment of congenital heart defects: state of the art

Os avanços na tecnologia nas últimas décadas em relação ao tratamento intervencionista das cardiopatias congênitas têm permitindo excelentes resultados, em termos de morbimortalidade, a curto e longo prazo para este grupo especial de pacientes.Este artigo descreve os principais tratamentos disponíveis realizados com cateterismo intervencionista neste grupo de pacientes.

Technological advances in recent decades, in relation to interventionist treatment of congenital heart defects, have enabled excellent short- and long-term results for this group of patients, in terms of morbidity and mortality. This article describes the main treatmentsavailable involving interventionist catheterization in this group of patients.

Resultados imediatos e de médio prazo da intervenção com stent ductal em recém-nascidos e lactentes / Immediate and medium-term outcomes of ductal stenting in neonates and infants

O implante de stents para manter o ducto arterial patente na cardiopatia congênita cianótica éuma alternativa à cirurgia de Blalock-Taussig modificada (BTm) em pacientes de alto risco. Descrevemos osresultados imediatos e de médio prazo do implante de stent em neonatos e lactentes com circulação pulmonarducto-dependente. Métodos: Trata-se de estudo descritivo e prospectivo, que incluiu diferentes cardiopatias congênitas cianóticas tratadas entre 2014 e 2015.Resultados: Avaliamos 14 pacientes, com média de idade de 46 dias e pesando 4,5 kg, sendo a atresia pulmonar associada à comunicação interventricular a cardiopatia mais tratada. A abordagem pela artéria femoral ocorreu em 70% dos procedimentos e, nos demais, por via carotídea. Stents de 3,5 × 12 mm foram usados na maioria dos casos, e o sucesso do implante foi obtido em 78% das intervenções (11/14). Os casos de insucesso foram encaminhados para cirurgia − uma delas em situação de urgência, que resultou em óbito. Ocorreu espasmo ductal < 48 horas em três pacientes que necessitaram de BTm, com evolução favorável. Complicações após a alta e nos primeiros 30 dias incluíram trombose de stent (2/11), uma delas controlada com redilatação e outra que evoluiu para óbito, e uma morte súbita (1/11). A mortalidade total foi de 21,4% (3/14). A patência do ducto arterial nos primeiros 6 meses foi obtida em 5 casos que foram submetidos à cirurgia paliativa.Conclusões: A experiência inicial de implante de stent ductal mostrou resultados imediatos favoráveis, e, emmédio prazo, mais de um terço dos pacientes com circulação pulmonar ducto-dependente manteve seus canaispatentes...

The implantation of stents to keep the ductus arteriosus patent in cyanotic congenital heart disease is an alternative to the modified Blalock-Taussig surgery (mBT) in high-risk patients. This study describes theimmediate and medium-term outcomes of stent implantation in neonates and infants with duct-dependentpulmonary circulation. Methods: This was a descriptive and prospective study including different cyanotic congenital heart diseases treated between 2014 and 2015. Results: Fourteen patients with a mean age of 46 days, and mean weight of 4.5 kg were assessed, andpulmonary artresia with interventricular communication was the most treated condition. The femoral artery approach was used in 70% of procedures; carotid approach was used in the remaining cases. Stents of 3.5 x 12 mm were used in most cases, and implant success was achieved in 78% of interventions (11/14). The failed cases were referred to surgery – one of them was an emergency, which resulted in death. Ductal spasm occurred in < 48 hours in three patients who required mBT, with favorable outcome. Complicationsafter discharge and within the first 30 days included stent thrombosis (2/11), one of which was controlled with redilation, another progressed to death, and one sudden death (1/11). The overall mortality was 21.4% (3/14). A patent ductus arteriosus in the first 6 months was present in five cases, which underwent palliative surgery.Conclusions: The initial experience of ductal stenting showed favorable immediate outcomes, but in the mediumterm, little more than a third of the cases maintained a patent ductus arteriosus within 6 months...

Procedimentos percutâneos combinados em defeitos estruturais e congênitos / Combined percutaneous treatment of structural and congenital heart defects

Defeitos congênitos múltiplos são tradicionalmente corrigidos cirurgicamente, mas, atualmente, podem ser tratados percutaneamente. Existem poucos relatos na literatura atestandosua eficácia e segurança. Objetivamos descrever uma experiência com a realização de procedimentoscombinados para tratar diferentes defeitos, congênitos e estruturais, numa mesma sessão terapêutica. Métodos: Desde 2007, foram tratados, numa mesma sessão terapêutica, diferentes defeitos. Todos foram selecionados por ecocardiograma. Os procedimentos foram realizados segundo as técnicas tradicionais já descritas para cada defeito encontrado. Resultados: Foram tratados dez pacientes, cinco do sexo masculino, com idades de 1 a 67 anos, e pesos de 11 a 90 kg. O defeito mais prevalente de forma isolada foi a persistência do canal arterial (PCA, n = 5), seguido da comunicação interatrial ostium secundum (CIA OS, n = 4) e da comunicação interventricular (CIV, n = 4). As combinações mais frequentes foram CIV com PCA (n = 2) e CIV com CIA OS (n = 2). Foram dilatadas duasestenoses valvares pulmonares com CIA OS e com forame oval patente (FOP), e uma coarctação de aorta com PCA. Adicionalmente, foi ocluído um apêndice atrial esquerdo com FOP e foi embolizada uma fístula aortopulmonar com PCA. Todos os procedimentos foram bem-sucedidos. O tempo médio de seguimento foi de 31 ± 28,1 meses, havendo apenas duas complicações. Não houve nenhum óbito. Conclusões: A pequena série de casos relatada mostrou que os procedimentos combinados foram seguros e eficazes, podendo ser reproduzidos por operadores experientes em centros especializados, podendo vir a se constituir como primeira opção terapêutica para esses pacientes...

Multiple congenital defects are traditionally corrected surgically, but nowadays can be treatedpercutaneously. There are few reports in the literature attesting to its efficacy and safety. We aimed to describe an experience with combined procedures to treat different congenital and structural defects, in a single therapeutic session.Methods: Since 2007, different defects were treated in a single treatment session. All were selected byechocardiography. The procedures were performed using traditional techniques already described for each defect.Results: Ten patients were treated, five males, aged 1-67 years, weighting 11-90 kilograms. The most prevalent isolated defect was patent ductus arteriosus (PDA, n = 5), followed by ostium secundum atrial septal defects (ASD, n = 4) and ventricular septal defects (VSD, n = 4). The most common combinations were VSD with PDA (n = 2) and VSD with osASD (n = 2). Two pulmonary valve stenosis were dilated with ASD and patent foramen ovale (PFO), and one aorta coarctation with PDA. Additionally, a left atrial appendage with PFO was occluded and an aorto pulmonary fistula with PDA was embolized. All procedures were successful. The mean follow-up was 31 ± 28.1 months, with only two complications. There were no deaths.Conclusions: The small number of reported cases showed that the combined procedures were safe andeffective and can be reproduced by experienced operators in specialized centers and may be considered asthe first therapeutic option in these patients...

Oclusão percutânea da persistência do ducto arterioso / Percutaneous occlusion of patent ductus arteriosus

Introdução: A persistência do ducto arterioso é uma condição congênita de alta morbidade, especialmente em recém-nascidos prematuros de extremo baixo peso, representando 5 a 10% das cardiopatias congênitas. Nosso objetivo foi descrever as abordagens realizadas em hospital de referência para o tratamento da persistência do ducto arterioso com o método percutâneo de oclusão. Métodos: Foi realizado estudo retrospectivo do tratamento transcateter da persistência do ducto arterioso no período de abril de 2008 a abril de 2010. Resultados: Foram revisados 47 casos, a maioria (78,8%) tratada com molas Flipper®; os demais tratados com a prótese Amplatzer®. A configuração morfológica ductal foi do tipo A de Krichenko em 89,4% (34 no grupo molas Flipper® e 8 no grupo Amplatzer®), tipo D em 6,4% (2 no grupo molas Flipper® e 1 no grupo Amplatzer®) e tipo E em 4,2% (1 em cada grupo) dos pacientes. Os diâmetros mínimos pré-cateterismo foram de 2,6 ± 0,8 mm e 3,8 ± 1,6 mm para os grupos de molas Flipper® e Amplatzer®, respectivamente. Obteve-se oclusão imediata total do defeito na angiografia de controle em 72,3% dos pacientes tratados. Sete pacientes tratados com molas Flipper® receberam molas adicionais e os tratados com prótese Amplatzer® mostraram apenas shunts residuais mínimos em dois casos. Não ocorreram complicações do procedimento. No acompanhamento após a alta, um paciente permaneceu com mínimo shunt residual à ecografia, 45 dias após o cateterismo. Conclusões: A oclusão da persistência do ducto arterioso por método percutâneo tem-se mostrado segura e efetiva na maioria dos casos...

Background: Patent ductus arteriosus is a congenital condition with high morbidity, especially in preterm infants of extremely low birth weight, representing 5% to 10% of congenital heart diseases. Our objective was to describe the approaches used at a reference hospital for the percutaneous occlusion of PDA. Methods: We conducted a retrospective study on the transcatheter treatment of patent ductus arteriosus from April of 2008 to April of 2010. Results: Forty-seven cases were reviewed and most of them (78.8%) were treated with FlipperTM coils while the remaining patients received the AmplatzerTM device. Ductal morphological configuration was Krichenko type A in 89.4% (34 in the FlipperTM coil group and 8 in the AmplatzerTM group), type D in 6.4% (2 in the FlipperTM coil group and 1 in the AmplatzerTM group) and type E in 4.2% (1 in each group) of patients. Pre-catheterization minimum diameters were 2.6 ± 0.8 mm and 3.8 ± 1.6 mm for the FlipperTM coil and AmplatzerTM groups, respectively. Immediate total occlusion of the defect was obtained in the control angiography in 72.3% of the patients. Seven patients treated with the FlipperTM coil received additional coils and two patients treated with the AmplatzerTM device presented minimal residual shunts. There were no procedure-related complications. In the follow-up after hospital discharge, one patient presented minimal residual shunt at the echography, 45 days after catheterization. Conclusions: Percutaneous patent ductus arteriosus occlusion has proven to be safe and effective in most cases...