Proporção de Largura de Distribuição de Hemoglobina/Glóbulos Vermelhos (HRR): Um Novo e Promissor Parâmetro de Glóbulos Vermelhos no Fechamento Ductal / Hemoglobin/Red Cell Distribution width Ratio (HRR): A Novel and Promising Red Cell Parameter in Ductal Closure

Resumo Fundamento Ainda não está clara a eficácia dos parâmetros hematológicos no fechamento da persistência do canal arterial (PCA). Objetivos O objetivo principal do nosso estudo é investigar o efeito da proporção (HRR) de largura de distribuição de hemoglobina (HB) para glóbulos vermelhos (RDW) no fechamento do PCA. Métodos Bebês prematuros com muito baixo peso ao nascer (MBPN: <1.500 g) e <32 semanas gestacionais foram incluídos no estudo, e todos os dados foram registrados retrospectivamente. Características demográficas, resultados clínicos, parâmetros de hemácias e HRR e suas proporções foram comparados entre grupos de PCA hemodinamicamente significativa (hsPDA) e não-hsPDA. Todos os resultados foram analisados estatisticamente, e p<0,05 foi considerado estatisticamente significativo. Resultados Um total de 677 bebês prematuros, 269 no grupo hsPDA e 408 no grupo não-hsPDA, foram incluídos no estudo. Hemoglobina (HB), hematócrito (HCT), volume celular médio (VCM), glóbulos vermelhos (RBC), largura de distribuição dos glóbulos vermelhos (RDW), volume plaquetário médio (VPM), relação VCM/RBC, relação HB/RBC, RDW A razão /RBC e a razão RDW/VPM foram semelhantes entre os grupos hsPDA e não hsPDA, (p>0,05). HRR foi significativamente menor no grupo hsPDA [mediana (Quartil 1 (Q1) - Q3) (Q1 - Q3): 0,93 (0,8-1,0)] em comparação com não-hsPDA [mediana (Q1 - Q3): 1,07 ( 1,0-1,2)] (p<0,001). A AUC para o valor diagnóstico de HRR em hsPDA foi de 0,816 e o valor de corte foi ≤0,98 (p<0,001, 95% [IC]: 0,785-0,845, sensibilidade: 90%, especificidade: 92%). Conclusões O valor de HRR foi considerado um parâmetro eficaz e poderoso no diagnóstico de hsPDA.

Abstract Background It is still unclear how effective hematological parameters are in the closure of patent ductus arteriosus (PDA). Objectives The primary aim of our study is to investigate the effect of hemoglobin (HB)-to-red cell distribution width (RDW) ratio (HRR) on the closure of PDA. Methods Premature babies with very low birth weight (VLBW: <1500 g) and <32 gestational weeks were included in the study, and all data were recorded retrospectively. Demographic characteristics, clinical results, red cell parameters, and HRR and their ratios were compared between hemodynamically significant PDA (hsPDA) and non-hsPDA groups. All results were statically analyzed, and P<0.05 was considered statistically significant. Results A total of 677 premature babies, 269 in the hsPDA group and 408 in the non-hsPDA group, were included in the study. Hemoglobin (HB), hematocrit (HCT), mean cell volume (MCV), red blood cell (RBC), red cell distribution width (RDW), mean platelet volume (MPV), MCV/RBC ratio, HB/RBC ratio, RDW/RBC ratio, and RDW/MPV ratio were found to be similar between hsPDA and non-hsPDA groups, (p>0.05). HRR was found to be significantly lower in the hsPDA group [median (Quartile 1 (Q1) - Q3) (Q1 - Q3): 0.93 (0.8-1.0)] compared to non-hsPDA [median ( Q1 - Q3): 1.07 (1.0-1.2)] (p<0.001). The AUC for the diagnostic value of HRR in hsPDA was 0.816, and the cutoff value was ≤0.98 (p<0.001, 95% [CI]: 0.785-0.845, sensitivity: 90%, specificity: 92%). Conclusions HRR value was found to be both an effective and powerful parameter in diagnosing hsPDA.

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.

Qual Deve Ser o Tratamento de Primeira Linha para o Fechamento de Persistência de Canal Arterial Hemodinamicamente Significativo em Bebês Prematuros? / What Should be the First-line Treatment for the Closure of Hemodynamically Significant Patent Ductus Arteriosus in Premature Infants?

Resumo Fundamento É importante saber qual medicamento usar como tratamento de primeira linha para fechar o duto. Objetivos O objetivo deste estudo é comparar a eficácia e os efeitos colaterais das formas intravenosas (IV) de ibuprofeno e paracetamol e contribuir para a literatura investigando o primeiro medicamento selecionado no tratamento clínico da persistência do canal arterial (PCA). Métodos Nosso estudo foi realizado entre janeiro de 2017 e dezembro de 2019. Foram incluídos no estudo bebês prematuros com peso ao nascer (PN) ≤1500 g e idade gestacional (IG) ≤32 semanas. No período do estudo, todos os bebês com persistência do canal arterial hemodinamicamente significativa (hsPCA) receberam ibuprofeno intravenoso (IV) como resgate como tratamento clínico primário ou tratamento com paracetamol IV se houvesse contraindicações para o ibuprofeno. Os pacientes foram divididos em dois grupos: pacientes que receberam ibuprofeno IV e pacientes que receberam paracetamol IV. Resultados Desses pacientes, 101 receberam paracetamol IV e 169 receberam ibuprofeno IV. A taxa de sucesso do fechamento da PCA com o primeiro curso do tratamento foi de 74,3% no grupo de paracetamol IV e 72,8% no grupo de ibuprofeno IV (p=0,212). Conclusões Nossos resultados mostram que o paracetamol IV é tão eficaz quanto o ibuprofeno IV no tratamento de primeira linha de hsPCA, podendo se tornar o tratamento preferencial para o controle de hsPCA.

Abstract Background It is important which medicine to use as a first-line treatment to close the duct. Objectives The aim of this study is to compare the effectiveness and side effects of intravenous (IV) forms of ibuprofen and paracetamol and to contribute to the literature investigating the first drug selected in the medical treatment of patent ductus arteriosus (PDA). Methods Our study was conducted between January 2017 and December 2019. Premature infants with birth weight (BW) ≤1500 g and gestational age (GA) ≤32 weeks were included in the study. In the study period, all infants with hemodynamically significant patent ductus arteriosus (hsPDA) were given rescue intravenous (IV) ibuprofen as a primary medical treatment or IV paracetamol treatment if there were contraindications for ibuprofen. The patients were divided into two groups: patients receiving IV ibuprofen and patients receiving IV paracetamol. Results Of these patients, 101 were given IV paracetamol and 169 were given IV ibuprofen. The success rate of PDA closure with first-course treatment was 74.3% in the IV paracetamol group and 72.8% in the IV ibuprofen group (p=0.212). Conclusions Our results show that IV paracetamol is as effective as IV ibuprofen in the first-line treatment of hsPDA, and can become the preferred treatment for the management of hsPDA.

Patent ductus arteriosus in preterm newborns: A tertiary hospital experience.

INTRODUCTION: Patent ductus arteriosus (PDA) in preterm infants has been associated with increased mortality and comorbidities. This study aimed to characterize the population of preterm infants diagnosed with PDA and to identify predictive factors of response to medical treatment of PDA. METHODS: An eight-year retrospective observational study was carried out, which included all preterm infants with a gestational age (GA) between 23 and 32 weeks diagnosed with PDA, admitted to the Neonatal Unit of the CHUSJ. Univariate comparative analysis was performed, and models for predicting the effectiveness of PDA treatment with ibuprofen were explored by multivariate logistic regression analysis. RESULTS: 115 cases were included and 34 were excluded, with a final sample of 81 preterm infants with PDA. The univariate analysis revealed significant differences in the closure efficacy via medical treatment with ibuprofen in several variables, and a multivariate logistic regression model was obtained (discriminative capacity 72.2%, sensitivity 98.1%, specificity 57.1%), taking into account the effect of GA, type of delivery, need for diuretics treatment and platelet transfusion. CONCLUSION: This study enabled the population of preterm infants diagnosed with PDA to be characterized and the identification of a predictive model that can help predict the efficacy of medical treatment and thus contribute to optimizing the medical approach to the non-responders.

Percutaneous patent ductus arteriosus closure: Twelve years of experience.

INTRODUCTION: Patent ductus arteriosus, a persistent communication between the descending thoracic aorta and the pulmonary artery, is one of the most common congenital heart defects. Transcatheter occlusion is an effective alternative to surgery and is currently standard of care for most patients. The authors present the results from a single center after twelve years of experience using this technique. METHODS: Retrospective analysis of medical records from all patients referred to a tertiary center for percutaneous ductus closure between January 2006 and September 2018. RESULTS: A total of 221 patients were referred, with a mean age of 5.5 years-old (16 patients were infants, with the youngest aged four months). A Nit-Occlud® coil was used 139 times (62.9%), an Amplatzer™ duct occluder 79 times (35.7%), and vascular plugs were used three times. Percutaneous closure was achieved in every treated patient, with 1.4% maintaining residual shunting. Although higher overall coil device implantation was noted, duct occluder usage has been greater since 2011. Of all the coils, 55% were either 4x4 or 5x4 mm, and 73% of all Amplatzer duct occluders were either 6x4 or 8x6 mm, which correlates to the majority of patients having a small to moderately sized ductus. No complications were noted during the procedure, with a 1.8% post-procedure complication rate (one device embolization after 48 hours and three cases of loss of arterial pulse). CONCLUSIONS: Percutaneous patent ductus arteriosus closure was safe and effective in this setting, with a low global complication rate and similar outcomes to most equivalent centers.

Patent ductus arteriosus closure: experience from a tertiary referral center / Experiência de uma maternidade terciária no fechamento do canal arterial patente

ABSTRACT Objective: To characterize the number and methods of closure of Persistent Ductus Arteriosus (PDA) over a span of 16 years in a third level maternity hospital. Methods: Retrospective study of neonates born between January 2003 and Deccember 2018, who underwent ductus arteriosus closure by pharmacological, surgical and/or transcatheter methods. Gestational age, birth weight, number and methods of closures per year were evaluated. The success rate of the pharmacologic method was calculated, as well as the mortality rate. The association between mortality and birthweight, treatment used and treatment failure was explored. Results: There were 47,198 births, 5,156 were preterm, 325 presented PDA and 106 were eligible for closure (median gestational age - 27 weeks, birthweight <1000 g - 61%). Frequency of PDA closure decreased during the study period, especially starting in 2010. Success rate with pharmacologic treatment was 62% after the first cycle and 74% after the second. After drug failure, 12 underwent surgical ligation and two underwent transcatheter closure. Exclusive surgical ligation was indicated in four infants. Ibuprofen replaced indomethacin in 2010, and acetaminophen was used in three infants. Among the 106 infants, hospital mortality was 12% and it was associated with birthweight <1000 g (13/65 <1000 vs. 0/41 >1000 g; p=0.002) and with failure in the first pharmacologic treatment cycle (13/27 with failure, vs. 0/75 without failure; p<0.001). Conclusions: The national consensus published in 2010 for the diagnosis and treatment of PDA in preterm infants led to a decrease in the indication for closure. Pharmacological closure was the method of choice, followed by surgical ligation. Birthweight <1000 g and first cycle of pharmacologic treatment failure were associated with higher mortality.

RESUMO Objetivo: Caraterizar o número e métodos de fechamento de canal arterial durante 16 anos numa maternidade de nível terciário. Métodos: Estudo retrospetivo de nascidos entre 01 de janeiro de 2003 a 31 de dezembro de 2018 submetidos a fechamento do canal arterial por métodos farmacológico, cirúrgico e/ou percutâneo. Avaliaram-se idade gestacional, sexo, peso ao nascimento, número de fechamentos por ano e método utilizado. Aferiram-se as taxas de sucesso de método farmacológico e de mortalidade e sua associação com peso ao nascer, fármaco utilizado e insucesso do fechamento. Resultados: Verificaram-se 47.198 recém-nascidos, 5.156 prematuros, dos quais 325 com canal arterial patente, sendo 106 com indicação para fechamento (idade gestacional mediana 27 semanas, peso <1000 g em 61%). Verificou-se diminuição do número de fechamentos ao longo dos anos, sobretudo a partir de 2010. O fechamento ocorreu em 62% após primeiro ciclo de tratamento farmacológico e em 74% após segundo. Após insucesso farmacológico, 12 realizaram ligadura cirúrgica e dois, fechamento percutâneo. Houve indicação de ligadura cirúrgica exclusiva em quatro. O ibuprofeno substituiu a indometacina em 2010. O acetaminofen foi usado em três doentes. A mortalidade nos 106 pacientes foi de 12%, associando-se ao peso ao nascer (13/65 <1000 vs. 0/41 >1000 g; p=0,002) e à falha do primeiro ciclo de tratamento farmacológico (13/27 com falha vs. 0/75 com sucesso; p<0,001). Conclusões: Consenso nacional de 2010 para diagnóstico e tratamento do canal arterial nos prematuros levou à diminuição do número de fechamentos desse canal. O fechamento farmacológico foi o método mais utilizado, seguido da ligadura cirúrgica. Peso <1000 g e falha no primeiro ciclo de fechamento farmacológico se associaram à maior mortalidade.

Alternative treatment for patent ductus arteriosus: a therapeutic challenge / Tratamento alternativo do canal arterial pervio: um desafio terapêutico

Abstract The ductus arteriosus is a fetal structure that spontaneously closes in 90% of newborns. Patency 3 months after birth is considered a congenital heart disease that, if untreated, can progress to serious cardiovascular complications. This report aims to review an alternative treatment with an aortic endoprosthesis in a 49-year-old man who presented with dyspnea on moderate exertion associated with a heart murmur. He was diagnosed with persistent ductus arteriosus (PDA) with cardiac complications. Clinical management was unsuccessful and surgical treatment was indicated. Endovascular treatment with a thoracic endoprosthesis was indicated and performed successfully. Percutaneous closure is the preferred method in adult patients. Endovascular intervention using an endoprosthesis is a safe and effective option, in addition to being applicable regardless of the anatomy of the PDA. This case demonstrates the natural history of the pathology and presents a safe and effective alternative for its management.

Resumo O canal arterial é uma estrutura fetal que se fecha espontaneamente em 90% dos recém-nascidos. A permeabilidade por mais de 3 meses é considerada uma cardiopatia congênita que, se não tratada, pode evoluir para complicações cardíacas graves. Este trabalho relata um tratamento alternativo com endoprótese aórtica. Trata-se de um homem, 49 anos, que apresentou dispneia aos moderados esforços, associada com um sopro cardíaco. Foi diagnosticado com canal arterial persistente (PCA) já com complicações cardíacas. Tentou-se manejo clínico sem sucesso, sendo indicado tratamento cirúrgico. Optou-se pelo tratamento endovascular com uma endoprótese torácica, o qual foi realizado com sucesso. O fechamento percutâneo é o método preferido em pacientes adultos. A intervenção endovascular com o uso da endoprótese é uma possibilidade segura e eficaz, além de ser aplicável independentemente da anatomia do PCA. Este caso, além de demonstrar a história natural desta patologia, apresenta uma alternativa segura e eficaz empregada no seu manejo.

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants / Desfechos clínicos após tratamento mais conservador da persistência do canal arterial em prematuros

Abstract Objective: Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. Method: Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. Results: This study included 188 patients (27 ± 2 weeks, 973 ± 272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p < 0.001) and surgical closure (34.5% P1 versus 16.1% P2, p < 0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p = 0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p = 0.403), necrotizing enterocolitis (15.5% versus 6.9%, p = 0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p = 0.264), mortality (17.5% versus 15.2%, p = 0.690) or survival-without-morbidity adjusted OR = 1.10 (95% CI: 0.55-2.22); p = 0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n = 82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p = 0.019) and more survival-without-morbidity (20% versus 45.6%, p = 0.028) were found. Conclusion: A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

Resumo Objetivo O tratamento da persistência do canal arterial ainda é controverso. Nosso objetivo foi descrever o impacto de uma abordagem mais conservadora em nossas taxas de tratamento e nos principais desfechos da prematuridade, especialmente em prematuros com < 26 semanas de gestação. Método Revisão de prontuários de lactentes com ≤ 30 semanas e persistência do canal arterial entre 2009-2016 em dois centros. Em 2011, mudamos o manejo da persistência do canal arterial: no primeiro período (2009-2011), os pacientes que não apresentaram sucesso com o tratamento clínico foram submetidos a fechamento cirúrgico; no segundo período (2012-2016), apenas aqueles com comprometimento cardiopulmonar foram submetidos ao fechamento cirúrgico. Comparamos o tratamento clínico, fechamento cirúrgico, mortalidade e sobrevida sem morbidade. Resultados Foram incluídos 188 pacientes (27 ± 2 semanas, 973 ± 272 gramas); 63 em P1 e 125 em P2. Em P2, foram observadas taxas significativamente mais baixas de tratamento clínico (85,7% no P1 versus 56% no P2, p < 0,001) e fechamento cirúrgico (34,5% no P1 versus 16,1% no P2, p < 0,001). Não foram encontradas diferenças em relação à doença pulmonar crônica (28,8% versus 13,9%, p = 0,056), retinopatia grave da prematuridade (7,5% versus 11,8%, p = 0,403), enterocolite necrosante (15,5% versus 6,9%, p = 0,071), hemorragia intraventricular grave (25,4% versus 18,4%, p = 0,264), mortalidade (17,5% versus 15,2%, p = 0,690) ou OR ajustado pela sobrevida sem morbidade = 1,10 (IC95%: 0,55-2,22); p = 0,783. Em P2, 24,5% dos pacientes receberam alta com persistência do canal arterial. O subgrupo nascido entre 23 a 26 semanas (n = 82) apresentou diferenças significativas, foram encontradas menor incidência de doença pulmonar crônica (50% versus 19,6%, p = 0,019) e maior sobrevida sem morbidade (20% versus 45,6%, p = 0,028). Conclusão Uma abordagem conservadora em prematuros com persistência do canal arterial pode evitar tratamentos clínicos e cirúrgicos, sem um impacto significativo na sobrevida sem morbidade. No entanto, dois terços dos prematuros com menos de 26 semanas ainda são tratados.

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants.

OBJECTIVE: Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. METHOD: Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. RESULTS: This study included 188 patients (27±2 weeks, 973±272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p<0.001) and surgical closure (34.5% P1 versus 16.1% P2, p<0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p=0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p=0.403), necrotizing enterocolitis (15.5% versus 6.9%, p=0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p=0.264), mortality (17.5% versus 15.2%, p=0.690) or survival-without-morbidity adjusted OR=1.10 (95% CI: 0.55-2.22); p=0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n=82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p=0.019) and more survival-without-morbidity (20% versus 45.6%, p=0.028) were found. CONCLUSION: A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

Preterm newborns undergoing selective correction surgery of the patent ductus arteriosus: is there still space for these procedures? / Recém-nascidos pré-termos submetidos à cirurgia seletiva da persistência do canal arterial: ainda há espaço para esses procedimentos?

INTRODUCTION: The ductus arteriosus is a small fetal structure that connects two large arteries (aorta and pulmonary) but becomes pathological when it is maintained after birth. Morbidities associated with persistent patent ductus arteriosus (PDA) may lead to the conclusion that the best approach is early surgical treatment. However, there is evidence that expectant (more selective) surgical management may reduce the chances of unnecessary surgeries and their risks. OBJECTIVE: To analyze the clinical and surgical profile of preterm newborns submitted to selective correction surgery of the patent ductus arteriosus. METHODS: This paper contemplates a series of cases, in which all patients submitted to the surgical treatment of PDA in preterm infants were described retrospectively (2009-2016), through the analysis of medical records of the Santa Marcelina Hospital, SP-Brazil. RESULTS: During this period, there were 13 cases of premature infants who underwent selective surgical correction of PDA. Gestational age was 26.92 weeks, maternal age ranged from 15 to 44, birth weight varied between 650 and 1500g, mostly women (61.54%). The diameter of the ductus arteriosus ranged from 1.7 to 4.1 mm, four patients had complex congenital heart disease (30.77%). The median courses of indomethacin were 1.77, congestive heart failure was shown in 11 patients (84.62%), the median age at surgery was 27.69 days and the median duration of orotracheal intubation was 22.62 days. The weight of the newborns at the time of the surgical act varied between 900 and 1820g. The postoperative complications were mostly infectious, with nine patients with bronchopneumonia (69.23%), one patient had pneumothorax. Sepsis occurred in two cases (15.35%) that died due to the same complication (15.35%). CONCLUSION: All preterm newborns who underwent surgery had birth weight less than 1500g. The median arterial canal was 3.05 mm in diameter. The median gestational age was 26.92 weeks and 62% of the cases were female. The most frequent surgical technique was the triple clipping, there was no bleeding or reoperation in this series of cases.

INTRODUÇÃO: O canal arterial é uma pequena estrutura fetal que comunica duas grandes artérias (aorta e pulmonar), mas que se torna patológica quando se mantem após o nascimento. As morbidades associadas à persistência do canal arterial (PCA) podem levar à conclusão de que a melhor conduta seja o tratamento cirúrgico precoce. No entanto, há evidências de que a conduta cirúrgica expectante (seletiva), poderia diminuir os riscos de cirurgias desnecessárias e suas complicações OBJETIVO: Analisar o perfil clínico-cirúrgico dos recém-nascidos pré-termos (RNPT) submetidos à cirurgia seletiva de correção da Persistência do Canal Arterial MÉTODO: Este trabalho contempla uma série de casos, onde foram descritos retrospectivamente (2009-2016) todos os recém-nascidos submetidos ao tratamento cirúrgico de PCA em RNPT através da análise de prontuários do Hospital Santa Marcelina, SP-Brasil RESULTADOS: Neste período, observou-se 13 casos de prematuros que foram submetidos à correção cirúrgica seletiva da PCA. A idade gestacional média foi de 26,92 semanas, a idade materna variou entre 15 e 44 anos. O peso ao nascimento variou entre 650 e 1500g e houve prevalência do sexo feminino (61,54%). O diâmetro do canal arterial variou entre 1,7 e 5 mm, quatro recém-nascidos apresentaram cardiopatia congênita complexa (30,77%). A média de ciclos de indometacina foi de 1,77. A insuficiência cardíaca congestiva se evidenciou em 11 recém-nascidos (84,62%); a idade média no ato cirúrgico foi de 27,69 dias e a média do tempo de intubação orotraqueal foi de 22,62 dias. O peso no momento do ato cirúrgico variou entre 900 e 1820g. As complicações pós-operatórias foram em sua maioria infecciosas, observando-se nove recém-nascidos com broncopneumonia (69,23%); um paciente apresentou pneumotórax. Ocorreram sepse em dois casos (15,35%) que evoluíram para óbito por esta mesma complicação (15,35% CONCLUSÃO: Todos os RNPT que foram submetidos a cirurgia tiveram peso ao nascimento menor de 1500g. A média de canal arterial foi de 3,05 mm de diâmetro. A idade gestacional média foi de 26,92 semanas e 62% dos casos eram do sexo feminino. A técnica cirúrgica mais frequente foi a da tripla clipagem, não houve sangramento ou reoperação nesta série de casos. A cirurgia seletiva de PCA ainda se faz necessária nos dias atuais

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.

Ductus arteriosus stenting: A promising percutaneous palliation in patients with duct-dependent pulmonary circulation.

OBJECTIVES: We aimed to study the feasibility and outcomes of ductal stenting in patients with duct-dependent pulmonary blood flow (PBF). METHODS: Duct-dependent hypoxic patients with confluent pulmonary artery (PA) branches were enrolled for ductal stenting and followed regularly. RESULTS: Sixty patients, with a median age of 12 (1-1095) days and weight of 2.8 (2.2-8.9) kg, were enrolled. Median right PA (RPA) and left PA (LPA) Z-scores were -1.23 (-10.54 to 2.81) and -0.96 (-8.03 to 3.0), respectively. Mean narrowest ductal diameter was 1.73±0.57 mm and length was 12.78±3.32 mm. Sixty-four stents with mean diameter of 4.21±0.32 mm and length of 14.34±3.44 mm were deployed in 59 patients. The procedure was unsuccessful in one. Post-stenting mean oxygen saturation (SO2) increased significantly from baseline of 68.88±7.47% to 90.43±6.04% (p<0001). Complications included pulmonary edema in one patient and acute stent occlusion in another. At a median follow-up of eight (2-14) months, mean SO2 (80.04±7.54%) was significantly higher than baseline (p<0.0001). Median RPA and LPA Z-scores, 0.56 (-2.89 to 3.29) and -0.02 (-2.81 to 3.86), respectively, were significantly higher than baseline. Six patients required re-interventions (shunt in three and angioplasty in three). Six patients died, three due to sepsis and another three with worsened cyanosis due to impaired PBF, probably due to ductal occlusion. CONCLUSION: Ductal stenting is an effective palliation in patients with duct-dependent PBF. It maintains adequate SO2 and promotes balanced PA growth at mid-term follow-up.

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.

Comparison of two dose regimens of ibuprofen for the closure of patent ductus arteriosus in preterm newborns / Comparação de dois esquemas posológicos de ibuprofeno para o fechamento do canal arterial em recém-nascidos pré-termo

Abstract Objective: To compare the efficacy of intravenous ibuprofen at high (20-10-10 mg/kg/dose) and low doses (10-5-5 mg/kg/dose) the closure of patent ductus arteriosus in preterm newborns. Methods: A cohort study with historical control of newborns that received high- and low-dose intravenous ibuprofen, from 2010 to 2013 in a neonatal intensive care unit, for closure of the patent ductus arteriosus, documented by echocardiography. Secondary outcomes included the number of ibuprofen cycles, incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, changes in renal function, and death. Results: Seventy-seven patients received three doses of ibuprofen for the treatment of patent ductus arteriosus, with 33 receiving high-dose and 44 low-dose therapy. The ductus closed after the first cycle in 25 (56.8%) low-dose patients and in 17 (51.5%) high-dose patients (p > 0.99). Sixteen patients received a second cycle of ibuprofen, and the ductus closed in 50% after low-dose and in 60% after high-dose therapy (p > 0.99). Seven patients required surgery for ductus closure, 13.6% in the low-dose group and 3% in the high-dose group (p = 0.22). Thirty-nine patients developed bronchopulmonary dysplasia, 50% in the low-dose group and 51.5% in the high-dose group (p > 0.99). Twenty-two (50%) low-dose patients died vs. 15 (45.5%) high-dose patients (p = 0.86). Conclusions: There was no difference in closure of the ductus arteriosus or occurrence of adverse effects between the two dose regimens.

Resumo Objetivo: Comparar a eficácia do ibuprofeno endovenoso em doses altas (20, 10 e 10 mg/kg/dose) e em doses baixas (10, 5 e 5 mg/kg/dose) para o fechamento do canal arterial em recém-nascidos pré-termo. Métodos: Estudo de coorte com controle histórico que pesquisou recém-nascidos que receberam ibuprofeno endovenoso, de 2010 a 2013, na unidade de internação neonatal, em doses altas e baixas para o fechamento do canal arterial, documentado por ecocardiograma. Como desfechos secundários foram avaliados o número de ciclos de ibuprofeno feitos, a incidência de displasia broncopulmonar, enterocolite necrosante, alteração de função renal e óbito. Resultados: Receberam três doses de ibuprofeno para tratamento do canal arterial 77 pacientes, 33 dose alta e 44 dose baixa; 25 (56,8%) dos que receberam dose baixa fecharam o canal após o 1° ciclo e 17 (51,5%) fecharam após receberem dose alta (p > 0,99); 16 pacientes receberam o 2° ciclo e 50% fecharam o canal após uso de dose baixa e 60% após o uso de dose alta (p > 0.99); sete pacientes foram à cirurgia para fechamento do canal, 13,6% do grupo que recebeu dose baixa e 3% dose alta (p = 0,22); 39 pacientes desenvolveram displasia broncopulmonar, 50% do grupo de dose baixa e 51,5% do grupo de dose alta (p > 0,99); 22 (50%) dos pacientes do grupo dose baixa evoluíram a óbito versus 15 (45,5%) dos pacientes do grupo de dose alta (p = 0,86). Conclusão: Não encontramos diferença em relação ao fechamento do canal arterial, assim como ocorrência de efeitos adversos, quando comparamos os dois esquemas posológicos.

Ibuprofen and indomethacin for the closure of the patent ductus arteriosus / Ibuprofen, indometacina e fechamento do canal arterial

The ductus arteriosus connects the pulmonary artery with the aorta and allows right ventricular blood to bypass the unexpanded lungs. In mature infants, the ductus arteriosus closes after birth. Patent ductus arteriosus occurs in 70% of preterm infants with a birth weight < 1,000 grams. Failure of the ductus arteriosus to close has been associated with intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, periventricular leukomalacia, renal failure, and persistent pulmonary hypertension. The drugs used to treat the patent ductus arteriosus are ibuprofen and indomethacin which are potent non-selective inhibitors of cyclo-oxygenase (COX) and therefore inhibit prostaglandin E2 synthesis. Prostaglandin E2 relaxes smooth muscle and tends to inhibit the closure of the patent ductus arteriosus. Intravenous ibuprofen and indomethacin inhibit prostaglandin E2 synthesis and thereby close the patent ductus arteriosus with similar efficacy. Indomethacin reduces the blood flow velocity in kidneys, intestine and brain. Ibuprofen has less effect on blood flow velocity in these organs. There is a significant increase in serum creatinine after indomethacin administration but not after ibuprofen and infants treated with ibuprofen have higher creatinine clearance. Oliguria (urine output < 1 ml/kg/h) occurs more frequently with indomethacin than with ibuprofen. Indomethacin requires furosemide for urine output more often than ibuprofen. Ibuprofen reduces the risk of necrotizing enterocolitis and transient renal insufficiency and it is the drug of choice for closing the patent ductus arteriosus. Ibuprofen and indomethacin may be administered orally. In conclusion, intravenous ibuprofen and indomethacin close the patent ductus arteriosus at the same rate, but indomethacin is more toxic than ibuprofen.

O canal arterial conecta a artéria pulmonar com a aorta e permite que o sangue oriundo do ventrículo direito evite passar pelos pulmões fetais não expandidos. Em recém-nascidos maduros, o canal arterial se fecha após o nascimento. A persistência do canal arterial ocorre em 70% dos recém-nascidos prematuros com peso de nascimento < 1.000 gramas. O não fechamento do canal arterial associa-se a hemorragia intraventricular, enterocolite necrosante, displasia bronco-pulmonar, leucomalacia periventricular, insuficiência renal e hipertensão pulmonar persistente. Os medicamentos utilizados para tratar a persistência do canal arterial são o ibuprofeno e a indometacina. Ambos são potentes inibidores não seletivos da ciclo-oxigenase e inibem a síntese de prostaglandina E2. Esta relaxa a musculature vascular lisa e tende a inibir o fechamento do canal arterial. O ibuprofeno e a indometacina inibem a síntese de prostaglandina E2 e favorecem o fechamento do canal arterial. A indometacina reduz a velocidade do fluxo sanguíneo renal, intestinal e cerebral. O Ibuprofeno tem efeito menor sobre a velocidade do fluxo de sangue nesses órgãos. Há um aumento significativo da creatinina sérica após a administração de indometacina, mas não após o ibuprofeno; por isso, recém-nascidos tratados com ibuprofeno têm maior depuração da creatinina. A oligúria ocorre mais frequentemente com a indometacina vs. ibuprofeno. A indometacina requer furosemida para a produção de urina mais frequentemente do que o ibuprofeno. O ibuprofeno reduz o risco de enterocolite necrotizante e de insuficiência renal transitória e é a droga de escolha para o fechamento do canal arterial patente. O ibuprofeno e a indometacina podem ser ministrados por via oral. Em conclusão, o ibuprofeno e a indometacina fecham o canal arterial patente com a mesma velocidade, mas a indometacina é mais tóxica.

Comparison of two dose regimens of ibuprofen for the closure of patent ductus arteriosus in preterm newborns.

OBJECTIVE: To compare the efficacy of intravenous ibuprofen at high (20-10-10mg/kg/dose) and low doses (10-5-5mg/kg/dose) the closure of patent ductus arteriosus in preterm newborns. METHODS: A cohort study with historical control of newborns that received high- and low-dose intravenous ibuprofen, from 2010 to 2013 in a neonatal intensive care unit, for closure of the patent ductus arteriosus, documented by echocardiography. Secondary outcomes included the number of ibuprofen cycles, incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, changes in renal function, and death. RESULTS: Seventy-seven patients received three doses of ibuprofen for the treatment of patent ductus arteriosus, with 33 receiving high-dose and 44 low-dose therapy. The ductus closed after the first cycle in 25 (56.8%) low-dose patients and in 17 (51.5%) high-dose patients (p>0.99). Sixteen patients received a second cycle of ibuprofen, and the ductus closed in 50% after low-dose and in 60% after high-dose therapy (p>0.99). Seven patients required surgery for ductus closure, 13.6% in the low-dose group and 3% in the high-dose group (p=0.22). Thirty-nine patients developed bronchopulmonary dysplasia, 50% in the low-dose group and 51.5% in the high-dose group (p>0.99). Twenty-two (50%) low-dose patients died vs. 15 (45.5%) high-dose patients (p=0.86). CONCLUSIONS: There was no difference in closure of the ductus arteriosus or occurrence of adverse effects between the two dose regimens.

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...

The hybrid approach for palliation of hypoplastic left heart syndrome: Intermediate results of a single-center experience.

INTRODUCTION: Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS: We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS: Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS: In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.