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298例动脉导管未闭的极低出生体重婴儿的预后分析

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

Alexander F, Chiu L, Kroh M 2009/5/31 18:19:25

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J Pediatr Surg, 2009,

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

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

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

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