Patência do canal arterial no recém-nascido prematuro: revisão do diagnóstico e tratamento
DOI:
https://doi.org/10.25753/BirthGrowthMJ.v23.i4.8785Palavras-chave:
canal arterial, recém-nascidos prematuros, diagnóstico, tratamentoResumo
A abordagem dos recém-nascidos prematuros (RNPT) constitui uma área de grandes avanços diagnósticos e terapêuticos. Entre as complicações associadas à prematuridade, destaca-se a patência do canal arterial (CA).
O CA no RNPT tem sido objeto de inúmeros estudos há mais de 50 anos. Desde o primeiro relato sobre encerramento do canal arterial em prematuros, realizado por Powell em 1963, há controvérsia a respeito da melhor abordagem terapêutica.
Inicialmente, os pesquisadores investigaram aspectos fisiopatológicos, morfofuncionais e fatores de risco na prevalência do canal arterial, além dos efeitos colaterais e eficácia dos tratamentos realizados. Entre 2000 e 2006 houve descoberta de novos agentes como alternativa terapêutica à indometacina. Na última década, os estudos concentraram-se no diagnóstico precoce por meio da ecocardiografia/Doppler, uma importante ferramenta na avaliação da necessidade de tratamento medicamentoso ou cirúrgico. Atualmente, a maioria dos autores tem optado por conduta observacional dos RNPT com mais 30 semanas e daqueles com CA sem repercussão clínica ou hemodinâmica. No entanto, para os pacientes com canal arterial hemodinamicamente signficativo (CAHS), há consenso para encerramento com medicação ou procedimento cirúrgico.
Muitas vezes há dificuldades para o diagnóstico e abordagem terapêutica do CA no RNPT, pois inúmeros fatores estão envolvidos em sua fisiopatogenia, assim como as variáveis clinicas e hemodinâmicas apresentadas podem ser confundidas com a evolução clínica própria dessa população, independente da presença do CA.
O objetivo dessa revisão é discutir a fisiopatologia do CA em recém-nascidos prematuros e as atuais recomendações diagnósticas e terapêuticas para seu manejo.
Downloads
Referências
Rudolph AM. The changes in the circulation after birth. Their importance in congenital heart disease. Circulation 1970; 41:343.
Clyman RI. Developmental physiology of the ductus arteriosus. In: Long WA. Fetal and Neonatal Cardiology. Philadelphia, WB Saunders; 1990. p.64–75.
Gittenberger-de-Groot AC, Van Ertbruggen I, Moulaert JM.: The ductus arteriosus in the preterm infant: Histologic and clinical observations. J Pediatr. 1980; 96(1): 88–93.
Moore P, Brook MM, Heyman MA. Patent ductus arteriosus. In: Allen HD, Driscoll DJ, Shaddy RE, Feltes TF. Heart Disease in Infants, Children and Adolescents: including the fetus and young adults. 7th Ed. Baltimore, Williams and Wilkins; 2008. p. 683–702.
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39:1890.
Huhta JC. Patent ductus arteriosus in the preterm neonate. In Long WA. Fetal and Neonatal Cardiology. Philadelphia, WB Saunders; 1990. p.389–400.
Reller MD, Rice MJ, McDonald RW. Review of studies evaluating ductal patency in the premature infant. J Pediatr 1993; 122:S59.
Dudell GG, Gersony WM. Patent ductus arteriosus in neonates with severe respiratory disease.J Pediatr. 1984 Jun; 104 (6): 915-20.
Koch J, Hensley G, Roy L, Brown S, Ramaciotti C, Rosenfeld CR. Prevalence of spontaneous closure of the ductus arteriosus in neonates at a birth weight of 1000 grams or less. Pediatrics. 2006 Apr; 117 (4): 1113–21.
Evans N. Diagnosis of patent ductus arteriosus in the preterm newborn. Arch Dis Child. 1993; 68: 58–61.
El-Khuffash AF, Jain A, McNamara PJ. Ligation of the patent ductus arteriosus in preterm infants: understanding the physiology. J Pediatr 2013; 162:1100.
Sehgal A, McNamara PJ. Coronaryartery perfusion and myocardial performance after patentductusarteriosus ligation. J.Thorac Cardiovasc Surg. 2012 Jun;143(6):1271-8.
El-Khuffash AF, Slevin M, McNamara PJ, Molloy EJ. Troponin T, N-terminal pro natriuretic peptide and a patent ductus arteriosus scoring system predict death before discharge or neurodevelopmental outcome at 2 years in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2011 Mar;96(2):F133-7.
El-Khuffash AF, Molloy EJ. Inß uence of a patent ductus arteriosus on cardiac troponin T levels in preterm infants.J Pediatr. 2008 Sep;153(3):350-3.
Gonzalez A, Sosenko IR, Chandar J, Hummler H, Claure N, Bancalari E. Inß uence of infection on patent ductus arteriosus and chronic lung disease in premature infants weighing 1000 grams or less. J Pediatr. 1996 Apr; 128 (4): 470–8.
Kluckow M, Evans N. Ductal shunting, high pulmonary blood flow, and pulmonary hemorrhage. J Pediatr. 2000 Jul; 137
(1): 68–72.
Bancalari E, Claure N, Sosenko IR. Bronchopulmonary dysplasia: changes in pathogenesis, epidemiology and definition. Semin Neonatol. 2003; 8: 63-71.
Sehgal A, Tran H, Carse E. Doppler manifestations of ductal steal: role in decision making. Eur J Pediatr.2011 Jun;170(6):795-8.
Sehgal A, Coombs P, Tan K, McNamara PJ. Spectral Doppler waveforms in systemic arteries and physiological significance of a patent ductus arteriosus. J Perinatol. 2011 Mar;31(3):150-6.
Martin CG, Snider AR, Katz SM, et al. Abnormal cerebral blood flow patterns in preterm infants with a large patent ductus arteriosus. J Pediatr 1982; 101:587.
Lemmers PM, Toet MC, van Bel F. Impact of patent ductus arteriosus and subsequent therapy with indomethacin on cerebral oxygenation in preterm infants. Pediatrics 2008; 121:142.
Coombs RC., Morgan MEI., Durbin GM. Gut blood flow velocity in the newborn: effects of patent ductus arteriosus and parenteral indomethacin. Arch Dis Child 1990; 65: 1067- 1071.. 1990; 111: 579-87.
Shimada S, Kasai T, Konishi M, Fugiwara T. Effects of patent ductus arteriosus on left ventricular output and organ blood ß ows in preterm infants with respiratory dystress syndrome treated with surfactant. J Pediatr. 1994 Aug; 125 (2): 270-7.
Benitz, WE. Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis? J Perinatol. 2010 Apr; 30 (4): 241-52.
Sehgal A, McNamara PJ. The ductus arteriosus: a reÞ ned approach! Semin Perinatol. 2012 Apr;36(2):105-13.
El-Khuffash AF, McNamara PJ. The patent ductus arteriosus ligationdecision.J Pediatr. 2011 Jun;158(6):1037-8.
Bose CL, Laughon MM. Patent ductus arteriosus: lack of evidence for common treatments. Arch Dis Child Fetal Neonatal. 2007; 92(6): 498–502.
Clyman RI, Jobe A, Heymann M, et al. Increased shunt through the patent ductus arteriosus after surfactant replacement therapy. J Pediatr 1982; 100:101.
Kääpä P, Seppänen M, Kero P, Saraste M. Pulmonary hemodynamics after synthetic surfactant replacement in neonatal respiratory distress syndrome. J Pediatr 1993; 123:115.
Mouzinho AI, Rosenfeld CR, Risser R. Symptomatic patent ductus arteriosus in very-low-birth-weight infants: 1987-1989. Early Hum Dev 1991; 27:65.
Burnard ED. The cardiac murmur in relation to symptoms in
the newborn. Br Med J. 1959; 1: 134–8.
Davis P, Turner GS, Cunningham K, Way C, Roberts R, Schmidt B. Precision and accuracy of clinical and radiological signs in premature infants at risk of patent ductus arteriosus. Arch Pediatr Adolesc Med. 1995 Oct; 149 (10): 1136–41.
Jacob J, Gluck L, DiSessa T, et al. The contribution of PDA in the neonate with severe RDS. J Pediatr 1980; 96:79.
Hamrick SE, Hansmann G. Patent ductus arteriosus of the preterm infant. Pediatrics 2010; 125:1020.
Harling S, Hansen-Pupp I, Baigi A, Pesonen E. Echocardiographic prediction of patent ductus arteriosus in need of therapeutic intervention. Acta Paediatr 2011; 100:231.
Kluckow M, Evans N. Early echocardiographic prediction of symptomatic patent ductus arteriosus in preterm infants undergoing mechanical ventilation. J Pediatr 1995; 127:774.
Thankavel PP, Rosenfeld CR, Christie L, Ramaciotti C. Early echocardiographic prediction of ductal closure in neonates 30 weeks gestation. J Perinatol 2013; 33:45.
McNamara PJ, Sehgal A. Towards rational management of the patent ductus arteriosus: the need for disease staging. Arch Dis Child Fetal Neonatal Ed 2007; 92:F424.
SehgalA, McNamara, PJ. Does echocardiography facilitate determination of hemodynamic signiÞ cance attributable to the ductus arteriosus? Eur J Pediatr 2009; 168(8): 907-914.
Wickremasinghe AC, Rogers EE, Piecuch RE, et al Neurodevelopmental outcomes following two different treatment approaches (early ligation and selective ligation) for patent ductus arteriosus. J Pediatr 2012; 161:1065.
Saldeño YP, Favareto V, Mirpuri J. Prolonged persistent patent ductus arteriosus: potential perdurable anomalies in premature infants. J Perinatol 2012; 32:953.
Clyman RI, Chorne N. Patent ductus arteriosus: evidence for and against treatment. J Pediatr 2007; 150:216.
Thibeault DW, Emmanouilides GC, Dodge ME, Lachman R. Early functional closure of the ductus arteriosus associated with decreased severity of respiratory distress syndrome in preterm infants. Am J Dis Child. 1977 Jul; 131 (7): 741-5.
Betkurer MV, Yeh TF, Miller K, Glasser RJ, Pildes RS. Indomethacin and its effect on renal function and urinary kallikrein excretion in premature infants with patent ductus arteriosus. Pediatrics. 1981; 68: 99–102.
Green TP, Thompson TR, Johnson DE, Lock JE. Furosemide promotes patent ductus arteriosus in premature infants with the respiratory-distress syndrome. N Engl J Med 1983; 308:743.
Noori S, Seri I. Treatment of the patent ductus arteriosus: when, how, and for how long? J Pediatr 2009; 155:774.
Carmo KB, Evans N, Paradisis M. Duration of indomethacin treatment of the preterm patent ductus arteriosus as directed by echocardiography. J Pediatr 2009; 155:819.
Herrera C, Holberton J, Davis P. Prolonged versus short course of indomethacin for the treatment of patent ductus arteriosus in preterm infants. Cochrane Database of Systematic Reviews. 2007.
Bagnoli F, Rossetti A, Messina G, et al. Treatment of patent ductus arteriosus (PDA) using ibuprofen: renal side-effects in VLBW and ELBW newborns. J Matern Fetal Neonatal Med 2013; 26:423.
Neumann R, Schulzke SM, Bührer C. Oral ibuprofen versus intravenous ibuprofen or intravenous indomethacin for the treatment of patent ductus arteriosus in preterm infants: a systematic review and meta-analysis. Neonatology 2012; 102:9.
Ohlsson A, Walia R, Shah SS. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews. 2013.
Amendolia B, Lynn M, Bhat V, et al. Severe pulmonary hypertension with therapeutic L-lysine ibuprofen in 2 preterm neonates. Pediatrics 2012; 129:e1360.
Bellini C, Campone F, Serra G. Pulmonary hypertension following L-lysine ibuprofen therapy in a preterm infant with patent ductus arteriosus. CMAJ 2006; 174:1843.
Fowlie PW, Davis PG, McGuire W. Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants. Cochrane Database of Systematic Reviews. 2010.
Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews. 2011.
Moin F., Kennedy K.A., Moya F.R. Risk factors predicting vasopressor use after patent ductus arteriosus ligation. Am J Perinatol. 2003 Aug; 20 (6): 313–20.
Nemerofsky SL, Parravicini E, Bateman D, Kleinman C, Polin RA, Lorenz JM. The ductus arteriosus rarely requires treatment in infants >1000 grams. Am J Perinatol. 2008 Nov; 25 (10): 661–6.
Malviya MN, Ohlsson A, Shah SS. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database of Systematic Reviews. 2008; Issue 1.
Noori S, McCoy M, Friedlich P, Bright B, Gottipati V, Seri I. Failure of ductus arteriosus closure is associated with increased mortality in preterm infants. Pediatrics. 2009; 123: 138–44.
Downloads
Publicado
Como Citar
Edição
Secção
Licença
Copyright e Direitos dos Autores
Todos os artigos publicados na Revista Nascer e Crescer – Birth and Growth Medical Journal são de acesso aberto e cumprem os requisitos das agências de financiamento ou instituições académicas. Relativamente à utilização por terceiros a Nascer e Crescer – Birth and Growth Medical Journal rege-se pelos termos da licença Creative Commons "Atribuição - Uso Não-Comercial - (CC-BY-NC)"".
É da responsabilidade do autor obter permissão para reproduzir figuras, tabelas, etc. de outras publicações.
Juntamente com a submissão do artigo, os autores devem enviar a Declaração de conflito de interesses e formulário de autoria. Será enviado um e-mail ao autor correspondente, confirmando a receção do manuscrito.
Os autores ficam autorizados a disponibilizar os seus artigos em repositórios das suas instituições de origem, desde que mencionem sempre onde foram publicados e de acordo com a licença Creative Commons.
