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ORIGINAL ARTICLE

Management of patent ductus arteriosus in the premature infant: ligation or indomethacin?

Milton A MeierI; Waldir JazbikII; Joaquim H CoutinhoII; João Carlos JazbikII; José Aldrovando de OliveiraIII; José Caetano SilvaIII; Rosa Célia BarbosaIII; Helder PaupérioIII; Astolfo Serra JrIII

DOI: 10.1590/S0102-76381989000100002

ABSTRACT

Patent ductus arteriosus (PDA) in low-birth-weight premature infants has been associated with congestive heart failure, bronchopulmonary dysplasia, necrotizing enterocolitis, intracranial hemorrhage, and death. Surgical ligation of the PDA in these infants has improved lung compliance, decreased the duration of assisted ventilation, and increased nutritional utilization. After the introduction of indomethacin for the pharmacological interruption of the PDA in the last decade, several studies have been reported which attempted to establish advantages of the pharmacological treatment over the surgical ligature. The purpose of our study is to compare the results obtained in 48 consecutive patients (Group 1) who underwent surgical ligature of the PDA in the last 8 years, with 28 patients (Group 2), who underwent indomethacin therapy. The mean gestational age of Group 1 was 29.13 ± 2.33 weeks (range, 24-34 weeks), and 28.39 ± 2.30 weeks (range, 25-32 weeks) in Group 2. The mean birth weight was 954.17 ± 220.86 g (range, 540-1750 g) in Group 1, and 923.21 ± 191.74 g (range 550-1400 g) in Group 2. Thirty three (60.75%) pts. from Group 1 weighed 1,000 g or less, and 21 pts. from Group 2 (75.0%) weighed less than 1,000 g. Nine pts. (32.1%) from Group 2 received indomethacin previously and were transferred to Group 1, due to failure to close the PDA or due to drug intolerance. Ligation of the PDA was performed in the neonatology intensive care unit, in 31 pts. (64.5%). Usually a small postero-lateral thoracotomy, with preservation of the latissimus dorsi and anterior serratus muscles, with thorax access through the 3rd or 4th intercostal spaces. The ductus is isolated by an extrapleural path, and ligated with two or three a medium hemoclips. In our early experience pleural drainage was employed routinely in all patients. Later, it was used only when the pleura was inadvertently opened, and more recently pleural drainage was used only in patients who had preexisting pneumothorax or excessive bleeding. The overall mortality in Group 1 was 18.75% (9 pts.) and in Group 2 was 25.0% (7 pts.). Four patients from Group 2 who were transferred to Group 1, died. Causes of death in Group 1, included sepsis, intraventricular hemorrhage, necrotizing enterocolitis and focal perforations, and pneumothorax. Patients who weighed more than 1,000 g had a better survival and a shorter period of assisted ventilation than patients weighing less than 1,000 g. Despite the problems of comparison between the two groups, and limited conclusions that can be drawn from a retrospective and non randomized study, we believe that surgical ligature for PDA was associated with significant less morbidity and mortality, than patients treated with indomethacin.

RESUMO

A presença de canal arterial patente (PCA) com grande shunt sistêmico -pulmonar no prematuro com síndrome de angústia respiratória (SAR) está quase sempre associada a insuficiência cardíaca, displasia broncopulmonar, enterocolite necrotizante, hemorragia intracraniana e morte. A ligadura do canal melhora a complacência pulmonar, reduz, significativamente, o tempo de assistência ventilatória e melhora 0 estado geral do paciente. Depois da introdução, nesta última década, da indometacina para a interrupção do PCA, no prematuro, vários estudos vêm procurando estabelecer as vantagens de uma forma de tratamento sobre a outra. O propósito do nosso estudo é comparar os resultados obtidos em 48 pacientes (pts.) (Grupo 1) submetidos a ligadura cirúrgica, nos últimos 8 anos, com 28 pts. (Grupo 2) nos quais a indometacina foi, preferentemente, utilizada. A idade gestacional média do Grupo 1 foi de 29,13 ± 2,33 semanas (24-34) e de 28,39 ± 2,30 semanas (25-32) no Grupo 2. O peso médio foi de 954,17 ± 220,68 g (540-1750 g) no Grupo 1 e de 923,21 ± 191,74 g (550-1400 g) no Grupo 2. Trinta e três (60,75%) dos pts. do Grupo 1 eram menores do que 1000 g (prematuros extremos), enquanto que 21 do Grupo 2 (75,0%) estavam nessa condição. Nove pacientes (32,1%) do Grupo 2 foram transferidos para o Grupo 1, devido ao insucesso da terapêutica com a indometacina, ou pela intolerância às doses indicadas. A ligadura foi realizada na própria unidade de terapia intensiva em 31 pts. (64,5%). A técnica empregada tem sido a de uma toracotomia póstero-lateral pequena, com preservação dos músculos do tórax e abertura pelo 3º ou 4º espaço intercostal. Por via extrapleural, o canal é alcançado e ligado com dois clips metálicos. Inicialmente, o tórax era rotineiramente drenado, apenas quando havia abertura da pleura. Mais recentemente, mesmo com a pleura aberta, somente são drenados os casos que apresentam pneumotórax prévio, ou então sangramento excessivo. A mortalidade no Grupo 1 foi de 18,75% (9 pts.) e, no Grupo 2, de 25,0% (7 pts.). Quatro pacientes do Grupo 2 transferidos para o Grupo 1 faleceram. As causas de óbito no Grupo 1 foram sépsis e hemorragia intracraniana; no Grupo 2, sépsis, enterocolite necrotizante com perfuração localizada, hemorragia intracraniana e penumotórax. Nos dois grupos, a mortalidade foi significantemente maior nos prematuros extremos. A despeito dos problemas de comparação entre os 2 grupos e das conclusões limitadas que podem ser retiradas de um estudo retrospectivo e não randomizado, acreditamos que os resultados da ligadura cirúrgica são nitidamente superiores aos obtidos com o uso da indometacina.
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