早产儿动脉导管未闭的临床特点及其心脏血流动力学研究

Clinical characteristics and cardiac hemodynamic changes of patent ductus ateriosus in preterm infants

目的 探讨早产儿动脉导管未闭（PDA）的临床特点及其对心脏血流动力学的影响.方法 入选2012年10月至2013年9月北京大学第三医院新生儿重症监护病房收治的出生胎龄≤34周、体重≤2 000 g的早产儿105例,其中男63例、女42例,出生胎龄（31.1±1.9）周,出生体重（1 401±314）g.均于生后第2、3、5、7天进行床旁超声心动图（UCG）检查,生后2～3d根据临床表现及UCG结果将患儿分为3组：有血流动力学意义的PDA（hsPDA）组34例,无血流动力学意义的PDA（nhsPDA）组44例,无PDA （nPDA）组27例.观察各组的一般情况、动脉导管内径、分流方向、评估左室功能及相关合并症.采用单因素分析或多因素Logistic回归分析比较各组差异.结果 hsPDA组胎龄明显小于nhsPDA组[（30.5±2.1）比（31.6±1.6）周,F=3.40,P=0.01],肺表面活性物质（PS）应用及生后2、3、5d的机械通气比例均显著高于nhsPDA组和nPDA组（x2 =11.62、14.95、12.73、11.59,P=0.00、0.00、0.01、0.01）.单因素和多因素Logistic回归分析示平均住院时间与hsPDA有相关性（F=3.52、P=0.03,OR=1.03,P=0.02）,hsPDA组的平均住院时间明显长于nhsPDA组和nPDA组[（39±23）比（30±16）和（29±13）d,P=0.02、0.03].hsPDA组死亡或放弃治疗患儿比例与其他两组比较差异无统计学意义[5.9％ （2/34）比0（0/44）和3.7％（1/27）,x2=5.26,P =0.06].早产儿在生后2、3、5d,hsPDA组的舒张压和平均压均显著低于nhsPDA组和nPDA组（P均＜0.05）,生后2 d hsPDA组脉压大于nPDA组（P=0.04）.单因素和多因素Logistic回归分析结果发现hsPDA与新生儿呼吸窘迫综合征（NRDS）、支气管肺发育不良（BPD）显著相关（x2=7.34、7.39,P=0.02、0.02;OR=3.46、4.01,P=0.04、0.02）.生后7d内hsPDA的存在使左室心输出量（CO）增加（F=6.93,P＜0.01）,而左室短轴缩短分数（FS）和左室射血分数（EF）无明显变化.生后第7天hsPDA组动脉导管关闭后与同时间nhsPDA和nPDA组比较各心脏血流参数的差异均无统计学意义（P均＞0.05）.hsPDA组内比较,胎龄、体重越小,CO值越低（F=5.16、14.87,P均＜0.01）.hsPDA组布洛芬治疗后动脉导管内径显著缩小（t=5.58,P＜0.01）.结论 胎龄小、PS应用和机械通气可能与早产儿hsPDA有关.hsPDA可能使平均压和舒张压下降,脉压增大;其与平均住院时间、NRDS和BPD显著相关.早产儿hsPDA可引起CO的增加,FS、EF值不受影响.生后1d后口服布洛芬能有效治疗hsPDA.

Objective To study clinical characteristics and evaluate cardiac hemodynamic changes in premature infants with patent ductus ateriosus （PDA）.Method One hundred and five infants born at ≤ 34 weeks＆#39; gestational age （GA） and ≤2 000 g birth weight （BW） were prospectively enrolled,including 63 males and 42 females,and the mean GA was （31.1 ± 1.9） weeks and BW （1 401 ± 314） g.Echocardiography was done to detect hemodynamically significant PDA （hsPDA） and to evaluate left ventricular function at 2,3,5 and 7 d respectively after birth.On the basis of clinical symptoms and echocardiographic outcome,all the cases were divided into 3 groups：hsPDA group （n =34）,non-hsPDA （nhsPDA） group （n =44） and non-PDA （nPDA） group （n =27） to survey and compare general conditions,DA diameter,shunt direction,left ventricular function and complications.Result The hsPDA group had smaller GA （（30.5 ±2.1）vs.（31.6 ± 1.6）weeks,P =0.01） and greater proportion of pulmonary surfactant use and mechanical ventilation （2,3,5 d of birth） than the nhsPDA and the nPDA group （x2 =11.62,14.95,12.73,11.59,P =0.00,0.00,0.01,0.01）.Univariate and multivariate Logistic regression analysis indicated that the average length of stay （ALOS） was correlated with hsPDA （F =3.52 and P =0.03,OR =1.03 and P =0.02）.The ALOS was longer in the hsPDA group than in the nhsPDA and the nPDA group （（39 ± 23） vs.（30 ± 16） and （29 ± 13） d,P =0.02,0.03）.There was no significant difference in rates of mortality/giving-up of treatment among the three groups （5.9% （2/34）vs.0 （0/44） and 3.7% （1/27）,x2 =5.26,P =O.06）.Diastolic blood pressure and mean blood pressure were significantly lower in the hsPDA group than in the other two groups （P all 〈 0.05） at 2,3 and 5 days after birth and the pulse pressure was found significantly higher in the hsPDA group than in the nPDA group at 2 d after birth.Univariate and multivariate Logistic regression analysis demonstrated that hsPDA was correlated significantly with neonatal respiratory distress syndrome （NRDS） and bronchopulmonary dysplasia （BPD） （x2 =7.34 and 7.39,P =0.02 and 0.02;OR =3.46 and 4.01,P =0.04 and 0.02）.Premature infants with hsPDA had normal left ventricular fractional shortening （FS） and left ventricular ejection fraction （LVEF）,although the cardiac output （CO） of left ventricle increased significantly（F =6.93,P 〈 0.01） within seven days of birth.There was no significant difference in cardiac hemodynamic parameters among closed group of hsPDA group,nhsPDA group and nPDA group simutaneously reexamined at 7th day after birth.The CO was extremely significantly different among premature infants who had different GAs and BWs.The lower the GAs and the BWs,the lower the value of CO（F =5.16 and 14.87,P all 〈 0.01）.The DA diameter was reduced much more dramatically after ibuprofen treatment than before in hsPDA group（t =5.58,P 〈 0.01）.Conclusion The GA,PS use and mechanical ventilation were probably associated with hsPDA.The mean blood pressure and diastolic blood pressure were decreased and pulse pressure was increased in preterm infants with hsPDA that correlated significantly with ALOS,NRDS and BPD.In addition,increased CO values were found in hsPDA group.Oral ibuprofen administered to preterm infants for hsPDA at 〉 24 h of life promoted ductal closure.