CENTRO MEDICO NACIONAL SIGLO XXI ECG: hipertrofia de ventrículo izquierdo con

HOSPITAL DE PEDIATRIA agrandamiento de auricula izquierda.

CIRUGIA PEDIATRICA EKG: método de diagnostico de elecció n.

PERSISTENCIA DE CONDUCTO ARTERIOSO. Cateterismo cardiaco: 2 iniciaciones: pacientes mayores

con sospecha de Hipertension pulmonar para evaluar la
Definició n: Estructura vascular que comunica la porció n enfermedad vascular pulmonar obstructiva, para ocluir el
distal del arco aó rtico con la regió n proximal de la arteria conducto.
pulmonar izquierda. MANEJO: 3 técnicas: FARMACOLOGICA, CIERRE
QUIRURGICO Y CIERRE ENDOVASCULAR.
Funció n: etapa fetal: desvía la sangre que sale del
ventrículo derecho al tronco pulmonar hacia la aorta FARMACOLOGICO: INDOMETACINA E IBUPROFENO.
descendente; su cierre se produce por aumento en la Efectos adversos: hipotensió n, disminució n de flujo a lecho
tensió n de oxigeno que acompañ a a la ventilació n esplacnico, interfieren en funció n plaquetaria.
posterior al nacimiento. (12-24hrs). Su cierre produce Ibuprofeno (elecció n) 10mg/kg IV, posterior 5mg/kg IV
ligamento arterioso. cada 24 hrs 3 dosis.
É xito 80% de prematuros.
Epidemiologia: incidencia 1/1200 recien nacidos vivos, Contraindicació n: sepsis, insuficiencia renal, enfermedades
frecuencia inversamente proporcional al peso y edad hemorrá gicas.
gestacional. 32-36 SDG: 20%, menos de 30 SDG 60%. 2 ciclos fallidos de ibuprofeno: indicació n de cirugía.

Lesió n aislada presenta entre 7% de las cardiopatía CIRUGIA:

congénitas. >2500m sobre el nivel del1648mar.PARTFrecuente
IX
en
SPECIAL AREAS
Abordaje toracotomía posterolateral izquierda por 3ro a
femeninos proporció n 2- 3 : 1. 4to EIC, se incide la pleura longitudinal sobre la aorta
IA LCCA torá cica descendente
inhibitors, are useful proximal,
for stimulating PDAdisecció
closure innpremature
de conducto (no
LSA infants. 8 Indomethacin and ibuprofen are known to have a
Factores predisponentes: antecedente de rubeola confundirlo).
number of possible side effects including hypotension,
materna en primer trimestre, cesarea, ciudades > 2500m El nervio decreased
laríngeo
rotizing
gastrointestin al blood flow (which may lead to nec-
enterocolitisrecurrente, correperforation),
or spontaneous intestinal por detrá s del
SNM. Prematurez, sulfactante y VMA. Cardiopatias con conducto
Isthmus (no
decreasedlesionarlo).
renal blood flow, El andducto se
interference cierra
with platelet con clips o
Ao function. Due to an improved side effect profile regarding
flujo pulmonar disminuido (atresia pulmonar) o flujo ligaduras gastrointestinal
con sedableeding y se and renalpuede cortar
dysfunction, entre
ibuprofen is las dos
current drug of choice. 9 It is rarely effective in full-term
sistémico inadecuado (coartació n de aorta grave). PDA ligaduras. the
babies. The dosing regimen is 10 mg/kg intravenously,
PA
En neonatos followed by 5 mg/kg intravenously
procedimiento at 24-hour intervals for
en cuna.
a total of three doses. This approach is successfu l in nearly
HISTORIA CLINICA Y DIAGNOSTICO: Toracoscopia: disminuye
80% of premature infants. 9 ,1 0
dolor y todías
Contraindications ibuprofende estancia
therapy include sepsis, renal insufficiency, and bleeding dis-
Cortocircuito de sangre atraves del conducto. El volumen LPA intrahospitalaria.
orders. FailureProblemas:
of ibuprofen after two curva de results
complete courses aprendizaje y
del cortocircuito se determina por el tamañ o del conducto tiempo quirúin referral
rgico. for surgical closure.
The surgical approach to the PDA is usually via a left pos-
y radio de resistencia vascular. Descenso de resistencia CIERRE ENDOVASCULAR.
terolateral thoracotomy throughConductosthe third or pequeñ os.
fourth intercos-
tal space (Fig. 127-2). The pleura is divided longitudinally
vascular pulmonar desciende dramá ticamente al nacer y over the proximal descending thoracic aorta. The vagus nerve
FIGURE 127-1 Anatomy of patent ductus arteriosus (PDA) as seen from
continua con descenso a la primer semana de vida.
a left thoracotom RESULTADOS:
y. The ductus extends from the main pulmonary artery is therebyEllifted medially.abierto
cierre Dissection isocarried
endoscóout to demon-
pico mortalidad
(PA) and enters the proximal descending thoracic aorta distal to the left strate unequivocally the distal transverse aortic arch and duc-
Permite cortocircuito de izquierda a derecha
subclavian entre
artery (LSA). la
Ao, aorta
aorta; IA, innominate artery; 0.
LCCA, left
carotid artery. (From Hillman ND, Mavroudis C, Backer CL: Patent ductus
Morbilidad:
common tus. In neumotó
some cases the rax,
ductus lesió
may be n
the del
largest nervio
vascular laríngeo
structure present, so it is critical that it not be confused with
descendente y arteria pulmonar izquierda,
arteriosus. incrementando
In Mavroudis C, Backer CL [eds]: Pediatric Cardiac
3rd ed. Philadelphia, Mosby, 2003.)
recurrente,
Surgery,
thelesió
aorta. n
Oncedelthe nervio
anatomy is frénico
confirmed, y
the quilotorax.
ductus is gently
dissected. Ductal tissue is extremely friable, especially in pre-
el flujo sanguíneo pulmonar. El hiperflujo pulmonar induce La supervivencia depende de la prematuridad y anomalías
mature infants, so direct manipulation is not recommended.
cambios histoló gicos sucesivos en vascular
el lecho obstructive vascular asociadas.
disease. In these cases, Eisenmenger’ s
physiology may develop when pulmonary vascular resistance
pulmonar: hipertrofia de la capa media,exceeds
infliltracion
systemic vascular celular
resistance, leading to a reversal of
shunting across the ductus (from left to right to right to left),
y fibrosis de la intima. causing cyanosis and, eventually, right ventricular failure.
Some patients with a small PDA may remain asymptomatic
until adulthood. Endocarditis and endarteritis have been
PRESENTACION CLINICA: reported as long-term complications of PDA.4
The clinical manifestations of PDA are determined by the
Depende del tamañ o y de la resistenciashunt
vascular
volume andpulmonar,
the presence of associated cardiac defects.
desde asintomá tico a cianosis. Left-to-right shunt flow leads to volume overload of the left
Ao
heart. Signs of congestive heart failure in infants commonly PA
Soplo sistó lico eyectivo en el foco include
pulmonar tachypnea,otachycardia,
regió nand poor feeding. Older Vagus
children may present with recurrent respiratory infections,
infraclavicular izquierdo. fatigue, and failure to thrive. Physical findings include a wid-
Recurrent
laryngeal
nerve

ened pulse pressure

Taquipnea, taquicardia o falla en la alimentació n. and an active precordium. Auscultation nerve
reveals a continuous “machinery” murmur heard best along
Niñ os mayores infecciones respirtorias the recurrentes, fatiga
left upper sternal border. Radiographic findings include
increased pulmonary vascular markings and left heart enlar- PDA
o falla de crecimiento. gement generally in proportion to the degree of shunting.
Electrocardiography
A la EF pulsos amplios, soplo tipo maquina de vapormayborde demonstrate left ventricular hyper-
trophy and left atrial enlargement. Echocardiography is
esternal izquierdo inferior, currently the diagnostic method of choice and can addition-
ally rule out the presence of associated defects. Cardiac cath-
RX: aumento de flujo pulmonar y crecimiento
eterization is de cavidades
reserved for two principal indications. First, in
izquierdas. older patients with suspected pulmonary hypertension, it can
be used to evaluate for pulmonary vascular obstructive dis-
ease. Second, transcatheter techniques have been developed
to occlude the ductus in selected cases. 5 – 7

FIGURE 127-2 Exposure of patent ductus arteriosus (PDA) by left

MANAGEMENT
Three management schemes for the closure of a PDA exist:
pharmacologic therapy, surgical closure, and endovascular
device closure. Indomethacin and ibuprofen, cyclooxygenase
thoracotom y. The mediastinal pleura has been divided and reflected with
preservation of the vagus and recurrent laryngeal nerves. Ao, aorta; PA,
pulmonary artery. (From Hillman ND, Mavroudis C, Backer CL: Patent
ductus arteriosus. In Mavroudis C, Backer CL [eds]: Pediatric Cardiac
Surgery, 3rd ed. Philadelphia, Mosby, 2003.)
purpose of transcatheter occlusion of the PDA. These mature infants depends primarily on the extent of prematurity
ces have proved to be so successfu l that at most centers, and the presence of associated anomalies.

Ao Vagus
nerve
MPA

Recurrent
laryngeal
nerve

PDA

C D
RE 127-3 Various techniques for control of the patent ductus arteriosus (PDA). A, Simple ligation. B, Ligation and hemoclip application. C and D,
on and adventitial pursestring. Ao, aorta; MPA, main pulmonary artery. (From Hillman ND, Mavroudis C, Backer CL: Patent ductus arteriosus.
vroudis C, Backer CL [eds]: Pediatric Cardiac Surgery, 3rd ed. Philadelphia, Mosby, 2003.)