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X Congreso Interamericano
de Pediatría
Colegio de Pediatría de Nuevo León
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Conducto Arterioso en el
Recién NacidoCuando cerrarlo, cuando no tocarlo
Colegio de Pediatría de
Nuevo León
2009
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Desarrollo de la Cardiología Pedíatrica
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
AnatomopatologíaClínica-Fisiología
CirugíaInfantil Desarrollo
AnatomíaPatología
Diagnóstico
FisiologíaFisiopatología
Fisiología Fetal
Cardiología Fetal
Clínica
Sobrevida Infantil20 50% 80%
RX
RaskindCateterismo
ValvuloplastíaECG
Marcapasos
Ablación
CirugíaFístula B-T
Corazón abierto
Corazón cerrado
Fontan
Cirugía Infantil
EcocardiogramaDoppler
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La Circulación fetal
1
2
3
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Comunicaciones
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Cambios al nacer
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Etapa Fetal
Conducto Arterioso
Vía de escape y distribución del VD
Cierre prematuro
Insuficiencia Cardiaca
Hipertensión Pulmonar
Por medicación
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Vena umbilical a la porta
El ductus venoso no
drena al higado, va a las
suprahepáticas
Una pequeña cantidad de
sangre va por la vena
umbilical al hígado.
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Foramen ovale Cierra al final del primer año. 20% permeable
Ductus arteriousus Cierra al nacer, ocluido al mes, ligamento a los 3/12
Ductus venosus Ligamentum venosum
Arterias umbilicales Ligamentos medioumbilicales
Vena umbilical Ligamento Teres
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Circulación Neonatal
1. Termino de la circulación
UMBÍLICO-PLACENTARIA
2. Termina la Circulacion Fetal y
se separan las dos circulacionesCierre del foramen
ovalCierre del
conducto arterioso
3. Aumento de la Circulación
Pulmonar
Disminuye la resistencia pulmonar a las
24 horas de vida es 50% menor que la
presión aórtica y el flujo pulmonar
aumenta de 4 a 10 veces más que en el
feto.
La sección provoca un aumento de la
resistencia vascular sistémica con
aumento de la presión aórtica a
mayores niveles que la presión de la
arteria pulmonar.
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Conducto Arterioso
Permeable
Persistente
Dependiente
Hasta el mes
Después del mes
Necesario para la sobrevida
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Recién Nacido
Cierre (horas-días)
Constricción mediada por hipoxia
Disrupción de la capa elástica
Proliferación de las células musculares lisas
Formación de montículos
Obstrucción al flujo y cierre
Prematuro
Síndrome de Insuficiencia Respiratoria
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Anomalías Congénitas
Fallecimientos
20% entre la semana 20 y 1 año de edad
1/3 de ellos son por Cardiopatías
Nacidos
5/1000 y el 50% requiere atención en el primer año
de vida, algunos la primer semana
Imágenes por Eco
Desde la 11-13 semanas
Optimo 18-22 semanas
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Eco Fetal
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Tamaño del Corazón
Corazón fetal
20 semanas
Frecuencia
120-160/min
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Indicaciones
Antecedente de Malformaciones
Maternas
Edad
Cardiopatía
Infecciones
Diabetes
Medicamentos
LES
Alcoholismo
Colagenopatía
Embarazo anormalCrecimiento fetal
Fluido
Arritmias
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Utilidad del Ultrasonido
A las 13 semanas
4 Cámaras
98%.
A. pulmonar y Aorta
Diagnóstico integral
Incluye complejos
Orina fetal hasta la
semana 16
Translucencía nucal
Cabeza
Cuello
Cara
Tórax
Corazón
Abdomen
Pared abdominal
Columna
Extremidades
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Circulación Fetal
21% Corazón
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El Ductus Venoso
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4 Cámaras
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Defecto de la tabicación A-V
Síndrome de Down
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4Cámaras
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Insuficiencia Cardiaca
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Datos de interés
Las emergencias neonatales
habitualmente se relacionan
con cardiopatías dependientes
de conducto
En niños la emergencia es por
la auscultación de un soplo
En adolescentes la
emergencia es por arritmias o
insuficiencia cardiaca
En estos casos no
tocar. Saturación fetal
hasta 40%.
Cianótico, tranquilo
no lo toques (No
administrar O2)
Es imperativo
mantenerlo
permeable
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En la cuna
Hipoxemia si
Acidosis No
Estable
Sin trastorno
respiratorio
Evaluarlo
Choque y aumento
cianosis y
desaturación
Cardiopatía grave
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Tener en cuenta
Saturaciones
variantes
Apnea con PGE1
Hipotensión
Perfusión pobre y
acidosis
Las prostaglandinas son
tus amigas … por ahora
Oxigeno es tu
amigo…con cuidado
Dopamina siempre amiga
Volumen es siempre
caprichoso
Acidosis el eterno
enemigo
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Es bueno saber
Edad gestacional
Dismorfias
Apgar
Pulsos
Gasometría
Tamaño del corazón
Ritmo cardiaco
PGE1 casi siempre
Apneico, intubarlo
Hipoperfusión e
hipotensión usar
Dopamina.
Acidosis
CORREGIRLA.
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Perinatal
Problemas periparto Sin problemas
Caos súbito en la cuna
PO2 no sube mas de 30
mm Hg
CARDIOPATIA CONGENITA
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Conducto Dependiente
La única vía por la
cual llega sangre a la
circulación pulmonar
o a la sistémica es
por el conducto.
Si este cierra el
paciente muere.
Transposición de las
grandes arterias
Corazón izquierdo
hipoplásico
Coartación de la aorta
Atresia tricuspidea
Atresia pulmonar
Tetralogía de Fallot
Interrupción del arco
aórtico
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PCA. Persistencia del Conducto Arterioso
La mas frecuente
Detención de
crecimiento y
desarrollo
Flujo pulmonar
aumentado
Riesgo de endarteritis
Cierre del defecto
Cirugía
Cateterismo
Intervencionista
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Niños
Pediatra Cardiólogo
Neonatólogo
Manejo Médico
Atención del partoNivel 2
Nivel 1
Etapa fetal
Recién nacido
Antecedentes
RECIEN NACIDOCON
CARDIOPATIAGRAVE
Valoración
Tratamiento médico
Tratamiento
Nivel 3
Control
Salud Mental
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Trabajo en Grupo
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Insuficiencia Cardiaca
Atresia Pulmonar sin CIV
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Trastornos del ritmo
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Tumores
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Tumores
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Bradicardia Fetal
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Recomendaciones al detectar
Asociados 20-25%
Trisomía
>Grosor nucal
Cara plana
Ausencia de
calcificación nasal
Deleción 22q11.2
Tronco-conal
Grupo
Discusión
Consejo
Apoyo al y para nacer
Manejo temprano
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Desarrollo de la Cardiología Pedíatrica
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
AnatomopatologíaClínica-Fisiología
CirugíaInfantil Desarrollo
AnatomíaPatología
FisiologíaFisiopatología
Fisiología Fetal
Cardiología Fetal
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Ecocardiografía
4C
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Desarrollo de la Cardiología Pedíatrica
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
AnatomopatologíaClínica-Fisiología
CirugíaInfantil Desarrollo
Diagnóstico RX
RaskindCateterismo
ValvuloplastíaECG
Marcapasos
Ablación
EcocardiogramaDoppler
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Desarrollo de la Cardiología Pedíatrica
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
AnatomopatologíaClínica-Fisiología
CirugíaInfantil Desarrollo
Clínica
Sobrevida Infantil20 50% 80%
CirugíaFístula B-T
Corazón abierto
Corazón cerrado
Fontan
Cirugía Infantil
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Tetralogía de Fallot
Ventriculo Derecho
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Ecocariografìa
4 Camaras
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La cirugía
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Alternativas
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Cirugía Paliativa
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Cirugía Paliativa
Blalock – Taussig Clásico y Modificado
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Prueba de Inclinación
0
20
40
60
0 2 4 6 8 10 12 14 16 18 20
Fallot Normal
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Prueba de Inclinación
0
20
40
60
80
100
120
140
160
180
2 4 6 8 10 12 14
|
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Prueba de Inclinación
0
5
10
15
20
25
30
35
40
45
50
0 2 4 6 8 10 12 14 16 18 20
Post
Pre
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Arritmias. Adulto con T de Fallot
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Adulto
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Intervencionismo
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Figure 21.1
Figure 21.1 A Comparison of a
Typical Artery and a Typical Vein
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Fig.21.01a-c
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Figure 21.7
Blood in the Cardiovascular
System
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Figure 21.2
Figure 21.2 Histological Structure
of Blood Vessels
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Figure 21.4 Capillary Structure
Figure 21.4
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Figure 21.5 The Organization of a Capillary Bed
Figure 21.5a, b
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Fig.21.03
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Figure 21.8
Figure 21.8 An Overview of
Cardiovascular Physiology
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Figure 21.9
Vessel Diameter, Cross-sectional
Area, Blood Pressure, and Blood
Viscosity
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Timing of Delivery in IUGR:
The Role of Ductus Venosus Doppler.
Raphi Pollack, MDCM, FRCSC, FACOG,
Bikur Cholim Hospital,
Jerusalem, Israel
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Outline
IUGR:
Significance
Pathophysiology
Management dilemma: when to deliver?? Too early iatrogenic prematurity
Too late perinatal asphyxia / IUFD
Just right.
Ductus venosus waveform analysis:
Rationale
Performance.
What is the appropriate delivery trigger?
CNS assessment
CV assessment
Conclusions.
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IUGR: Morbidity & Mortality
Manning FA 1995
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Outcome vs. GA in IUGR
Baschat O&G, 2007
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Mammalian Dive Reflex
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Redistribution During Fetal Hypoxemia
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GRIT Design
RCT in 69 centers in 13 countries.
587 babies studied.
GA 24-36 wks.
Is immediate delivery indicated?
Is delay deleterious?
Outcome PNM and morbidity.
GRIT, BJOG, 2003
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GRIT: Morbidity & Mortality
0.7
3
7.7
4.1
7
4
0
1
2
3
4
5
6
7
8
%
SB ND Disability
Immediate Delayed
Lancet, 2004
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GRIT: PNM
84.4
72.2
0
20
40
60
80
100
PNM (/1000)
immediate delayed
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The Fetal Circulation
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Ductus Venosus Flow
Modulated by:
DV diameter
Portal venous resistance
Increased Hct increased DV shunt.
Humoral factors: PGs
NO
Adrenergic stimulus
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Ductus Venosus Flow Waveform
Hecher, Circulation, 1995
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Copyright ©1995 American Heart Association
Hecher, K. et al. Circulation 1995;91:129-138
Flow velocity waveforms of the ductus venosus with low pulsatility (top) and high pulsatility (bottom), which is caused by a decrease of early diastolic forward flow (D) and
in particular by very low velocities during atrial contraction
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Pathologic Venous Doppler
Late sign of CV decompensation
Reflects decreased ability to handle venous return.
Increase in RAP causes a-wave.
Accentuated A-wave may be: Transmitted to DV.
Transmitted to UV.
Precedes FHR decels, IUFD.
Present in 79/211 (37%) of preterm IUGR.
Highly predictive of pH<7.2 (LR=4.2)
Baschat, O&G, 2007
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Survival in Preterm IUGR:
Normal vs. Abnormal DV Doppler
Baschat O&G, 2007
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DV Doppler : Prediction of Adverse
Neonatal Outcome
Bilardo, Ultr O&G, 2004
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Delivery Trigger in IUGR
Baschat, Ultr O&G, 2001
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Should Abnormal DV Trigger
Delivery?
Does presages fetal deterioration? Yes
Does it lead time vs. BPP testing? By 3 days
Does this improve perinatal outcome? No data from RCTs available.
Is DV doppler readily accessible? No
Is it cost effective vs. BPP testing?
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TRUFFLE Study
Trial of umbilical & fetal flow in Europe
Study of CTG vs. DV as delivery trigger
CTG vs. Early changes vs. Late changes.
Objective: 562 pts. to be recruited
Recruited 04/07: 200 pts
Completion & publication ???
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Conclusions
DV doppler velocimetry Window on fetal CV homeostasis.
May be used as a trigger for delivery of IUGR fetus.
Useful > 29wks. in minority (37%) of cases.
“too little, too late” ??
“a test in search of a purpose”.
No evidence that its’ use improves outcome.
Await TRUFFLE study results.
Ghidini, O&G,2007
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Fetal Circulation
By the third month of development, all
major blood vessels are present and
functioning.
Fetus must have blood flow to placenta.
Resistance to blood flow is high in lungs.
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Umbilical Circulation Pair of umbilical
arteries carry
deoxygenated
blood & wastes to
placenta.
Umbilical vein
carries
oxygenated blood
and nutrients from
the placenta.
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The Placenta
Facilitates gas and
nutrient exchange
between maternal
and fetal blood.
The blood itself does
not mix.
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foramen ovale Blood is shunted from
right atrium to left
atrium, skipping the
lungs.
More than one-third of
blood takes this route.
Is a valve with two
flaps that prevent
back-flow.
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ductus arteriousus
The blood pumped
from the right
ventricle enters the
pulmonary trunk.
Most of this blood is
shunted into the aortic
arch through the
ductus arteriousus.
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What happens at birth? The change from fetal to postnatal circulation
happens very quickly.
Changes are initiated by baby’s first breath.
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Problem with persistence
of fetal circulation
Patent (open) ductus arteriosus and patent foramen ovale each characterize about 8% of congenital heart defects.
Both cause a mixing of oxygen-rich and oxygen-poor blood; blood reaching tissues not fully oxygenated. Can cause cyanosis.
Surgical correction now available, ideally completed around age two.
Many of these defects go undetected until child is at least school age.