sexta-feira, 10 de dezembro de 2010

PCA diagnosticado = PCA tratado? by Gildo Oliveira

Dr. Gildo encaminha o seguinte caso:
Paciente feminina, 8 anos de idade, nascido de parto prematuro, assintomática. Comparece ambulatorialmente para realização de ecocardiograma transtorácico. Familiar refere já ter realizado vários exames previamente



Indications for PDA closure:

We recommend PDA closure for patients with a significant left-to-right shunt who are symptomatic, have evidence of left cardiac overload (ie, left atrial or ventricular enlargement), or have mild to moderate pulmonary arterial hypertension (PAH) (Grade 1B).
We recommend PDA closure for patients with a previous episode of endocarditis regardless of the size of PDA in the absence of severe PAH (Grade 1C).
We suggest closure of small but audible PDAs even in the absence of a significant left-to-right shunt, because we believe the long-term benefit of closure (eg, prevention of endocarditis) outweighs the risk of intervention, especially in infants and children (Grade 2C). An alternative approach is to defer PDA closure and routinely follow patients.
The management of silent PDAs (no audible murmur) is controversial. In our institution, the decision for PDA closure is made on an individual basis, primarily based upon physician and patient/family preference.
We suggest observation rather than closure of PDAs in patients with severe PAH and/or right-to-left shunt (Grade 2C). These patients have or are likely to develop Eisenmenger syndrome (PAH, right-to-left shunting, and cyanosis) and may need the shunt to maintain cardiac output.


Treatment — Interventions for ductal closure include pharmacologic therapy, which is used exclusively in premature infants, percutaneous catheter occlusion, and surgical ligation. Once the decision is made for PDA closure, the age and size of the patient, and the availability of experienced clinicians to perform the procedure dictate the choice of intervention.

In premature infants, we recommend inhibitors of prostaglandin synthesis, such as indomethacin and ibuprofen, as initial treatment for PDA closure (Grade 1B).
Term and older infants (below 6 kg in weight) who have symptomatic PDAs, are medically treated (ie, lasix and/or digoxin) until they are large enough to safely undergo percutaneous PDA occlusion. If the patient fails medical therapy or the PDA is not suitable for device closure, surgical ligation is indicated.
In children with indications for PDA closure, we suggest percutaneous PDA closure, which should be performed in centers with experienced pediatric interventional cardiologists (Grade 2B). Surgical ligation is a reasonable alternative option if these services are not available.
In adolescents and adults, we recommend percutaneous PDA closure be performed by experienced pediatric interventional cardiologists (Grade 1B).

In patients who undergo percutaneous PDA closure , the choice of occluders (coil versus device) is dependent upon the ductal morphology and size, and the size of the patient.
Prophylactic antibiotics are only indicated for six months after percutaneous PDA closure.

Fonte: Up To Date 2010

Um comentário:

  1. Olá Fábio,
    obrigada pela visita ao "A Arte da Medicina" e fique a vontade para postar aqui o conteúdo do blog. Fico feliz que queiras colocar um link do meu blog aqui, será um prazer!
    Parabéns pelo "Ecobahia". Grande abraço! http://medicineisart.blogspot.com/

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