Saturation With Oxygen for Ductal Dependent Congenital Heart Diseases Before and After the Prostaglandin Therapy

Ductal dependent congenital heart diseases represent -  of all congenital heart diseases. A primary goal of the treatment of these diseases is to retain ductus open until the fi nal cardiosurgical treatment. Prostaglandins are presently the only medicaments, which have a capability to keep ductus open. By means of a retrospective study in a period from January,  until December,  at the Paediatric clinic of the Clinical centre of the University in Sarajevo,  patients (treated with prostaglandins) diagnosed with ductal dependent congenital heart diseases were analyzed. In our sample, there are / male patients (. ), / (.) were full-term newborns, while / (. ) were eutrophic at birth. An average saturation increase, after the prostaglandin therapy, measured in blood from the capillaries is , and measured transcutanlly is  units. Duration of prostaglandin therapy in our study was on average . days. Th e most common cause of death was insuffi cientia cardiorespiratoria ( out of ), but sepsis/infection ( out of ) and insuffi cientia renalis were also common. .  ( out of ) patients died partly because of the complexity of these diseases, but also because a cardiosurgical treatment is delayed. A goal of this study is evaluation of saturation with oxygen before and after the prostaglandin therapy.

SENKA DINAREVIĆ ET AL.: SATURATION WITH OXYGEN FOR DUCTAL DEPENDENT CONGENITAL HEART DISEASES BEFORE AND AFTER THE PROSTAGLANDIN THERAPY

Introduction
Congenital cardiac diseases have an incidence of .  () and ductal dependent congenital heart diseases are represented with -  ().Ductus arteriosus in a foetal period exists as a large vascular structure, with a diameter equal to lung truncus and descending aorta.About -  of foetus systemic circulation fl ows from the right to the left side of circulation through ductus.Lung resistance decreases with a first breath intake, ductus constriction starts and it is functionally closed - hours after the birth.Structural closure of ductus usually ends between the  th and the .day ().Newborns with ductal dependent congenital heart diseases can be symptomatic until the moment ductus closes, so a number of children are sent home as healthy.Decrease of blood flow through ductus causes dangerous hypoxia or cardiogenic shock, metabolic acidosis, multisystemic failure and death.Ductal dependent congenital heart diseases consist of the following congenital heart disease groups:

Patients and Methods
During the period from January,  until December, ,  patients who were treated with prostaglandins at the Paediatric clinic of the Clinical centre of the University in Sarajevo, neonatology unit, with ducal dependent congenital heart diseases have been analyzed by a retrospective study.A source of information were patient records (disease histories) and computer information bases.Diagnosis for heart disease in all cases was obtained with an echocardiography, after the history, physical fi ndings, ECG, lung and heart X-rays, and a complete blood analysis with the acidobasic status (ABS).Th e group was analyzed according to sex, birth weight, weeks of gestation, time duration of prostaglandin therapy, fi nal outcome and a death cause.All the patients received Alprostadil (prostaglandin E) intravenously in a continuous infusion.Saturation with oxygen before and after the prostaglandin therapy was recorded transcutanly and from capillary blood.

Results
A total of  patients formed this study.Males were presented with  (/) which has been shown in Table .
Out of a total number of newborns with ductal depen- full-term premature dent congenital heart diseases -.  (/) were euthropic (Graph ).Considering that oxygen exchange until birth is conducted through mother's placenta (as most important role), it is not a surprise that all the patients were well developed for their age at birth.An average increase of saturation after the prostaglandin therapy followed via gases analyses of capillary blood was  units, ranging from  to  (Table ).From the same Table it is visible that increase of transcutan saturation was  units, ranging from  to  units as well as an average maintenance dose of prostaglandins: . mcg/kg/BW/min (from . to .).Table  represents data on an average duration of prostaglandin therapy was . days ranging from  to  days.Out of  patients,  of them died (.), and the three who survived were transferred to the cardiosurgical centres outside of Bosnia and Herzegovina.In Table : causes of death: four patients (. ) died due to cardiac insufficiency, three died due to systemic infection and three because of renal insufficiency.In one newborn cause of death was massive intracranial haemorrhage.

Discussion
Usage of prostaglandins goes back to the 's.The Nobel prize for a research on prostaglandins in  won Von Euler, and in  Suneu K. Bergstrom, John R.Vane.Th e drug Alprostadil -prostaglandin E is in use in neonatal cardiology, but also Dinoprost -prostaglandin E.All the patients in our study received Alprostadil by infusion.However, use of prostaglandin E is recommended by Silove, because he found that they have fewer side-eff ects ().Unwanted eff ects are in a close correlation with a dose.Th e most common complications are apnoea, febrile states and infection.Silove recommends . mcg/kg/BW/min, while larger doses are given for a few hours at the beginning.An average maintenance dose in our study is . mcg/kg/BW/min.Prostaglandins directly eff ect smooth muscles of ductus arteriosus and dilate it.Th ey cause vasodilatation of all the arterioles.Th ey inhibit aggregation of platelets.A maximum effect of the drug occurs after  minutes from the start of infusion for cyanotic, and after a few hours for the obstructive lesions.Th ey have to be given before ductus closes completely, because this drug cannot open it.An eff ectiveness of the drug depends on the starting values of pO; the more serious hypoxia is, the more pO increases.Th us, we can say that age of a child and starting values of pO have a key role in effectiveness of the drug.A way of drug intake (venous or arterial), sex or pCO do not aff ect the drug eff ectiveness (,,).In our study,   (/) of the children started the prostaglandin therapy on the fi rst day of life.An average increase of saturation measured in capillary blood was  units, ranging from  to  units.An average increase of saturation measured transcutanly was  units, ranging from  to .Prostaglandins are given for a relatively short period of time, a few hours to a few days, longest for a month.During that time, a child is cardiosurgically cared for.If a duration of the therapy is prolonged, side-eff ects are more common and more serious, and ductus becomes very brittle, so that during a surgical intervention it can potentially burst (,,).In our study, .  (/) of the patients died./ had a complex congenital heart disease, (Transposition of Great Arteries -TGA), which needs to be corrected within the fi rst - weeks after the birth, and that is currently not available in Sarajevo, because the cardiosurgical treatment of paediatric patients is done - times a year during the visits of the cardiosurgeons from Vienna.Th e local team has not yet been trained for surgical interventions of complex congenital heart diseases.High mortality is a consequence of a discontinued cardiosurgical treatment, prolonged prostaglandin therapy, as well as a long duration of mechanical ventilation with infections.

Conclusion
This randomized, clinically selected study confirms a justifi cation for the use of prostaglandins in neonatal cardiology, and their useful effect.However, in order to increase a survival rate and life quality of these patients, it is necessary to improve and to establish a proper paediatric cardiosurgery in Bosnia and Herzegovina.Cardiosurgery in Bosnia has been improved during the past four years, which can be seen in a total number ( patients) and outcomes (figures in co-relation with European centres) of the treated patients by the local team and the cardiosurgeons from Austria.However, improvement concerns primarily a continuos prostaglandin supply, education in the foetal echocardiology (which would signifi cantly decrease a number of complex congenital heart diseases) and a paediatric cardiosurgery, so that the patients with congenital heart diseases can have an adequate treatment on time.
AL.: SATURATION WITH OXYGEN FOR DUCTAL DEPENDENT CONGENITAL HEART DISEASES BEFORE AND AFTER THE PROSTAGLANDIN THERAPY SENKA DINAREVIĆ ET AL.: SATURATION WITH OXYGEN FOR DUCTAL DEPENDENT CONGENITAL HEART DISEASES BEFORE AND AFTER THE PROSTAGLANDIN THERAPY

Ductal dependent congenital heart diseases with- out an adequate blood mixing: transposition
A. Ductal dependent pulmonary circulation: pulmonary atresia with intact intraventricular septum, tetralogia Fallot (more serious forms), tricuspid atresia, univentricular heart with critical stenosis or with pulmonary artery atresia;B.Ductal dependent systemic circulation: hypoplastic left heart syndrome, critical aortic side-effects are numerous, and some of them are: apnoea, convulsions, vasodilatation, arrhythmia, hypotension, fever, infection, hypoglycaemia, hypocalcaemia, bleeding, thrombocytopenia and diarrhoea(,).