The work is devoted to improving diagnostic and prognostic assessment of persistent fetal communications in newborns of different gestational age on the basis of complex clinical and paraclinical studies on the diagnostic role of cardiac sounds and development of the screening algorithm of congenital heart disease, patent ductus arteriosus.
The study had the three stages. At the first stage, a diagnostic assessment of the functioning of fetal communications (patent ductus arteriosus) was performed in full-term and late preterm infants without clinical manifestations of cardiac pathology in the early neonatal period in the context of the possibility of differential diagnostics of congenital heart defects and study of the significance of electronic auscultation (E-PCG) as means for early screening diagnostics. To perform this task, the following groups were studied: 114 full-term and late preterm infants (gestational age 35 0/7 - 41 6/7 weeks) with Doppler echocardiographic signs of patent ductus arteriosus (PDA group), 42 full-term and late preterm infants (gestational age 35 0/7 - 41 6/7 weeks) with Doppler echocardiographic signs of congenital heart disease, diagnosed after birth (CHD group), and 167 term and late preterm infants (gestational age 35 0/7 - 41 6/7 weeks) without any signs of the PDA or CHD (control group). Inclusion criteria for these groups: no prenatal diagnosed cardiovascular pathology, no clinical signs of hemodynamic or respiratory disorders or other clinical signs that would require additional examinations, no pathological heart murmurs in the early neonatal period, no pathological abnormalities of pulse oximetry at the age of 24 hours.
At the second stage, the features of phonocardiographic manifestations of the progression of hemodynamic disorders in requiring intensive care preterm infants with PDA were studied, and the diagnostic capabilities of E-PCG were assessed to determine the hemodynamic significance of PDA. To perform this task, 45 preterm infants with patent ductus arteriosus who required intensive care were examined (preterm PDA group).
At the final stage, the algorithm was developed for using E-PCG to diagnose PDA and predict its condition. Newborns with PDA in the maternity hospital were studied.
The following examination methods were used: evaluation of anamnesis data, clinical examination, traditional auscultation, pulse oximetry, echocardiography, electronic heart auscultation with phonocardiogram recording and its computer analysis.
The frequency of detection of hemodynamically significant PDA among premature infants with gestational age 26 0/7 - 34 6/7 weeks was 11.0 % (95.0 % CI 2.79 - 19.43 %), the frequency of the possibility of progression of hemodynamic disorders in this case - up to 48.8 % (95.0 % CI 43.57 - 48.83 %).
E-PCG indicators (both absolute values and ratios) had significant differences (by Kruskal-Wallis criterion) between observation groups (CHD, PDA and control groups), both in terms of age and auscultation point.
At the age of 48-72 hours the indicator s1_width/s2_width (the ratio of the width of the first and second tones) showed significant differences in groups CHD vs control, CHD vs PDA. At all auscultation points the ratio s1_width/s2_width was highest for the CHD group. The maximum level of significance (р < 0,0001) for the fourth auscultation point in the indicator s1_width/s2_width was following for the groups: CHD 0.982 ± 0.077, control 0.654 ± 0.014, PDA 0.685 ± 0.020. That displayed the imbalance in the functioning of the heart valvular apparatus.
The diagnostic significance of electronic heart auscultation with phonocardiogram recording at different degrees of hemodynamic significance of the patent ductus arteriosus in premature infants was studied. By clinical criteria and by DEchoCG it was found that PDA with significant shunting has significantly higher (compared to hemodynamically insignificant PDA) rates of transtricuspid (p <0.05), transpulmonary (p<0.01) blood flow. Differences between hemodynamically insignificant PDA and hemodynamically significant PDA (varying degrees) included a significant increase in s1_energy/m1_energy (the ratio of the energy of the first tone and the total suspended energy in the interval between the second and first tones) of the second auscultation point (analog of the intensity of systolic noise). Increased hemodynamic changes to significant shunting were accompanied by a decrease in s1_a_max/s2_a_max and s1_energy/s2_energy (energy ratios of the first and second tone) in the first and second auscultation points, which may be due to differences in blood shunt volumes and excessive pulmonary circulation. Therefore, E-PCG indicators can be used not only for screening diagnostics, but also for dynamic assessment of hemodynamic status.
Based on the assessment of the clinical significance of
