MeSH
| patent arterial duct |
surgery |
|
| |
|
|
Abstract
Objectives: To present by illustration the surgical options
in neonatal PDA closure with emphasis on clip application.
Methods: Photo/video-documentation of surgical closure of PDA
in a neonate by clip application coupled with free-hand drawings showing
PDA closure by ligation and division. Review of 38 neonates undergoing
surgical PDA closure in our institution between 1998 and 2006.
Results: Overall survival following surgery was 100%. There
was one case of residual PDA and three postoperative complications – 2
cases of pneumothorax and one chylothorax.
Conclusion: The outcome of surgical closure of PDA in neonates
is very good with zero mortality in our series and only few postoperative
complications.
Introduction
Patent ductus arteriosus (PDA) accounts for about 10% of all congenital
heart anomalies.1 Its incidence is highest in premature babies
and twice more frequent in females than in males.2 The clinical
manifestation of PDA depends on the volume of blood shunt through it, which
in turn is determined by the diameter and length of the ductus and the
pulmonary vascular resistance. Untreated PDA can lead to obstructive pulmonary
diseases and heart failure. In pre-term babies initial treatment is usually
pharmacological. Surgical options are considered when the duct fails to
close following treatment with drugs. In older infants treatment options
also include percutaneous closure using coil embolization or by devices.
Video assisted closure (VATS) of PDA - a less invasive alternative to posterolateral
thoracotomy has been used in some centres.3 Here we present
by illustration the surgical closure of PDA in a pre-term baby through
a left lateral thoracotomy.
Surgical approach
The patient is in a lateral position with the left side up
(Fig. 1). Surgical approach is through
a left thoracotomy performed in the third or fourth intercostal space,
as in the case of surgery for isolated coarctation of the aorta.
Figure 1: Patient position (All images are shown from the surgeon’s
view with the patient’s head to the right).
A curved incision is made starting at the anterior axillary line and extending
posteriorly (Fig. 2). The serratus anterior is mostly preserved while the
fourth intercostal space is identified and opened.
Figure 2: Incision
The rib spreader is inserted and opened in stages to avoid rib fractures
(Fig. 3). The lung is retracted anteriorly and the mediastinal pleura opened
over the aorta. Stay sutures may be placed along each side of the pleural
incision.
Figure 3: Left thoracotomy
The ductus is partially mobilised with the aid of a dissector (Fig.
4, 5).
Figure 4: Dissection of the ductus
Figure 5: Anatomy
Surgical techniques
1. PDA closure by clip - single or double
After the ductus has been dissected, a clip of appropriate size is
placed around it and closed by applying gentle pressure on the clip holder
(Fig. 6, 7).
Figure 6: Position of the clip
Figure 7: Position of the clip
Care should be taken to avoid injury to the recurrent laryngeal nerve.
The position of the clip is reviewed before closing the chest (Fig. 8).
Figure 8: Position of the clip
A second clip can be placed to ensure the ductus is completely closed.
The entire procedure is shown on the attached video (Fig. 9).
Figure 9: PDA closure by clip placement captured on video
![]()
2. PDA ligation: The ductus is mobilized; a ligature is passed
around it and gently tied down.
Double ligation technique involving ligatures on the pulmonary and aortic
ends of the ductus has also been widely used (Fig. 10).4,
5 Purse-string sutures may be used in place of simple ligatures.
A metal clip may be placed for additional security.
Figure 10: Ligation
3. Ligation and Division: This method is rarely used for the
closure of isolated PDA. It entails placing two 6/0 prolene purse-string
sutures around the ductus, tying and dividing the ductus as shown in Fig.
11. In coarctation patients a single purse-string suture is used, hence
the aortic end of the ductus is completely excised prior to coarctation
repair.
Figure 11: Ligation and division
Surgical closure of PDA in pre-term babies – our experience
We conducted a retrospective study of 38 pre-term neonates who underwent
surgical PDA closure in our centre between 1998 and 2006. Of these, 24
were females and 14 males. The average age of gestation was 30 weeks (range:
24 – 37 wks), the median birth weight was 1200g (range: 670 – 3580g). The
median age at operation was 34 days (range: 10 – 130days). 66% of patients
weighed less than 1500g at the time of surgery; median weight at operation
was 1430g (range: 730 – 4170g). 84% of all procedures were performed in
the operating room; the remaining cases were done in the neonatal intensive
care unit.
In 71% of cases, PDA closure was achieved by use of single or double
clip. One patient had PDA ligation only, while 10 patients (26%) had both
ligation and clip. The mean time of surgical procedure was 58min ±
20 (27-101).
There was zero mortality in our series and only few procedure-related
complications. 2 patients (5%) had pneumothorax, while one patient (2.6%)
had chylothorax requiring surgical revision. There was only one case of
residual PDA on immediate postoperative echo, which on follow-up examination
was discovered to have spontaneously closed.
Comments
Despite the advance on pharmacological and other less invasive procedures,
surgery still plays a vital role in the treatment of patients with persistent
arterial duct. The surgical procedures are quite straight-forward, postoperative
complications are few with near-zero mortality in recent years.6
Our preferred surgical technique for ductal closure in pre-term neonates
is clip application. A single clip will always suffice, but where in doubt,
the surgeon may place a second clip to achieve complete closure. This method
is relatively simple and entails minimal dissection around the friable
ductal tissue unlike ligation. Hence, it is a safer procedure with very
low risk of ductal tissue tear and consequent life-threatening bleeding.6
References
-
Hillman ND, Mavroudis C, Backer CL. Patent ductus arteriosus. In: Pediatric
Cardiac Surgery. Mavroudis C, Backer CL (editors) Mosby, Philadelphia 2003;
223-233
-
Haas G, Patent ductus arteriosus and aortopulmonary window. In: Glenn’s
thoracic and Cardiovascular Surgery. Baue AE (editor) Appleton and Lange,
Stamford 1996; 1137-1161
-
Villa E, Eynden FV, Le Bret E, Folliguet T, Laborde F. Paediatric video-assisted
thoracoscopic clipping of patent ductus arteriosus: experience in more
than 700 cases. Eur J Cardiothorac Surg 2004; 25:
387-393
-
Brandt B, Marvin WJ, Ehrenhaft JL, # Heintz S, Doty DB. Ligation of patent
ductus arteriosus in premature infants. Ann Thorac Surg 1981; 32:166-72
-
Ghosh PK, Lubliner J, Mogilnar M, Yakirevich V, Vidne BA. Ligation of patent
ductus arteriosus in very low birthweight premature neonates. Thorax
1985; 40:533-537
-
Mandhan PL, Samarakkody U, Brown S, Kukkady A, Maoate K, Blakelock R, Beasley
S. Comparison of suture ligation and clip application for the treatment
of patent ductus arteriosus in preterm neonates. J Thorac Cardiovasc
Surg 2006; 132:672-674
-
Jonas RA. Patent ductus arteriosus, aortopulmonary window, sinus of Valsalva
fistula, aortoventricular tunnel. In: Comprehensive Surgical Management
of Congenital Heart Disease. Arnold, London 2004; 187-206
|
Contact information
|
Matej Nosál
Department of Cardiac Surgery
The Slovak Children’s Heart center
Limbova 1, 833 51 Bratislava
Slovakia.
Tel: +421 (2) 59371327
Fax: +421 (2) 54775766
nosal@dkc-sr.sk
|
(272Kb)
