Asian Cardiovasc Thorac Ann 2008;16:59-61
© 2008 Asia Publishing EXchange Ltd
Surgical Closure of Adult Patent Ductus Arteriosus Using a Pursestring Suture
Hirotaka Inaba, MD,
Kazuhiko Higuchi, MD,
Kenji Koseni, MD,
Hiroshi Osawa, MD,
Osamu Kinoshita, MD
Department of Cardiac Surgery, Asahi General Hospital, Chiba, Japan
For reprint information contact: Hirotaka Inaba, MD, Tel: 81 479 638 111, Fax: 81 479 638 580, Email: hinaba-circ{at}umin.ac.jp, Department of Cardiac Surgery, Asahi General Hospital, I-1326 Asahi-shi, Chiba 289-2511, Japan.
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ABSTRACT
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A 52-year-old woman with patent ductus arteriosus underwent transpulmonary surgical closure through a median sternotomy. The procedure was performed under cardiopulmonary bypass with normothermia and a beating heart, using transductal balloon occlusion and a pursestring suture around the orifice of the ductus. The use of a pursestring suture allowed minimization of the risk of balloon breakage, obviated the need for profound hypothermia and circulatory arrest, and greatly increased the technical facility of the procedure.
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INTRODUCTION
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The management of patent ductus arteriosus (PDA) in an adult may be complicated by a friable aortic wall due to atherosclerotic changes, calcification of the aortic wall and/or peri-ductus area, and a short and wide ductus. Transpulmonary surgical closure of a PDA using cardiopulmonary bypass (CPB) is safe and effective.1–4 We describe the use of a pursestring suture as a technically simpler method of closing the PDA.
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CASE REPORT
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A 52-year-old woman was admitted to our hospital after left ventricular hypertrophy was noted on a routine electrocardiogram performed during an adult health examination sponsored by the city government. On auscultation, a continuous murmur was audible at the left upper sternal border. Transthoracic echocardiography revealed continuous disturbed flow in the pulmonary artery (PA). Aortography showed contrast medium entering the PA from the aorta. Computed tomography (CT) clearly demonstrated the PDA, PA, and aorta (Figure 1A
). The patient referred to us for surgical closure of the PDA. The heart was exposed through a median sternotomy. Cardiopulmonary bypass was established with ascending aortic and bicaval venous cannulation. Systemic normothermia was maintained, and the procedure was performed on the beating heart without cardioplegia. Under total CPB, the main PA was longitudinally opened without reducing CPB flow. A 14F Foley catheter was easily inserted through the PDA because a jet of blood from the aorta indicated its orifice. The jet was interrupted by balloon occlusion and a pursestring suture of pledgeted CV-4 Gore-Tex was made around the orifice of the PDA. The suture was tied outside the PA, with the last stitches of each needle going outside the PA, just after removing the Foley catheter (Figure 2). This resulted in complete cessation of shunt flow. To reinforce the closure, another pledgeted 3/0 Prolene suture was placed so that the orifice of the PDA was between the 2 pledgets. The suture was again tied outside the PA, with each stitch coming from inside the PA and below the orifice, to outside the PA and above the orifice. The PA was closed, and occlusion of the PDA was confirmed by transesophageal echocardiography. The CPB time was 67 min, with no ischemic time. The patient’s postoperative course was uneventful. Computed tomography verified closure of the PDA (Figure 1B), and she was discharged from hospital on the 9th postoperative day.
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Figure 1. Three-dimensional computed tomography: (A) preoperative, clearly showing the spatial relationship between the aorta (AO), the patent ductus arteriosus (PDA), and the pulmonary artery (PA), with no calcification of the PDA; (B) postoperative, showing closure of the ductus with no deformation at the PA. The pledgets can be seen on the PA (arrow).
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Figure 2. The pursestring suture was placed around the orifice of the patent ductus arteriosus (PDA); the last stitches of each needle went outside the pulmonary artery (PA); the suture was tied outside the PA.
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DISCUSSION
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A PDA can be closed using various strategies including transcatheter closure, video-assisted thoracoscopic surgery, and conventional surgery with division and suture.5–7 These procedures are feasible for treatment of PDA in a child, but prove challenging when employed in an adult. The management of PDA in the adult may be complicated by a friable aortic wall due to atherosclerosis, calcification of the aortic wall and/or peri-ductus area, and a short and wide ductus.1–3 Such changes may make adults with PDA poor candidates even for a minimally invasive approach such as transcatheter closure. Furthermore, because PDA is more frequently repaired in childhood, the surgeon’s experience of repair in an adult may be limited.
The optimal procedure for repair of PDA in the adult remains controversial. Transpulmonary surgical closure under CPB is reportedly safe and technically simple in adults, even in those with recurrent PDA.1–4 Toda and colleagues2 reported good long-term outcomes in 9 patients, without recanalization or pseudoaneurysm. In these reports, transductal balloon occlusion was employed to control blood flow originating from the aorta, allowing direct closure of the PDA on a beating heart without cardioplegia. However, some surgeons have warned of a risk of balloon catheter breakage when placing the sutures, particularly in a short and/or wide PDA, and have recommended profound hypothermia and circulatory arrest.3,4
We attempted to simplify the operative procedure. In this patient, the balloon occlusion method was very effective in controlling shunt blood flow, and a pursestring suture, rather than direct closure or patch closure, was used to occlude the PDA. Based on the preoperative CT, placement of the sutures as described allowed sufficient distance between the sutures and the balloon, thereby minimizing the risk of balloon rupture. Furthermore, the pursestring suture allowed placement of sutures without precisely locating the edge of the PDA orifice, and obviated the need for profound hypothermia and circulatory arrest. The PA wall was not stenotic after tying the pursestring suture, and postoperative CT revealed no deformation of the PA. The PA of an adult with PDA is usually dilated, and the orifice of the ductus on the pulmonary side is located at the end of a straight line from the outflow tract of the right ventricle (region of the bifurcation of the PA). Because of these structural features, a relatively large pursestring suture is not expected to induce PA stenosis or disturb blood flow from the outflow of the right ventricle into the right and left PA in adults.
Transpulmonary closure results in a ductus that is still connected to the aorta. Although no recanalization or aneurysmal change was noted in their patients, Toad and colleagues2 emphasized the importance of annual echocardiography for these patients. Long-term follow-up with echocardiography is also indicated in our patient. The balloon occlusion method and the pursestring suture allowed safe and simple closure in this adult case of PDA, via median sternotomy on CPB at normothermia with a beating heart.
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REFERENCES
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ABSTRACT
INTRODUCTION
