Adult Patent Ductus Arteriosus: Successful Surgery With Mitral Valvuloplasty
Kyoko Hobo, MD,
Naoji Hanayama, MD,
Kentaro Umezu, MD,
Naohiro Shimada, MD,
Akihiko Toyama, MD,
Arihumi Takazawa, MD
Department of Cardiovascular Surgery, Ageo Central General Hospital, Saitama, Japan
Naoji Hanayama, MD, Tel: +81 48 773 1111, Fax: +81 48 773 7122, Email: aortic-valve{at}umin.net, Department of Cardiovascular Surgery, Ageo Central General Hospital, Saitama, Japan.
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ABSTRACT
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The development of left ventricular dysfunction is a serious complication of longstanding patent ductus arteriosus. An 80-year-old woman who underwent patent ductus arteriosus ligation 13 years previously developed congestive heart failure and mitral regurgitation. She underwent surgical repair with transpulmonary ductus closure and mitral valve annuloplasty under cardiopulmonary bypass. She made a full recovery with improved left ventricular function.
Key Words: Mitral Valve Insufficiency • Patent Ductus Arteriosus
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INTRODUCTION
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Patent ductus arteriosus (PDA) ligation via a left thoracotomy was developed for children as a relatively less invasive and safe operation, but it is not applicable to adults because of calcification or PDA aneurysmal dilatation. We describe a unique surgical strategy for a patient with history of PDA ligation who presented with congestive heart failure, recurrent PDA, and mitral regurgitation.
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CASE REPORT
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An 80-year-old woman was transferred to our hospital for evaluation of progressive dyspnea due to congestive heart failure. Her history was significant for recurrent congestive heart failure, atrial fibrillation, and PDA ligation 13 years previously at another hospital. On admission, she was noted to have orthopnea with hypercarbia. S1, S2, and S3 heart sounds and a high-pitched early systolic murmur were detected. Chest radiography showed pulmonary edema and cardiomegaly. Echocardiography revealed severe enlargement of the right atrium and ventricle, and a dilated pulmonary artery. Moderate mitral valve regurgitation with mitral annular calcification of the posterior leaflet and significant PDA flow were observed. Catheterization showed a high pulmonary pressure of 51/26 mm Hg. Shunt flow was calculated as 48% and the pulmonary-systemic flow ratio was 1.9. Computed tomography of the thorax with 3-dimensional reconstruction (Figure 1A
) demonstrated a broad flat communication between the anterior aspect of the proximal descending thoracic aorta and the posterior aspect of the left main pulmonary artery, accompanied by significant calcification (Figure 1B). The 2 vessels were fused over a short segment and had no tubular communication. The patient underwent a median sternotomy and peri-cardiotomy with systemic heparinization. Total cardiopulmonary bypass was established with bicaval drainage, and a retrograde coronary sinus cannula was placed. The aorta was crossclamped and cardiac arrest was obtained using antegrade tepid blood cardioplegic solution. After a main pulmonary arteriotomy, a 3F Foley balloon catheter was inserted into the aorta through the ductus to prevent aortic backflow. The internal diameter of the PDA was approximately 5 mm. It was closed with 3 pledgeted 4-0 polypropylene sutures (Figure 2). The pulmonary artery was closed using 5-0 polypropylene suture. Attention was then turned to the mitral valve, and the left atrium was incised. Both leaflets were intact, but the mitral valve annulus was dilated, possibly due to long-term volume overload. A 26-mm Carpentier-Edwards Physio ring (Edwards Lifesciences, Irvine, CA, USA) was implanted. The left atrium was closed and the aortic crossclamp was removed. The patient was weaned from cardiopulmonary bypass. Intraoperative transesophageal echocardiography established no residual mitral regurgitation. She was discharged with no mitral regurgitation nor systolic anterior motion of the anterior leaflet on pre-discharge transthoracic echocardiography. At 1 year postoperatively, she was noted to be doing well.
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Figure 1. (A) Three-dimensional computed tomography of the thorax, showing a broad flat-shaped patent ductus arteriosus (black circle). (B) A plain computed tomography scan showing significant calcification of the ductus (white circle).
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Figure 2. Diagram illustrating the Foley balloon catheter inserted into the aorta through the ductus to prevent aortic backflow.
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DISCUSSION
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The natural history of adult PDA is characterized by a rising annual death rate from heart failure and bacterial endocarditis; over 60% of untreated patients fail to reach 60 years of age.1 Percutaneous PDA occlusion is the standard treatment for this congenital heart disease. Several case reports have described management of PDA with congestive heart failure in the elderly.2 However, surgical management of left ventricular (LV) failure, rather than right ventricular failure, due to high pulmonary pressure has been rarely described. In view of the possibly increasing prevalence of this condition, it is valuable to examine patients with left-sided heart valve involvement and to consider valve reconstruction at the time of shunt closure. To the best of our knowledge, this is the oldest successful case of both surgical repair of adult PDA and mitral annuloplasty under cardiopulmonary bypass.
Progressive LV dilatation leads to mitral regurgitation, which gives rise to more mitral regurgitation and further LV dilatation. Sarris and colleagues3 reported that preservation of the mitral valve apparatus resulted in improved ventricular geometry and clear long-term functional benefits. Badhwar and Bolling4 stated that all morphologic changes, myocardial thinning and dilatation, blunting of the aortomitral angle, widening of the interpapillary distance, increased leaflet tethering, and decreased leaflet-closing forces lead to loss of the zone of coaptation and subsequent central mitral regurgitation. Successful restoration of coaptation area is effective in preventing recurrent mitral regurgitation and improving LV function. As confirmed by postoperative echocardiography in this case, the integrity of the mitral valve was maintained and LV function recovered. This case demonstrates that transpulmonary PDA closure with mitral annuloplasty under cardiopulmonary bypass is safe, and moreover it improves LV function. PDA closure and mitral reconstruction offer a new strategy for adult cases of PDA with congestive heart failure.
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REFERENCES
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- Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968;30:4–13.[Free Full Text]
- John S, Muralidharan S, Jairaj PS, Mani GK, Babuthaman Krishnaswamy S, et al. The adult ductus: review of surgical experience with 131 patients. J Thorac Cardiovasc Surg 1981;82:314–9.[Medline]
- Sarris GE, Cahill PD, Hansen DE, Derby GC, Miller DC. Restoration of left ventricular systolic performance after reattachment of the mitral chordae tendineae. The importance of valvular-ventricular interaction. J Thorac Cardiovasc Surg 1988; 95:969–79.[Abstract]
- Badhwar V, Bolling SF. Mitral valve surgery: when is it appropriate? Congest Heart Fail 2002;8:210–3.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:302-303
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104770
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ABSTRACT
INTRODUCTION
