Asian Cardiovasc Thorac Ann 1998;6:34-36
© 1998 Asia Publishing EXchange Pte Ltd
Surgical Interruption of Patent Ductus Arteriosus in Children
Li Shu Sen, MD,
Xu Si An, MS,
Zheng You Ren, MD,
Zhao Xi Wu, MD
|
Department of Cardiac Surgery The Second Clinical College, China Medical University Shenyang, People's Republic of China
|
|
For reprint information contact: Li Shu Sen, MD Dept. of Cardiac Surgery The Second Clinical College China Medical University Shenyang 110003 People's Republic of China Tel:86 24 389 3501 Ext. 526 Fax:86 24 389 4848
|
 |
ABSTRACT
|
|---|
From January 1981 to September 1996, 447 patients with patent ductus arteriosus (122 male and 325 female) aged from 0.75 to 14 years, underwent surgery in our institute. Systolic blood pressure was maintained below 90 mm Hg with sodium nitroprusside and a vertical incision was made under the left axilla through the third intercostal space. Simple ligation was performed when the ductus was less than 10 mm in diameter. In 313 patients with a patent ductus arteriosus of 10 mm diameter or greater, a Dacron cushion was placed under the ligature. There was no death or evidence of residual patency. We recommend careful control of systolic blood pressure during the whole procedure and the use of a cushion under the ligature when closing a large ductus.
|
INTRODUCTION
|
|---|
Patent ductus arteriosus (PDA) is one of the simplest and most common types of congenital cardiac anomaly. The first successful ligation of a PDA was reported in 1938 by Gross and Hubbard.1 Since then, various methods have been used for interruption of a PDA, such as simple ligation, multiple transfixed ligatures, titanium clip occlusion, suture and division, as well as the more recent transcatheter closure or video-assisted thoracoscopic surgical interruption. We report a retrospective study of 447 sequential PDA surgical closures performed through a vertical incision under the left axilla.
MATERIALS AND METHODS
From January 1981 to September 1996, 447 children underwent surgical interruption of a PDA. These comprised 122 males and 325 females with a mean age of 5.3 years (range 0.75 to 14 years). Symptomatic pulmonary hypertension was present in 52 patients. Transthoracic echocardiography was performed preoperatively and after surgery in all patients. Before 1985, two-dimensional and Doppler echocardiography were used, the color Doppler method has been used since then. With the transducer placed in the parasternal short axis position, the ductus was observed or the characteristic audio and spectral signal or color shunt from the descending aorta to the pulmonary artery was obtained. Associated cardiac anomalies included 5 atrial septal defects, 15 ventricular septal defects, 1 anomalous pulmonary venous connection, 1 case of dextrocardia, and 2 cases each of pulmonary valve stenosis, coarctation of the aorta, and trilogy of Fallot. The clinical profile of these patients is shown in Table 1
.
General anesthesia was carried out with 50 to 100 mg•kg–1 pentothal and 1% to 2% enflurane. After induction of general anesthesia and intubation, the patient was positioned on the right side and a vertical incision was made under the left axilla through the third intercostal space. The length of the incision was 50 to 70 mm. The intercostal space was opened widely with two retractors. When the left lung was retracted forward and downward, the aortic arch, the left subclavian artery, the pulmonary artery, and the vagus and phrenic nerves were visualized. A thrill could be palpated. The aortic sheath was opened by a vertical incision extending from the left subclavian artery to below the ductus. After the aortic sheath was reflected forward, the ductus was dissected. A right-angled dissecting instrument allowed access to the back of the ductus. The effects of occluding the ductus were ascertained by test-clamping with a vascular clamp. Two ligatures of 1/0 plaited silk were passed around the ductus and the aortic end was ligated first. For a ductus of 10 mm in diameter or more, a Dacron cushion was made by rolling a piece of Dacron patch of width 5 to 7 mm and length 10 to 40 mm. This was placed around the ductus before tightening the ligature. During this procedure systolic blood pressure was maintained below 90 mm Hg with the use of sodium nitroprusside in doses ranging from 3 to 10 µg•kg–1•min–1.
After surgery the patients were extubated when indicated and kept in the intensive care unit for at least 24 hours. Most patients were followed up at 6 months postoperatively by physical, radiographic, and echocardiographic studies and a group of 268 patients volunteered for long-term follow-up between 1 and 10 years.
|
RESULTS
|
|---|
Of the 447 patients, 313 had a PDA greater than 10 mm in diameter that was ligated using a Dacron cushion. There was no mortality or residual patency in any of the patients. The mean operating time was 48.4 minutes (range 30 to 78 minutes). The mean hospital stay was 18.2 days (range 12 to 42 days). There were postoperative complications in 7 patients (1.6%). One patient had bleeding from an intercostal vessel and required reoperation for control, 3 had transient recurrent laryngeal nerve dysfunction that resolved within 7 days in all cases, and 3 had episodes of chylothorax. In one of the patients with chylothorax, the chest duct was ligated through a right thoracotomy. The results are summarized in Table 2.
|
DISCUSSION
|
|---|
Isolated PDA is the second most common congenital cardiac anomaly, accounting for 12% of the total and detected in 1 out of 2500 to 5000 infants.2,3 Spontaneous closure is usual within 15 hours of birth but is rare after the third month. It is generally accepted that surgical closure should be performed between the ages of 2 and 5 years. Surgical closure of a PDA is now well standardized and provides excellent results with low mortality and morbidity.4–9 The original method of ligation has been used and developed for more than half a century and provides a simple and effective method of interrupting a PDA.1 A left axillary vertical incision has been used for over 40 years.10 Wada and colleagues11 divided 118 cases of PDA through this incision and all has a satisfactory outcome. Ligation of the PDA was successful in all 447 cases in this series using the left axillary vertical incision with or without the use of a Dacron cushion. There were 7 patients with postoperative complications, of whom 2 required reoperation.
Our experience with this technique has been favorable and we recommend the use of a Dacron cushion because more force can be applied to the ductus with less risk of complications such as bleeding, false aneurysm, and residual shunt. We also found the results after the left axillary vertical incision to be cosmetically acceptable, there was less tissue injury and the function of the left upper limb was less affected compared with a posterolateral thoracotomy. In addition, this technique is less time consuming than a thoracotomy.
|
REFERENCES
|
|---|
-
Gross RE, Hubbard JP. Surgical ligation of a patent ductus arteriosus: report of first successful case. JAMA
1939;112:729–31.[Abstract/Free Full Text]
-
Jackson JW. Patent ductus arteriosus. In: Wisheart JD, editor. Operative surgery: cardiothoracic surgery. 3rd ed. Boston: Whitefriars, 1978:37–42.
-
Wang ZW. Patent ductus arteriosus. In: Operative surgery: cardiac surgery. Beijing: People's Army Medical Press, 1995:213.
-
Taylor RL, Grover FL, Harman PK, et al. Operative closure of patent ductus arteriosus in premature infants in the neonatal intensive care unit. Am J Surg
1986;152:704–8.[Medline]
-
Palder SB, Schwartz MZ, Tyson KR, Marr CC. Management of patent ductus arteriosus: a comparison of operative versus pharmacologic treatment. J Pediatr Surg
1987;22:1171–4.[Medline]
-
Dasnahapatra BS, Pollock JC. Surgical closure of persistent ductus arteriosus in infants before 30 weeks gestation. J Cardiovasc Surg
1986;27:675–8.[Medline]
-
Eggert LD, Jung AJ, McGough EC, Ruttenburg HD. Surgical treatment of patent ductus arteriosus in preterm infants: four-year experience with ligation in the newborn intensive care unit. Pediatr Cardiol
1982;2:1508.
-
Coster DD, Gorton MF, Grooters RK, et al. Surgical closure of the patent ductus arteriosus in the neonatal intensive care unit. Ann Thorac Surg
1989;48:386–9.[Abstract]
-
Miles RH, Delcon SY, Muraskas, et al. Safety of patent ductus arteriosus closure in premature infants without thoracotomy. Am Thorac Surg
1995;59:668–7.[Abstract/Free Full Text]
-
Stark J, deLeval M. Surgery for congenital heart defect. New York: Grune & Stratton, 1983:170.
-
Wada J, Ajiki H, Kitamo I. Left axillary incision for PDA division. Ann Thorac Surg
1978;26:180–91.
TOP
ABSTRACT
INTRODUCTION
