Asian Cardiovasc Thorac Ann 2001;9:275-278
© 2001 Asia Publishing EXchange Pte Ltd
Video-Assisted Thoracoscopic Surgical Closure of Patent Ductus Arteriosus: 300 Cases
Mohammad Hassan Nezafati, MD,
Seyed Hassan Hashemian, MD1,
Eftekhar Mahmoodi, MD2,
Ali Hamedanchi, MD1
Department of Cardiovascular Surgery
2 Department of Pediatric Cardiology Ghaem Hospital Medical Center Mashhad University of Medical Sciences Mashhad, Iran
1 Department of Cardiology Imam Reza Hospital Medical Center Mashhad University of Medical Sciences Mashhad, Iran
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For reprint information contact: Mohammad Hassan Nezafati, MD Tel: 98 511 842 9735 Fax: 98 511 843 9595 email: nezafati{at}mums.ac.ir Department of Cardiovascular Surgery, Ghaem Hospital Medical Center, Mashhad University of Medical Sciences, Ahmad-Abad AV, P.O. Box 155, Mashhad 91735, Iran.
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ABSTRACT
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From June 1997 to October 2000, 300 consecutive patients (mean age, 6 years) with patent ductus arteriosus recognized by echocardiography and/or cardiac catheterization underwent video-assisted thoracoscopic surgery. Under general anesthesia, three 5-mm holes were made in the left thoracic wall. A video camera and specialized surgical devices were introduced. The ductus was dissected and 2 titanium clips were applied for complete closure of the ductus. Exclusion criteria were: diameter of the ductus > 9 mm; complicated patent ductus arteriosus (aneurysm formation, endocarditis, or calcification); and pleural adhesion or a previous left-sided thoracic operation. All cases were reassessed immediately after the procedure, and followed up by echocardiography. No residual shunt was recorded. The procedure was changed to a thoracotomy in 3 adults due to inappropriately dilated canal (> 9 mm); 2 others developed transient recurrent laryngeal nerve dysfunction. Mean procedure time was 20 ± 2 minutes. All patients were discharged shortly after the procedure (at approximately 20 hours). The results indicate that video-assisted thoracoscopic surgery was superior to other techniques of ductal closure.
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INTRODUCTION
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Surgical interruption of a patent ductus arteriosus (PDA) using a left posterolateral thoracotomy was the only available technique until 1971 when Porstmann and colleagues1 described nonsurgical PDA closure by a catheter-delivered device. In 1979, Rashkind and colleagues2 developed a smaller device for the transcatheter approach. In 1981, their device was introduced into clinical trials, but this technique is not performed in infants weighing less than 7 or 8 kg.3,4 In 1993, Laborde and colleagues5 in Paris described video-assisted thoracoscopic surgery (VATS) for PDA closure in 39 infants and children. VATS is a rapidly progressing new field of minimally invasive surgery, and since then, Laborde has performed it in over 500 cases.6,7 Since June 1997, the VATS technique for PDA closure has been carried out at Mashhad University of Medical Sciences, which is the referral center for PDA closure by this procedure in Iran. The aim of this study was to assess the safety and efficacy of the technique.
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PATIENTS AND METHODS
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From June 1997 to October 2000, 300 consecutive patients with PDA recognized by color Doppler and 2-dimensional echo and/or catheterization, who presented for PDA closure by the VATS technique, were enrolled in this study. Exclusion criteria for a VATS procedure were: diameter of the ductus > 9 mm; complicated PDA such as true ductal aneurysm, endocarditis, or calcification; and pleural adhesion or a left-sided thoracic operation in the past.
Specialized surgical instruments necessary for the VATS technique included an electrocautery hook, titanium clips (Ligaclip LT 400; Ethicon Endosurgery, Inc., Cincinnati, OH, USA) and a clip applier, lung retractor, trocar, suction device, and a videoscope (Karl Storz Endoskope GmbH & Co., Tuttlingen, Germany). Management of general anesthesia included insertion of a large intravenous catheter, 3-lead electrocardiographic monitoring, and pulse oximetry preinduction. Anesthesia was induced with thiopental 5 to 7 mg•kg-1, atracurium 0.5 mg•kg-1, and fentanyl 5 µg•kg-1. For better surgical vision, single-lung ventilation was established by selective right bronchial intubation with a Murphy-eye tracheal tube. To reduce bronchial damage, a tracheal tube of half the size expected for the age was selected. Arterial oxygenation and end-tidal CO2 were monitored with a pulse oximeter (North American Dräger, Telford, PA, USA) and a capnograph (Capnostat; GE Medical Systems, Milwaukee, WI, USA). Oxygen saturation was maintained above 92% with a fraction of inspired oxygen of 100%, and in difficult cases in which oxygen saturation dropped below 90%, positive endexpiratory pressure (2.5 to 5 cm H2O) was added. Blood pressure was controlled and monitored through a 20F catheter inserted into the right radial artery. General anesthesia was maintained with halothane 0.5% v/v in O2 100% without nitrous oxide.
All patients were positioned on their right sides as for the classic posterolateral thoracotomy approach. Three 5-mm holes were made in the left hemithorax. The first incision was made in the 3rd intercostal space on the left axillary line, for the videoscope (4 mm). The next hole was made in the 3rd intercostal space in the midaxillary line for the introduction of 2 right-angled hooks for lung retraction. The last hole was made in the 4th intercostal space beneath the angle of the scapula, for insertion of the clip applier and electrocautery hook. The surgical field was viewed on a video screen, and after identification of the PDA, the posterior pleura was opened, the ductus was dissected free from surrounding tissues, as was the aorta at its junction with the ductus. The pericardium was also dissected on the pulmonary side to protect the easily identifiable recurrent laryngeal nerve from injury. It should be stressed that both sides of the ductus were dissected for appropriate placement of clips. A titanium clip was fixed at the junction of the aorta and the PDA, and another on the pulmonary side. After visual confirmation that both clips were well in place, the trocars were removed. A small pleural catheter was placed, and the lung was expanded. After closure of the access ports, the pleural catheter was removed. Immediately after extubation, the vocal cords were directly evaluated by an anesthesiologist. A chest radiograph and echocardiogram were assessed to exclude pneumothorax and residual shunt, respectively (Figures 1 and 2
). The patients were dis-charged after approximately 20 hours. Mean procedure time was 20 ± 2 minutes. There was a "learning curve" phenomenon in this series, that is, the operation time gradually reduced after the first hundred cases.
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Figure 1. Chest radiograph after video-assisted thoracoscopic closure of patent ductus arteriosus. The arrow shows the clips placed on the site of the ductus.
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Figure 2. Postoperative echocardiogram showing complete closure of a ductus arteriosus. AO = aorta, DA = ductus arteriosus, DAO = descending aorta, PA = pulmonary artery.
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RESULTS
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Mean age was 6 years (range, 3 months to 35 years), mean weight was 11 kg (range, 6 to 65 kg), and 60% of patients were female; all had been born at full term. All cases were reassessed by echocardiography immediately before discharge and followed up monthly for 3 months, at 6 months, 12 months, and then annually. There was no significant complication requiring thoracotomy, such as hemorrhage (which is usually caused by ductal rupture or laceration) or residual shunt. The procedure was changed to a thoracotomy in 3 adult patients due to inappropriately dilated canal (> 9 mm). Two patients among the first 50 cases developed transient laryngeal nerve dysfunction, but they recovered completely in 3 to 5 weeks (Table 1).
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DISCUSSION
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The anatomical presence of PDA is usually considered to be significant and sufficient indication for closure at any time and at any age, whether or not there are symptoms.8 A variety of approaches have been described for nonsurgical transcatheter closure via a relatively large diameter femoral sheath, such as coils, buttons, plugs, and umbrellas.9,10 This approach is especially feasible in patients over 10 kg of body weight and in adults with calcified ducts who have high operative risks. In experienced hands, initial occlusion is successful in 85% to 90% of patients. At the 6-month follow-up of 205 procedures, Ali Khan and colleagues11 reported that 22% of the patients had a small residual shunt following transcatheter PDA closure, of which 59% were in ducts greater than 6 mm. Disadvantages of this method include its cost, availability of limited sizes of occluders, rather bulky delivery apparatus making it unsuitable for most infants, potential proximal left pulmonary artery narrowing developing in small patients, occasional hemolysis after implantation, a relatively high incidence of color Doppler-detected residual ductal flow in 10% to 20% of cases, device embolization, and late endarteritis.12
Although a traditional thoracotomy is still the gold standard for PDA closure, with success rates of 77% to 100%, it requires larger incisions and is associated with late complications such as scoliosis, wing scapula, breast disfigurement, and rib fusion with respiratory compromise in 22% to 33% of cases, recurrent laryngeal nerve dysfunction in 1.1% to 4.2%, and residual shunt in 5% to 23%. Its other relative disadvantages include longer hospitalization, lower cost-effectiveness, and more painful postoperative course. The VATS technique is a natural evolution of minimally invasive surgery. It allows ductal closure with minimal chest wall trauma, with a success rate of 88% to 98%, laryngeal nerve dysfunction in 0.6% to 3.4%, residual shunt in 0% to 5.9%, and without the other potential limitations of the two alternative methods.
Our experience in 300 cases supports the advantages of this method. The technique is feasible even in low-weight infants, without any need for blood transfusion, whereas transcatheter endovascular closure is usually not possible in those cases. VATS can be considered as a cost-effective method (at least in our country) as it carries approximately one-fifth of the cost of a traditional thoracotomy. The only major complication in this series was transient laryngeal nerve dysfunction manifesting as dysphonia, and mainly caused by thermal and traumatic injury. This problem can be mitigated by precise and gentle dissection and avoidance of cautery near the nerve. The most significant limitation of the VATS technique is its inability to close a wide ductus (> 9 mm) due to the unavailability of clips greater than 9 mm. In an effort to overcome this problem, Kim and colleagues13 used a self-made endoscopic loop for ligation in 10 patients, using only a small window, with successful ligation of the ductus in all cases, and no residual shunts.
It was concluded from this experience that compared to the traditional thoracotomy approach, the VATS technique for PDA closure is simple, rapid, cost-effective, and more comfortable for the patients, in addition to the cosmetic benefits.
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REFERENCES
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Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. Radiol Clin North Am
1971;9:203–18.[Medline]
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Rashkind WJ, Cuaso CC, Gibson R. Closure of patent ductus arteriosus in infants and small children without thoracotomy. Proceedings of the 7th Annual Meeting of the Association of European Pediatric Cardiologists; 1979 May 8–11; Madrid, Spain.
-
Mullins CE. Patent ductus arteriosus. In: Garson A Jr, Bricker JT, Fisher DJ, editors. The science and practice of pediatric cardiology. 1st ed. Philadelphia: Lea & Febiger, 1990:1055–69.
-
Hoskino MCK, Benson LN, Musewe N. Transcatheter occlusion of the persistently patent ductus arteriosus: forty months follow-up and prevalence of residual shunting. Circulation
1991;84:2313–7.[Abstract/Free Full Text]
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Laborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg
1993;105:278–80.[Abstract]
-
Laborde F, Folliguet T, Batisse A, Dibie A, da-Cruz E, Carbognani D. Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg
1995;110:1681–5.[Abstract/Free Full Text]
-
Laborde F, Folliguet TA, Etienne PY, Carbognani D, Batisse A, Petrie J. Video-assisted thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases. Eur J Cardio-thoracic Surg
1997; 11:1052–5.[Abstract]
-
Friedman WF. Congenital heart disease in infancy and childhood. In: Braunwald E, editor. Heart disease. A textbook of cardiovascular medicine. 5th ed. Philadelphia: WB Saunders, 1996:906.
-
Moore JW, George L, Kirkpatrick SE, Mathewson JW, Spicer RL, Uzark K, et al. Percutaneous closure of the small patent ductus arteriosus using occluding spring coils. J Am Coll Cardiol
1994;23:759–65.[Abstract]
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Moore JW, Cambier PA. Transcatheter occlusion of patent ductus arteriosus. J Interv Cardiol
1995;8:517–31.[Medline]
-
Ali Khan MA, al Yousef S, Mullins CE, Sawyer W. Experience with 205 procedures of transcatheter closure of ductus arteriosus in 182 patients, with special reference to residual shunts and long-term follow-up. J Thorac Cardiovasc Surg
1992;104:1721–7.[Abstract]
-
Sullivan ID. Patent arterial duct: when should it be closed? Arch Dis Child
1998;78:285–7.[Free Full Text]
-
Kim BY, Choi HH, Park YB, Yu BS, Oh BS. Video-assisted thoracoscopic ligation of patent ductus arteriosus. Technique of sliding loop ligation. J Cardiovasc Surg
(Torino) 2000;41:69–72.[Medline]
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ABSTRACT
INTRODUCTION
