Patent ductus arteriosus surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Priyamvada Singh, M.B.B.S. [2], Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]
Overview
Infants without overt symptoms may simply be monitored as outpatients, while symptomatic PDA can be treated with both surgical and non-surgical methods.[1] Surgically, the ductus arteriosus may be closed by ligation, wherein the DA is manually tied shut, or with intravascular coils or plugs that lead to the formation of a thrombus in the duct. Surgical ligation of the PDA can be accomplished with excellent results in uncomplicated patients. Recent experience with transcatheter closure has also been favorable, being today the procedure of choice for most patients. In certain cases it may be beneficial to the newborn to prevent the closure of the ductus arteriosus. For example, in transposition of the great vessels, a PDA may prolong the child's life until the surgical correction is possible. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs.
Surgery
Indications for Surgery
- Symptomatic patients with left-to-right shunt (left-sided volume overload)[2]
- Reversible pulmonary arterial hypertension
- If medical therapy fails (fluid restriction and prostaglandin inhibitors such as indomethacin)
- If a child is more than 6 to 8 months old, surgical correction of PDA is warranted
There is some lack of consensus on the management strategies of silent and small patent ductus arteriosus
Small PDA
- Small PDA may present with audible murmur with or without symptoms of left volume overload.
- The American College of Cardiology/American Heart Association (ACC/AHA) recommends closure of small PDA, even without evident left-sided volume overload. In case the PDA is left untreated, a follow-up every 3-5 years is recommended.
Silent PDA
- No audible murmur
- Detected incidentally on diagnostic procedures done for other conditions.
- Some experts are of opinion that silent PDA should be closed to decrease the risk of future endocarditis.
- Others believe that since silent PDA has very little risk for causing any hemodynamic complications in the future so it could be left without any surgical intervention.
Contraindications for Surgery
- Severe and irreversible pulmonary artery hypertension
- Eisenmenger's syndrome
Risks Associated with Surgery
Small and Medium-Sized Ductus
Three risks exist:
- Endocarditis
- Deposition of calcium in the walls of the ductus which can compromise surgical results
- Heart failure with a medium-sized ductus.
Because of these risks, the mere presence of a ductus in childhood is an indication for operation at age 1 to 2 years.
Large PDAs with Severe Pulmonary Vascular Obstructive Disease
- If the pulmonary vascular resistance is > 10 units/m2 then this contraindicates closure.
- The risk of death from repair at all ages is < 2% and is under 1% when patients with pulmonary hypertension and small infants are excluded.
- LVH regresses, but if there is pulmonary hypertension, RVH does not regress. the risk of endocarditis disappears.
- The lesion can also be closed using a Rashkind device. There may be a 1 in 5 times risk of embolization of the occluder.
Operative Technique
The decision about the operative technique used depends on the size of the duct (left-to-right shunt) and the age and weight of the patient.[3]
- Ligation
- Percutaneous occlusion (coils, occlusive devices)
- Surgical closure by thoracotomy or sternotomy is indicated in cases where device and coil closures are not possible.
Video-Assisted Thoracoscopic Surgical Ligation (VATS)
- The PDA is ligated with the help of a surgical clip via a posterolateral thoracotomy approach.[4][5]
- VATS PDA ligation is as successful as traditional open surgery with a high degree of efficacy in all the ductus diameters <9 mm, and the results are promising with the following benefits:[6][7][8][9][10][11]
- Safe
- Minimal operative time
- Fast recovery
- Shorter hospital stay
- Cost-effective
- Painless and more cosmetic
- Avoids morbidity related to chest wall trauma
- More access to percutaneous vessels
Percutaneous Occlusion
- Percutaneous occlusion is the treatment of choice in the majority of adult patients and an alternative to surgical ligation in patients beyond infancy. It is achieved in two ways:[12][13][14][15][16][17]
Advantages
- It has been found to be successful in moderate and large PDA.
- Patients beyond the neonatal period have better postoperative prognosis by this device.
- Gives good results with conical ductus (narrowest segment located at the PA end).
- It can adapt to a variety of ductal sizes and shapes.
Videos
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Surgical Closure by Thoracotomy or Sternotomy
- Indicated in cases where device and coil closures are not possible.
- In conditions with large ductus, infections and aneurysm.
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[18]
Therapeutic Recommendations for Patent Ductus Arteriosus
| Class I |
| 1. PDA closure in adults is recommended if left atrial or LV enlargement is present and attributable to PDA with net left-to-right shunt, PA systolic pressure less than 50% systemic and pulmonary vascular resistance less than one third systemic. (Level of Evidence: C-LD) |
| Class IIb |
| 1.PDA closure in adults may be considered in the presence of a net left-to-right shunt if PA systolic pressure is 50% or greater systemic, and/or pulmonary vascular resistance is greater than one third systemic. (Level of Evidence: B-NR) |
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[19]
Recommendations for Closure of Patent Ductus Arteriosus (DO NOT EDIT)[19]
| Class I |
| "1. Closure of a PDA either percutaneously or surgically is indicated for the following:" |
| "a. Left atrial and/or LV enlargement or if PAH is present, or in the presence of net left-to-right shunting. (Level of Evidence: C) " |
| "b. Prior endarteritis. (Level of Evidence: C) " |
| "2. Careful evaluation and consultation with ACHD interventional cardiologists is recommended before surgical closure is selected as the method of repair for patients with a calcified PDA. (Level of Evidence: C) " |
| "3. Surgical repair, by a surgeon experienced in CHD surgery, is recommended when:" |
| "a. The PDA is too large for device closure. (Level of Evidence: C) " |
| "b. Distorted ductal anatomy precludes device closure (eg, aneurysm or endarteritis).[20] (Level of Evidence: B) " |
| Class III |
| "1. PDA closure is not indicated for patients with PAH and net right-to-left shunt. (Level of Evidence: C) " |
| Class IIa |
| "1. It is reasonable to close an asymptomatic small PDA by catheter device. (Level of Evidence: C) " |
| "2. PDA closure is reasonable for patients with PAH with a net left-to-right shunt. (Level of Evidence: C) " |
References
- ↑ Zahaka, KG and Patel, CR. "Congenital defects.'" Fanaroff, AA and Martin, RJ (eds.). Neonatal-perinatal medicine: Diseases of the fetus and infant. 7th ed. (2002):1120-1139. St. Louis: Mosby.
- ↑ Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease)". Circulation. 118 (23): e714–833. doi:10.1161/CIRCULATIONAHA.108.190690. PMID 18997169.
- ↑ Schneider DJ (2012). "The patent ductus arteriosus in term infants, children, and adults". Semin Perinatol. 36 (2): 146–53. doi:10.1053/j.semperi.2011.09.025. PMID 22414886.
- ↑ Bensky AS, Raines KH, Hines MH (2000). "Late follow-up after thoracoscopic ductal ligation". Am J Cardiol. 86 (3): 360–1. doi:10.1016/s0002-9149(00)00936-x. PMID 10922455.
- ↑ Vanamo K, Berg E, Kokki H, Tikanoja T (2006). "Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus". J Pediatr Surg. 41 (7): 1226–9. doi:10.1016/j.jpedsurg.2006.03.002. PMID 16818053.
- ↑ Villa E, Vanden Eynden F, Le Bret E, Folliguet T, Laborde F (2004). "Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases". Eur J Cardiothorac Surg. 25 (3): 387–93. doi:10.1016/j.ejcts.2003.12.023. PMID 15019665.
- ↑ Nezafati MH, Mahmoodi E, Hashemian SH, Hamedanchi A (2002). "Video-assisted thoracoscopic surgical (VATS) closure of Patent Ductus Arteriosus: report of three-hundred cases". Heart Surg Forum. 5 (1): 57–9. PMID 11937464.
- ↑ Villa E, Folliguet T, Magnano D, Vanden Eynden F, Le Bret E, Laborde F (2006). "Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques". J Cardiovasc Med (Hagerstown). 7 (3): 210–5. doi:10.2459/01.JCM.0000215275.55144.17. PMID 16645388.
- ↑ Stankowski T, Aboul-Hassan SS, Marczak J, Cichon R (2015). "Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery?". Interact Cardiovasc Thorac Surg. 21 (4): 532–8. doi:10.1093/icvts/ivv185. PMID 26160963.
- ↑ Lupoglazoff JM, Laborde F, Magnier S, Casasoprana A (1995). "[Closure of patent ductus arteriosus by video-thoracoscopy in 45 children]". Arch Mal Coeur Vaiss. 88 (5): 705–10. PMID 7646281.
- ↑ Chen H, Weng G, Chen Z, Wang H, Xie Q, Bao J; et al. (2011). "Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants". Pediatr Cardiol. 32 (4): 386–90. doi:10.1007/s00246-010-9863-x. PMID 21188372.
- ↑ Eerola A, Jokinen E, Boldt T, Pihkala J (2006). "The influence of percutaneous closure of patent ductus arteriosus on left ventricular size and function: a prospective study using two- and three-dimensional echocardiography and measurements of serum natriuretic peptides". J Am Coll Cardiol. 47 (5): 1060–6. doi:10.1016/j.jacc.2005.09.067. PMID 16516094.
- ↑ Benson, L (2001). "The European experience with coil occlusion of PDA: strength in numbers". European Heart Journal. 22 (19): 1768–1769. doi:10.1053/euhj.2001.2755. ISSN 0195-668X.
- ↑ Cambier, Patrick A.; Kirby, William C.; Wortham, Dale C.; Moore, John W. (1992). "Percutaneous closure of the small (< 2.5 mm) patent ductus arteriosus using coil embolization". The American Journal of Cardiology. 69 (8): 815–816. doi:10.1016/0002-9149(92)90514-Y. ISSN 0002-9149.
- ↑ Wierny L, Plass R, Porstmann W (1986). "Transluminal closure of patent ductus arteriosus: long-term results of 208 cases treated without thoracotomy". Cardiovasc Intervent Radiol. 9 (5–6): 279–85. doi:10.1007/bf02577958. PMID 3100042.
- ↑ Bilkis AA, Alwi M, Hasri S, Haifa AL, Geetha K, Rehman MA; et al. (2001). "The Amplatzer duct occluder: experience in 209 patients". J Am Coll Cardiol. 37 (1): 258–61. doi:10.1016/s0735-1097(00)01094-9. PMID 11153748.
- ↑ Thanopoulos BD, Hakim FA, Hiari A, Goussous Y, Basta E, Zarayelyan AA; et al. (2000). "Further experience with transcatheter closure of the patent ductus arteriosus using the Amplatzer duct occluder". J Am Coll Cardiol. 35 (4): 1016–21. doi:10.1016/s0735-1097(99)00626-9. PMID 10732903.
- ↑ Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
- ↑ 19.0 19.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
- ↑ Deanfield J, Thaulow E, Warnes C, Webb G, Kolbel F, Hoffman A, Sorenson K, Kaemmer H, Thilen U, Bink-Boelkens M, Iserin L, Daliento L, Silove E, Redington A, Vouhe P, Priori S, Alonso MA, Blanc JJ, Budaj A, Cowie M, Deckers J, Fernandez Burgos E, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth O, Trappe HJ, Klein W, Blömstrom-Lundqvist C, de Backer G, Hradec J, Mazzotta G, Parkhomenko A, Presbitero P, Torbicki A (2003). "Management of grown up congenital heart disease". European Heart Journal. 24 (11): 1035–84. PMID 12868424. Retrieved 2012-11-12. Unknown parameter
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