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 leads to 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 closure of the ductus arteriosus. For example, in transposition of the great vessels, a PDA may prolong the child's life until surgical correction is possible. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs.
Surgery
Indications for Surgery [2]
- Symptomatic patients with left-to-right shunt (left sided volume overload).
- 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 on 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 year 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 have very less risk for causing any hemodynamic complications in 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 size of duct (left-to-right shunt) and age and weight of the patient.
- 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
The PDA is ligated with the help of a surgical clip via posterolateral thoracotomy approach.
Advantages
- Less invasive than thoracotomy
- Safe and effective
Percutaneous Occlusion
Percutaneous occlusion is the treatment of choice in the majority of adult patients. It is achieved by two ways-
- Coils - Coils give better results with small ducts compared to large.
- Occlusion devices - Amplatzer ductal occluder (ADO)
Advantages
- It has been found to be successful in moderate and large PDA.
- Patients beyond the neonatal period have better post operative 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.
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[3]
Recommendations for Closure of Patent Ductus Arteriosus (DO NOT EDIT)[3]
| 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).[4] (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.
- ↑ 3.0 3.1 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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