Interruption Of Patent Ductus Arteriosus Research Articles

Transcatheter Closure of Patent Ductus Arteriosus

Patent ductus arteriosus (PDA) constitutes 6 to 11% of all congenital heart defects. While surgical ligation and video-assisted, thoracoscopic interruption of PDA are still available, transcatheter occlusion of PDAs has recently assumed a major role in closure of PDA. A large number of devices have been designed and tested both in animal models and human subjects, but only few devices (free and detachable Gianturco coils, GGVOD and Amplatzer duct occluder) are approved by the FDA for general clinical use. A few other devices are in clinical trials and are available only at institutions participating in clinical trials within or outside the US. At the present time, Gianturco coils for closure of very small and small PDAs and Amplatzer duct occluder for occlusion of small, moderate and large PDAs appear to be feasible, safe and effective in the majority of patients.

Comparison of Posterolateral Thoracotomy and Video-Assisted Thoracoscopic Clipping for the Treatment of Patent Ductus Arteriosus in Neonates and Infants

This study was designed to compare the long-term clinical outcomes and costs between video-assisted thoracic surgery (VATS) and posterolateral thoracotomy (PT) in neonates and infants. This study enrolled 302 patients with isolated patent ductus arteriosus (PDA) from January 2002 to 2007 and followed them up until April 2010. A total of 134 patients underwent total VATS (VATS group), and 168 underwent PDA closure through PT (PT group). The two groups were compared according to clinical outcomes and costs. The demographics and preoperative clinical characteristics of the patients were similar in the two groups. No cardiac deaths occurred, and the closure rate was 100% successful in both groups. The operating, recovery, and pleural fluid drainage times were significantly shorter in the VATS group than in the PT group. Statistically significant differences in length of incision, postoperative temperature, and acute procedure-related complications were observed between the two groups. The cost was $1,150.3 ± $221.2 for the VATS group and $2415.8 ± $345.2 for the PT group (P < 0.05). No cardiac deaths or newly occurring arrhythmias were detected in either group during the follow-up period. Statistically significant differences in the rate of residual shunt and scoliosis were observed between the two groups. The left ventricular end-diastolic diameter and the pulmonary artery diameter could be restored to normal in the VATS group but not in the PT group. The study confirmed that VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in neonates and infants.

The future of minimally invasive cardiac surgery

The ultimate goal of minimally invasive cardiac surgery (MICS) is the perfection of totally endoscopic cardiovascular surgery, without the need for thoracotomy; instead opening a number of access apertures ( ≤1 cm), and treatimg cardiovascular conditions using only the endoscope and narrow instruments. The first step on the road to minimally invasive surgery was endoscopic cholecystectomy, commenced in earnest in America and Europe in 1988. This minimally invasive method of removing the gall bladder laparoscopically, without the need for laparotomy, has a high level of patient satisfaction attributable to decreased postoperative pain, better cosmetic appearance due to the lack of a laparotomy scar, and earlier recovery, discharge and return to activities. The introduction of minimally invasive surgery techniques to cardiovascular surgery have been extremely difficult, however, due to the need to manipulate the heart and aorta, usually under cardiopulmonary bypass (CPB), and technical difficulties with endoscopic surgery. Following training and animal experiments, in July 1992 we successfully performed the first endoscopic interruption of patent ductus arteriosus. 1) This success was

Surgical Interruption of Patent Ductus Arteriosus in a Child With Severe Aortic Stenosis: Anesthetic Considerations

PATENT DUCTUS ARTERIOSUS (PDA) is among the most common congenital heart diseases 1 Schwartz A.J. Campbell F.W. Pathophysiological approach to congenital heart disease. in: Lake C.L. Pediatric Cardiac Anesthesia. Appleton and Lange, Stamford, CT1998: 7-20 Google Scholar and is often associated with other cardiac defects (eg, ventricular septal defect, tetralogy of Fallot, transposition of great arteries). Early series of children requiring repair of PDA reported an incidence of clinical aortic stenosis (AS) of 3% to 10%. 2 Bonham-Carter R.E. Walker C.H.M. Matthews M.B. et al. Patent ductus arteriosus with an abnormal aortic valve. Br Heart J. 1955; 17: 255-261 Crossref PubMed Scopus (4) Google Scholar The treatment options for PDA include surgical interruption, video-assisted thoracoscopic surgical clipping, 3 Laborde F. Folliguet T. Batisse A. et al. 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: 1681-1685 Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and coil embolization or device closure of the PDA in the catheterization laboratory. 4 Rosen D.A. Rosen K.R. Anomalies of the aortic arch and valve. in: Lake C.L. Pediatric Cardiac Anesthesia. Appleton and Lange, Stamford, CT1998: 431-489 Google Scholar The presence of severe AS can adversely affect the intraoperative course in a patient undergoing surgical interruption of PDA. A patient is described in whom surgical interruption of PDA was done in the presence of severe AS.

One-Lung Ventilation for Video-Assisted Thoracoscopic Interruption of Patent Ductus Arteriosus

Video-assisted endoscopic techniques have recently been employed in congenital heart surgery for patent ductus arteriosus (PDA) interruption. We report our preliminary experience of using a new technique of single-lung ventilation to perform video-assisted thoracoscopic PDA interruption (VATS-PDA) in small infants and children. Sixteen infants with a mean body weight of 6.5 +/- 2.4 kg (range 2.6-12.8 kg) underwent VATS-PDA under selective right-lung ventilation using a 2-F balloon catheter for arterial embolectomy. We did not need to reposition the retractor or reinflate the atelectatic lung, as there was no transient hypoxia or hypercarbia. The mean procedure time was 81 +/- 27 min (range 45-145 min) and all patients, with the exception of one with a total anomalous pulmonary venous connection, were extubated in the operating room. This technique using single-lung ventilation for infants and small children was safe and effective in providing pediatric thoracic access and exposure within confined and delicate anatomic spaces.

Inadvertent interruption of descending thoracic aorta on cardiopulmonary bypass during repair of a ventricular septal defect and interruption of a patent ductus arteriosus: Its recognition, consequences, and prevention

PATENT DUCTUS ARTERIOSUS (PDA) is commonly closed through a left thoracotomy. The sizes of the PDA, pulmonary artery (PA), and aorta can be quite similar, and to identify the ductus, the surgeon can test occlude the vessel to be ligated.1 Accidental interruption of the ascending aorta, pulmonary artery (PA) or descending thoracic aorta (DTA) can lead to devastating results. Placement of the pulse oximeter on a lower extremity and the blood pressure cuff on the right arm allow the anesthesiologist to assess flow in the ascending and descending aorta. Occlusion of the PA is characterized by a decrease in the arterial saturation and a decrease followed by an increase in end-tidal carbon dioxide tension.1 These methods of identification of the vessel test occluded are dependent on pulsatile blood flow and intermittent positive-pressure ventilation. During simultaneous repair of intracardiac lesions and interruption of PDA through a midsternotomy,2 PDA is ligated either before3 or after4 initiation of cardiopulmonary bypass (CPB). PDA is identified by its anatomic location, by its relationship with the left pulmonary artery and the undersurface of the aorta4 and by identifying its opening from within the pulmonary artery.2 On CPB, collapse of the PA and rise in the mean arterial pressure after ligation are the indirect features that suggest that the vessel occluded is the PDA. The monitoring used during PDA ligation through a left thoracotomy to prevent accidental ligation of a vessel other than the PDA is less useful during CPB because of the loss of pulsatile blood flow and discontinuation of ventilation. A case of fatal accidental ligation of DTA in a child who underwent ventricular septal defect (VSD) repair and PDA interruption under CPB is described.

The use of multiplane transesophageal echocardiography to evaluate residual patent ductus arteriosus during video-assisted thoracoscopy in adults.

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for interruption of patent ductus arteriosus (PDA), while intraoperative transesophageal echocardiography (TEE) has proven to be an effective monitor in the evaluation of residual patency. Previous reports on the adequacy of surgical interruption of PDA under VATS and TEE are available for pediatric patients, but only limited information is available for adults with PDA. MATEIALS AND METHODS: Between August 1995 and October 1997, we monitored 35 adult patients undergoing PDA interruption via VATS with Hewlett-Packard color Doppler multiplane TEE throughout the procedure. The average PDA diameter was 10.2 +/- 1.8 mm. All the PDA were completely ligated. Thirty-two patients showed no ductal flow after double ligation. In the other three patients, residual flow was detected intraoperatively after double ligation, but it was quickly abolished by the third ligation. One patient showed faint ductal flow by transthoracic echocardiography at postoperative follow-up, but no reintervention was needed. Our study showed that, with the refinement of adult PDA interruption via VATS, intraoperative multiplane TEE provides higher resolution for direct evaluation of the entire course of PDA ligation without interrupting the surgical procedure and minimizes the incidence of complications.

Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants.

Video-assisted thoracoscopic surgery (VATS) has been assuming an expanded role in the management of cardiothoracic disease. As instrumentation and experience increase, VATS is being applied to treat smaller patients. We report our experience with 34 low birth weight infants undergoing VATS interruption of patent ductus arteriosus (PDA). VATS allows PDA interruption without the muscle cutting or rib spreading of a standard thoracotomy. Four small, 3-mm incisions are made along the line of a potential thoracotomy incision. Ports placed through these incisions admit endoscopic instruments, a camera, and a vascular clip applier. Median age at surgery was 15.5 days (range: 1-44 days). Median weight at surgery was 930 g (range: 575-2500 g). Twenty patients weighed <1 kg, and 13 weighed <750 g. All patients had congestive heart failure and had either failed indomethacin therapy or had contraindications to indomethacin. Median surgical time was 60 minutes (range: 31-171 minutes). Echocardiography documented elimination of ductal flow in all patients. Operative mortality was zero. Four patients (4/34 = 12%) required conversion to open thoracotomy: 1 because of difficult exposure, 1 because of pulmonary dysfunction and anasarca, 1 because of a large 1-cm duct, and 1 because of coagulopathy and poor pulmonary compliance. Two patients died before discharge: 1 patient (surgical weight: 605 g) died on postoperative day 2 because of intracranial hemorrhage, and 1 patient (surgical weight: 1725 g) died on postoperative day 88 because of multiple system organ failure. Follow-up has demonstrated no PDA murmur in any patient, but echocardiography revealed trace ductal flow in 2 patients. VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in low birth weight neonates and infants.

Thoracoscopic Interruption of Patent Ductus Arteriosus Compromises Cardiopulmonary Function in Newborn Pigs

Interruption of patent ductus arteriosus (PDA) using video-assisted thoracoscopic surgery (VATS) has recently been introduced into clinical practice. To study cardiovascular and pulmonary function during VATS, we treated 16 newborn pigs (weight 1421 +/- 44 g) with PDA with conventional surgical interruption (CSI; n = 7) or interruption via VATS (n = 9). Measurements of hemodynamics and gas exchange were performed before, during, and after surgery. Systemic perfusion was calculated using Fick's equation. Stress hormones (ACTH, epinephrine, and norepinephrine) were determined before and after surgery. The duration of the surgical procedure was 41 +/- 8 min for CSI and 49 +/- 9 min for VATS (mean +/- SEM). With VATS, PaO2 decreased during and after surgery (P < 0.05), whereas alveolar-arterial PO2 difference (PA-aO2) and PaCO2 were increased (P < 0.05). Compared with CSI after surgery, PaO2 with VATS was decreased (130 +/- 10 vs 171 +/- 12 mm Hg; P < 0.05). Systemic perfusion was lower during VATS (76.7% of baseline) than during CSI (107% of baseline; P < 0.05). Heart rate, mean arterial pressure, and right ventricular end-diastolic pressure remained unchanged with both treatments. Stress hormones were comparable between groups. We conclude that systemic perfusion and oxygenation were impaired during VATS compared with CSI. Therefore, VATS may be contraindicated in pediatric patients with minor cardiopulmonary reserve. Implications: We studied the cardiopulmonary effects of endoscopic interruption of the patent ductus arteriosus in an animal model of newborn pigs. Gas exchange and systemic perfusion were impaired compared with conventional interruption of the patent ductus arteriosus after thoracotomy. (Anesth Analg 1998;87:1037-40)

Thoracoscopic interruption of patent ductus arteriosus compromises cardiopulmonary function in newborn pigs.

Interruption of patent ductus arteriosus (PDA) using video-assisted thoracoscopic surgery (VATS) has recently been introduced into clinical practice. To study cardiovascular and pulmonary function during VATS, we treated 16 newborn pigs (weight 1421+/-44 g) with PDA with conventional surgical interruption (CSI; n = 7) or interruption via VATS (n = 9). Measurements of hemodynamics and gas exchange were performed before, during, and after surgery. Systemic perfusion was calculated using Fick's equation. Stress hormones (ACTH, epinephrine, and norepinephrine) were determined before and after surgery. The duration of the surgical procedure was 41+/-8 min for CSI and 49+/-9 min for VATS (mean+/-SEM). With VATS, PaO2 decreased during and after surgery (P < 0.05), whereas alveolar-arterial PO2 difference (PA-aO2) and PaCO2 were increased (P < 0.05). Compared with CSI after surgery, PaO2 with VATS was decreased (130+/-10 vs 171+/-12 mm Hg; P < 0.05). Systemic perfusion was lower during VATS (76.7% of baseline) than during CSI (107% of baseline; P < 0.05). Heart rate, mean arterial pressure, and right ventricular end-diastolic pressure remained unchanged with both treatments. Stress hormones were comparable between groups. We conclude that systemic perfusion and oxygenation were impaired during VATS compared with CSI. Therefore, VATS may be contraindicated in pediatric patients with minor cardiopulmonary reserve. We studied the cardiopulmonary effects of endoscopic interruption of the patent ductus arteriosus in an animal model of newborn pigs. Gas exchange and systemic perfusion were impaired compared with conventional interruption of the patent ductus arteriosus after thoracotomy.

Video-assisted thoracoscopic ligation of patent ductus arteriosus: safe and outpatient

Background. Minimally invasive techniques for interruption of patent ductus arteriosus have been reported, but are in use at only a few centers. We examined our series of patients who underwent thoracoscopic patent ductus arteriosus ligation. Methods. We reviewed 59 consecutive patients, age 6 days to 50 years, weighing 640 g to 62 kg, who underwent video-assisted placement of a stainless steel clip across the patent ductus arteriosus. Results. Thirty-eight nonneonates and 21 neonates (18 were ≤1,500 g) underwent video-assisted thoracic surgery for patent ductus arteriosus closure with intraoperative echocardiographic confirmation in nonneonates. There were no residual shunts, transfusions, chylothoraces, or significant pneumothoraces. Four were converted to thoracotomy, 3 for anatomic variances, and 1 for coagulopathy. Thirty-six of 38 nonneonate patients stayed less than 24 hours; 18 were discharged the evening of the operation. Two were admitted, one after thoracotomy, and one for a small mucosal intubation injury. No others required a chest tube. There were two recurrent nerve injuries. All neonates survived, and were extubated. Conclusions. Video-assisted thoracoscopic ductus closure is a safe, reliable technique and can be performed as an outpatient procedure in nonneonate patients.

Detection of Residual Flow by Transesophageal Echocardiography During Video-Assisted Thoracoscopic Patent Ductus Arteriosus Interruption

Detection of Residual Flow by Transesophageal Echocardiography During Video-Assisted Thoracoscopic Patent Ductus Arteriosus Interruption

Video-Assisted Thoracoscopic Operation for Interruption of Patent Ductus Arteriosus in Adults

Background. Patent ductus arteriosus (PDA) is a frequent congenital heart disease encountered in premature neonates, infants, and children. Video-assisted endoscopic techniques have been used in PDA interruption since 1993. Almost all the experiences are in pediatric patients. Applications in adults with PDA have been limited. Methods. We report our experience of video-assisted thoracoscopic surgical ligation of PDA in adults. From August 1995 to January 1996, 60 patients with PDA were operated on with a video-assisted thoracoscopic technique. Twelve adults were identified with mean age of 30 years (range, 20 to 57 years). With the patient under general anesthesia and double-lumen endotracheal intubation, two 5-mm holes were made in the left lateral chest wall. Another 4-cm incision was made in the left third intercostal space for manipulation, dissection, and ligation. Conventional surgical instruments were used except an endoscopic grasper and an endoscopic tube that connected to a video camera. The surgical procedure was viewed on a video screen. Transesophageal echocardiography was used for monitoring during PDA ligation. Results. All patients had successful ligation of the PDA. There was no surgical mortality, but there was one morbidity; transient recurrent nerve injury, which recovered 3 months later. Ten patients were extubated in operative room and 2 patients were extubated 2 hours after the operation. Tube thoracostomy was performed in the first 2 cases; it was omitted thereafter. No patients needed narcotic to control chest pain. Postoperative follow-up by echocardiography showed faint ductal flow in 1 patient without any murmur. All patients were discharged within 3 days after the operation. Conclusions. Our experience suggests that with refinement of instruments and surgical technique, video-assisted thoracoscopic surgical ligation can be safely applied not only in pediatric patients, but also in adults with PDA. (Ann Thorac Surg 1997;63:175–9)

Video-Assisted Thoracoscopic Surgery for the Treatment of Congenital Cardiac Defects in the Pediatric Population

Recent technologic advances have contributed to a renewed interest in thoracoscopic surgery.In our institution, thoracoscopy through video-assisted technology has been successfully applied to congenital heart surgery. We reviewed the charts of 45 consecutive patients (ASA physical status II-IV) who underwent video-assisted thoracoscopic surgery (VATS) for various congenital heart defects. The mean age of the patients was 2.65 yr and the mean weight was 11.78 kg. The surgical procedures included patent ductus arteriosus interruption (n = 28) and vascular ring division (n = 8), and 9 patients had miscellaneous procedures. The most commonly used anesthetic regimen consisted of isoflurane, pancuronium, fentanyl, air, and oxygen. Seven patients were managed with one-lung ventilation, the remainder by two-lung ventilation with surgical lung retraction. Intraoperative desaturation occurred in 12 patients (26.7%) but resolved quickly with brief reexpansion of the lungs. Postoperative complications included: pleural effusions (n = 3), chylothorax (n = 2), right upper lobe atelectasis (n = 1), small pneumothorax (n = 1), and vocal cord paralysis (n = 1). Seven patients (15.5%) required conversion to a thoracotomy for insufficient exposure (n = 4) or due to concern over bleeding (n = 3). This experience with VATS in pediatric patients with congenital heart disease may provide a database for comparison with others who work with the VATS technique. (Anesth Analg 1996;82:563-67)

Video-Assisted Thoracoscopic Surgery for the Treatment of Congenital Cardiac Defects in the Pediatric Population

Recent technologic advances have contributed to a renewed interest in thoracoscopic surgery. In our institution, thoracoscopy through video-assisted technology has been successfully applied to congenital heart surgery. We reviewed the charts of 45 consecutive patients (ASA physical status 11-IV) who underwent video-assisted thoracoscopic surgery (VATS) for various congenital heart defects. The mean age of the patients was 2.65 yr and the mean weight was 11.78 kg. The surgical procedures included patent ductus arteriosus interruption (n = 28) and vascular ring division (n = 8), and 9 patients had miscellaneous procedures. The most commonly used anesthetic regimen consisted of isoflurane, pancuronium, fentanyl, air, and oxygen. Seven patients were managed with one-lung ventilation, the remainder by two-lung ventilation with surgical lung retraction. Intraoperative desaturation occurred in 12 patients (26.7%) but resolved quickly with brief reexpansion of the lungs. Postoperative complications included: pleural effusions (n = 3), chylothorax (n = 2), right upper lobe atelectasis (n = 1), small pneumothorax (n = 1), and vocal cord paralysis (n = 1). Seven patients (15.5%) required conversion to a thoracotomy for insufficient exposure (n = 4) or due to concern over bleeding (n = 3). This experience with VATS in pediatric patients with congenital heart disease may provide a database for comparison with others who work with the VATS technique.

A new technique for one-lung ventilation during video-assisted thoracoscopic surgical interruption of patent ductus arteriosus in children

A new technique for one-lung ventilation during video-assisted thoracoscopic surgical interruption of patent ductus arteriosus in children

Detection of residual flow by transesophageal echocardiography during video-assisted thoracoscopic patent ductus arteriosus interruption.

The purpose of this study is to examine prospectively the efficacy of intraoperative transesophageal echocardiography (TEE) monitoring in reducing the incidence of residual ductal flow during video-assisted thoracoscopic (VATS) patent ductus arteriosus (PDA) interruption. Thirty consecutive patients undergoing PDA interruption via the VATS procedure were monitored with an appropriately sized Hewlett-Packard color-Doppler TEE probe. All examinations were performed by the same individual and interpreted with a cardiologist. Real time TEE monitoring was used, but the results were not disclosed to the surgeon until he was prepared to close the wound. The mean age was 2.4 yr and the average weight 11.2 kg. Two patients had residual flow after placement of the vascular clip. One patient had residual flow detected intraoperatively after placement of the vascular clip and residual flow was quickly abolished by the placement of a second clip, thus avoiding a reintervention. A follow-up transthoracic echocardiography was performed on 18 patients 1 mo postoperatively. Three patients presented residual ductal flow. This study using a novel application of TEE, demonstrates that TEE monitoring during PDA interruption may improve the surgical result, thus avoiding reintervention and the complications associated with residual ductal flow. However, late recurrence due to recanalization may occur and may not be detected by intraoperative TEE monitoring.

Detection of Residual Flow by Transesophageal Echocardiography During Video-Assisted Thoracoscopic Patent Ductus Arteriosus Interruption

Detection of Residual Flow by Transesophageal Echocardiography During Video-Assisted Thoracoscopic Patent Ductus Arteriosus Interruption

A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children: F. Laborde, P. Noirhomme, J. Karam, et al. J Thorac Cardiovasc Surg 105:278–280, (February), 1993

A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children: F. Laborde, P. Noirhomme, J. Karam, et al. J Thorac Cardiovasc Surg 105:278–280, (February), 1993

A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children

Classic surgical interruption of patent ductus arteriosus was partially replaced by transcatheter endovascular closure in 1971. We describe a new technique for ductus closure by video-assisted thoracoscopic surgical interruption, derived from video-assisted endoscopic surgery. With the patient under general anesthesia and intubated, two 5 mm holes were made through the left thoracic wall. A video camera and specially devised surgical tools were introduced; such as scissors, dissectors, and clip appliers. The ductus was dissected, and two titanium clips were applied, completely interrupting the ductus. Thirty-eight patients were operated on from April 1991 to April 1992. Mean age was 23.3 months (range 1.5 to 90 months) and mean weight was 9.5 kg (range 2.4 to 25 kg). Six had associated lesions not necessitating immediate surgical treatment. All had successful closure of the patent ductus with the video-assisted technique, but two needed two such procedures, one because of incomplete immediate ductus closure and one because of partial opening of the clip after 24 hours. One patient had recurrent laryngeal nerve injury and four had pneumothorax on the left side. The usual hospital stay was 2 or 3 days. There were no other complications and no deaths. Video-assisted thoracoscopic surgical interruption was a rapid, safe, and successful technique for closure of the patent ductus arteriosus. Better dissection of the ductus decreased the risk of recurrent laryngeal nerve injury and that of clip opening. In the last 26 patients, in whom a 2 mm multiperforated catheter was used for chest drainage during the first hours, no pneumothoraces occurred. Video-assisted thoracoscopic interruption of the patent ductus arteriosus is feasible in low-weight infants, whereas transcatheter endovascular closure of the ductus usually is not possible. The technique will be applied to premature infants with new instruments designed for the size of these patients.