Ann Thorac Surg 1997;63:175-179
© 1997 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Video-Assisted Thoracoscopic Operation for Interruption of Patent Ductus Arteriosus in Adults
Jaw-Ji Chu, MD,
Chau-Hsiung Chang, MD,
Pyng Jing Lin, MD,
Hui-Ping Liu, MD,
Feng-Chun Tsai, MD,
Delon Wu, MD,
Cheng-Wen Chiang, MD,
Fen-Chiung Lin, MD,
Peter P.C. Tan, MD
Divisions of Thoracic and Cardiovascular Surgery and Cardiology and Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China
Accepted for publication August 8, 1996.
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Abstract
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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.
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Introduction
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See also page 178.
Patent ductus arteriosus (PDA) is a frequent congenital heart disease encountered in premature neonates, infants, and children. The incidence is approximately 1 in every 200 births and increases with great prematurity [1]. Surgical intervention is always recommended once the diagnosis is established. Classically, PDA was surgically ligated through a posterolateral thoracotomy. Surgical ligation was first performed by Gross and Hubbard in 1939 [2]. Nonsurgical closure of PDA was developed in 1971 by Portsmann and associates [3] and modified by Rashkind and associates in 1979 [4]. With advancements in video-assisted endoscopic techniques, video-assisted thoracoscopic operation for PDA interruption using a titanium clip was first applied in 1993 by Laborde and colleagues [5]. Subsequently in 1994, this technique was performed in patients with conditions other than PDA by Burke and associates [6]. Those experiences are limited to pediatric patients. We present our procedure using video-assisted thoracoscopy for PDA ligation in 12 adult patients. This short-term report reviews our initial experience of this technique, which provides successful ligation, less discomfort, and an excellent cosmetic result.
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Material and Methods
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Patient Population
Between August 1995 and January 1996, 60 patients underwent elective PDA ligation. All were operated on by the video-assisted thoracoscopic technique. Twelve patients (3 men and 9 women) were adults, with a mean age of 30.1 ± 9.6 years (range, 20 to 57 years). Two patients had subacute bacterial endarteritis (group D Streptococcus) before the operation and had received 6 weeks of antibiotic treatment preoperatively. No aneurysmal change or calcification of PDA was found preoperatively by echocardiography. The diameter of the PDA was 10.2 ± 1.8 mm (range, 8.4 to 11.5 mm). Preoperative mean pulmonary artery pressure was 27.8 ± 11.2 mm Hg (range, 22 to 64 mm Hg). Other data including total operative time, procedure time, intraoperative transesophageal echocardiography, duration of endotracheal intubation, complications, and the need for tube thoracostomy were retrospectively reviewed. Operative consent was obtained before operation, and the risks were well explained to the patients.
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Operative Technique
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Conventional surgical instruments were used in our technique except for an endoscopic grasper (Stryker) and an endoscopic tube (5 mm; Stryker) that connected to a video camera. The surgical procedure was viewed on a video screen.
ANESTHESIA.
Intravenous administration of fentanyl (5 µg/kg), midazolam (0.1 mg/kg), and vecuronium bromide (0.1 mg/kg) was used for anesthesia induction and to facilitate endobroncheal intubation. A Chang Gung modified endotracheal tube (for infants and children) or a double-lumen endotracheal tube (Broncho-cath; Mallinckrodt Medical, Athlone, Ireland; for adults) was applied for one-lung anesthesia. Isoflurane with oxygen was used for anesthesia maintance. A right radial arterial line, lead II electrocardiography, and pulse oximetry were applied as basic monitoring. End-tidal carbon dioxide tension and arterial blood gas levels were routinely checked during the operation. Transesophageal echocardiography (HP Sonos 1000 with a multiplane transesophageal echocardiographic probe; Hewlett-Packard) was used throughout the procedure.
PROCEDURE.
After general anesthesia and intubation, patients were placed in a right lateral decubitus position, and two thoracostomies were made in the left hemithorax, each corresponding in size to the appropriate instrument for that position: a 5-mm incision through the sixth intercostal space on the middle axillary line for the endoscopic grasper, and a 5-mm incision through the third intercostal space, posterior, for the videothoracoscope. A 3.5- to 4.0-cm incision was made through the anterior part of the third intercostal space for manipulation of the instruments. A small retractor was used to keep the intercostal space free for instrumentation.
The left upper lobe was retracted inferomedially by the grasper. The parietal pleura overlying the ductus was grasped with a forceps, and a cautery was used to incise the pleura along the aorta above and below the ductus. This pleural flap was suspended by two stitches, and the PDA was dissected out from surrounding tissue with the cautery. The recurrent laryngeal nerve was identified and swept medially (Fig 1
). When the upper and lower borders of PDA were free, a right-angled clamp was passed beneath the PDA bluntly to clear a circumferential space. Then the PDA was first ligated with 2-0 Ethibon (Ethicon, Somerville, NJ) with Teflon pledgets anteriorly and posteriorly around the PDA using instrumental tie technique and a tie pusher (Fig 2). Two more ligations without Teflon pledgets were added for reinforcement. Sodium nitroprusside and labetalol were used to control the systolic blood pressure around 70 to 80 mm Hg before the PDA was ligated. Intraoperative transesophageal echocardiography was used to confirm the completeness of interruption of ductal flow. After the PDA ligation, the lung was inflated and the skin wound was closed by layers. Tube thoracostomy was done in the first 2 cases; it was omitted thereafter. Patients were extubated in either the operating room or the recovery room and transferred to the intensive care unit for 1 day, then to the ward. All patients were regularly followed up after discharge and received a complete physical and echocardiographic examination. The other 48 pediatric patients underwent the same procedure except that the manipulation wound length was 2.0 cm and the PDA was doubly ligated. No titanium clip was used for interruption of PDA flow in either group. Transesophageal echocardiography was not used if body weight was less than 10 kg.
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Fig 1. . Intraoperative video-assisted thoracoscopic view of patent ductus arteriosus ligation. The mediastinal pleura was suspended, and the vagus nerve, recurrent laryngeal nerve, and patent ductus arteriosus were identified and dissected.
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Fig 2. . Patent ductus arterosus was triply ligated under video- assisted thoracoscopy using instrumental tie technique and a tie pusher.
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Results
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From August 1995 to January 1996, 60 patients with PDA underwent VATS interruption by one surgeon (J.J.C.). Twelve adult patients (>20 years) were identified in this group with a mean age of 28.1 ± 9.6 years. Results are summarized in Table 1. All adult patients presented with typical continuous murmur in the left upper sternal border. Two patients had bacterial endarteritis before the operation and were treated with antibiotics. No other associated intracardiac lesion was found. The size of the PDA measured from 8.4 up to 11.5 mm, with a mean diameter of 10.2 mm. The mean preoperative pulmonary artery pressure was 27.8 ± 11.2 mm Hg. The mean procedure time was longer in the beginning of this series, but it improved as more experience was gained. No hemothorax or pneumothorax was found after tube thoracostomy was omitted. Ten of the 12 patients (83.3%) were extubated in the operating theater. The other 2 patients were extubated in the intensive care unit within 4 hours after the operation. No patients needed narcotic medication to control chest wall pain after the operation. Most of the patients were discharged within 3 days after the procedure. There were no deaths, transfusions required, or chylothorax. The patient with transient recurrent nerve paresis was completely recovered 3 months later.
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Table 1. . Results of Video-Assisted Thoracoscopic Patent Ductus Arteriosus Interruption in Adults ( 20 Years Old)
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The incidence of residual ductal flow was (8.3%) on intraoperative transesophageal echocardiography, 0/12 (0%) on discharge auscultation, and 1/12 (8.3%) on postoperative transthoracic or transesophageal echocardiography. All the adult PDAs were triply ligated. Nine of the 12 patients showed no ductal flow after double ligation. Three patients needed a third ligation to complete the interruption of ductal flow. All patients showed successful ligation without any shunt under transesophageal echocardiographic monitoring during the operation. One patient showed a tiny residual ductal flow by transthoracic echocardiographic study 1 month after the operation without a cardiac murmur. The other 11 patients showed no residual shunt after discharge. The mean follow-up time was 2.3 months.
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Comment
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Patent ductus arteriosus is a frequent and relatively simple congenital heart disease. Therapeutic options for this lesion are changing and continue to evolve. The classic approach is through a thoracotomy with division of muscles and spreading of the intercostal space [2]. This open method provided a near-zero mortality rate in premature infants [7] with residual ductal patency around 0.4% to 3.1% [8, 9]. Even though the results of open surgical interruption of PDA are excellent, concerns over postthoracotomy syndrome and postoperative pain [10–12] have given rise to a less traumatic approach, especially in adult patients [13].
Transcatheter occlusion of PDA has been established as effective management to avoid a surgical incision and achieve low morbidity and no mortality [14–16]. This procedure obviates the need for an operation in up to 92% of PDA patients, but concern has been expressed regarding high residual shunt rate (34% at 1 year), ductal size limitations (not more than 8 mm), and patient size restrictions (not less than 4 kg). In addition, complications such as coil embolization, hemolysis, and bacterial endarteritis have been reported [15, 17]. Catheter occlusion also seems not justified in a patient with preexisting bacterial endarteritis if another option without foreign body insertion is available.
Video-assisted thoracoscopic operation for PDA ligation was first introduced in 1993 by Laborde and associates [5]. It was then applied by Burke and colleagues [6] to PDA and other congenital heart disease in 1995. This procedure provides not only a safe, minimally traumatic, and rapid method but also an effective means to interrupt PDA flow, with residual flow in only 2.1% of cases [18]. Occlusion of the PDA was accomplished with a titanum clip in the original report. It is feasible to apply this metal clip in premature infants, neonates, and children with a PDA less than 9 mm in diameter, but it is not appropriate in patients with a PDA more than 9 mm in diameter or calcification of the PDA [18].
We began using video-assisted thoracoscopic techniques for PDA interruption in August 1995. So far, 60 patients have been operated on including both pediatric and adult patients. The surgical procedures for adult and pediatric patients are almost the same except for the manipulation wound length (adult, 4.0 cm; pediatric, 2.0 cm). The mean size of the PDA in our adult patients was 10.2 mm (range, 8.4 to 11.5 mm); it was neither possible to apply a titanium clip nor suitable for transcatheter occlusion. Besides, 2 patients had preoperative bacterial endarteritis, making foreign body occlusion frankly not justified. Our technique using mostly conventional surgical instruments and ligature, with the aid of a video camera and a limited manipulation port, is universally applicable to all ages of patients and different sizes and situations of PDA. There was no surgical mortality. All patients showed successful ligation of the PDA. Only 1 patient showed a faint residual shunt by echocardiographic study without cardiac murmur 1 month after operation. The patient with transient recurrent nerve injury recovered 3 months later. The mechanism of transient nerve injury was possibly due to inadequate exposure of the lower edge of the PDA during the learning period of video-assisted thoracoscopy. As more experience is gained, this complication can be avoided. Besides, electrocautery should be used carefully during dissection of PDA. The mean admission time has been shortened significantly (2 to 3 days) as compared with conventional thoracotomy (5 to 7 days) in our hospital, and the hospital charges also have decreased.
The wound length for the manipulation port is another concern. The 4.0-cm incision in adult patients provides adequate instrumentation under video-assisted thoracoscopy without increasing wound pain. None of our patients needed narcotics to control surgical wound pain after operation. Exsanguinating hemorrhage is a potential hazard during PDA interruption, especially in adults [5]. In case of bleeding, this 4.0-cm port with a retractor can be easily extended as a route for clamping. This wound also provides satisfactory cosmetic results.
Video-assisted thoracoscopy has been shown to be a less traumatic, effective procedure for PDA interruption. Our technique, like conventional thoracotomy, achieves complete ductal occlusion, but with a minimally invasive surgical wound. No restrictions based on patient or ductal size were needed. With refinement of surgical techniques, anesthetic procedure, and instruments, this procedure can be safely applied not only in pediatric patients but also in adults with PDA.
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Footnotes
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Address reprint requests to Dr Chu, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa North Rd, Taipei, Taiwan, ROC.
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References
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Abstract
Introduction
