Ann Thorac Surg 1998;66:277-278
© 1998 The Society of Thoracic Surgeons
How to Do It
Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion
Bassam O. Omari, MDa,
Shelly Shapiro, MDb,
Leonard Ginzton, MDb,
Jeffrey C. Milliken, MDa,
Fritz J. Baumgartner, MDa
a Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
b Division of Cardiology, Harbor-UCLA Medical Center, Torrance, California, USA
Accepted for publication March 2, 1998.
Address reprint requests to Dr Baumgartner, Pacific Cardiothoracic Surgery Group, St. John’s Medical Center, 1700 N Rose Ave, #440, Oxnard, CA 93030
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Abstract
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The wide, short patent ductus arteriosus in adults and older adolescents poses an extreme hazard with standard closed ligation techniques. The method of transpulmonary balloon catheter occlusion and repair of pediatric ductus arteriosus is herein reported in older patients using a Foley catheter and normothermic bypass. Transesophageal echocardiography is crucial in assessing the size of the ductus and confirming adequacy of repair. The technique is simple and safe even in the presence of a wide, short ductus.
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Introduction
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A patent ductus arteriosus may be complicated for various reasons (wide, short, calcified, infected), making standard ligation via a left thoracotomy hazardous. We have applied a previously reported technique used urgently in children with concomitant congenital cardiac lesion [1] to older patients with isolated large patent ductus arteriosus. The feasibility of the technique with a short, wide ductus is demonstrated. The importance of intraoperative transesophageal echocardiography (TEE) with this technique is emphasized.
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Technique
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In the operating room TEE is done with a multiplane probe and color-flow Doppler echocardiography to visualize the ductus. Cardiopulmonary bypass is established with a two-stage single venous cannula. The patient remains at systemic normothermia. The flow is transiently shut off as a pulmonary arteriotomy is made. A 16F Foley catheter is inserted into the patent ductus and inflated (Fig 1). Full cardiopulmonary bypass is again achieved. Pledgeted 4-0 polypropylene sutures are passed from one side of the defect to the other but not tied. Care is taken to avoid damage to the balloon during suture placement. Pump flow is again transiently decreased and the Foley catheter is removed. The sutures are tied and more sutures placed as necessary. If a patch is thought to be necessary, pledgeted sutures are placed around the circumference of the orifice and then up through the patch.
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Fig 1. Transpulmonary Foley catheter occlusion of a large patent ductus arteriosus. Pledgeted sutures are placed, carefully avoiding damage to the balloon.
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The pulmonary arteriotomy is closed and the patient weaned from bypass. Transesophageal echocardiography is again performed before chest closure to confirm adequacy of the repair. A combination of color-flow Doppler echocardiography and imaging is used to localize the ductus and ensure that there is no residual flow.
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Results
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The patients and method of repair are tabulated in Table 1. Echocardiography was performed preoperatively and intraoperatively for every case. In all patients the ductus was wide and extremely short with the pulmonary artery and aorta in close apposition such that closed ligation methods would have been hazardous.
The defect in patient 1 was large (Fig 2), but we thought primary repair was feasible. Intraoperative TEE after repair and weaning from bypass revealed persistent left to right flow with a 1- to 2-mm channel; therefore, bypass was reinitiated and further suture repair was undertaken, with subsequent TEE showing a successful repair.
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Fig 2. Transesophageal echocardiogram demonstrating the wide, short ductus in patient 1. (PA = pulmonary artery; PDA = patent ductus.)
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Patients 2 and 4 also underwent successful primary closure and patient 3 underwent successful Dacron patch closure. In no instance was the Foley balloon broken during the repair. All patients did well with no subsequent problems.
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Comment
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Untreated patent ductus arteriosus can develop complications in adulthood including endocarditis, congestive heart failure, pulmonary hypertension with pulmonary vascular disease, aneurysm formation, and calcification. Closure of a patent ductus arteriosus in adults is a challenge, especially when it is large, short, or friable or when the aortic orifice is calcified. In these situations, simple dissection and isolation of the ductus carries a risk and closure may not be safe or possible. The pulmonary end of the ductus is seldom involved with calcification and the pulmonary artery wall holds sutures well, lending itself well to transpulmonary closure of patent ductus in adults.
Isolated patent ductus in infants and children is surgically ligated or divided by closed techniques with little morbidity. The surgical difficulties arising from managing a patent ductus arteriosus during repair of concomitant congenital heart defects are related to the approach to the ductus and repair of a ductus discovered after initiation of cardiopulmonary bypass. Bhati and associates [1] reported the use of transpulmonary control of the ductus with a venous Fogarty catheter to facilitate repair in 3 pediatric patients with other cardiac disorders (atrial septal defect, ventricular septal defect, and tetralogy of Fallot). In none of the cases was the use of the transvenous Fogarty catheter planned beforehand (in 2 cases the ductus was not diagnosed until after bypass was initiated; in 1 case the heart fibrillated during attempted intrapericardial exposure of the ductus, necessitating bypass). A modification of the technique [2] employs systemic cooling to 20° to 25°C under cardiopulmonary bypass while the ductus is finger-occluded from the outside. Transpulmonary balloon catheter occlusion is performed and repair is done under a low-flow state.
Profound hypothermia and circulatory arrest [3] has been advocated for transpulmonary closure of complex ductus arteriosus. It was thought that in cases of a short, wide ductus, balloon catheter occlusion had a great danger of balloon catheter breakage during suture placement, and circulatory arrest was the preferred method. In another method, bypass is used with profound hypothermia and repair of the ductus is done in a low-flow state but without circulatory arrest and without the benefit of balloon occlusion [4]. Internal shunts from the left subclavian artery to the descending thoracic aorta with descending aortic cross-clamping also have been reported to obviate the need for cardiopulmonary bypass during transaortic repair of calcified ductus arteriosus [5].
We have here reported successful use of Foley catheter balloon occlusion to repair the short, wide patent ductus arteriosus in adults and older children during normothermic cardiopulmonary bypass. The method is effective for both primary and patch repairs, and with careful technique balloon rupture has not occurred in our hands. The method obviates systemic cooling, profound hypothermia, circulatory arrest, and descending aortic cross-clamping and internal shunting. The use of TEE is vital to confirm adequacy of the repair because it allows visualization of small shunts. We believe that this method is a simple and relatively noninvasive approach to the difficult patent ductus arteriosus in adults.
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References
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- Bhati B.S., Nandakumaran C.P., Shatapathy P., John S., Cherian G. Closure of patent ductus arteriosus during open-heart surgery: surgical experience with different techniques. J Thoracic Cardiovasc Surg 1972;63:820-826.[Medline]
- Stark J. Persistent ductus arteriosus. In: Stark J., de Leval M., eds. Surgery for congenital heart disease, 2nd ed. Philadelphia: Saunders, 1994:275-284.
- Goncalves-Estella A., Perez-Villorai J., Gonzalez-Reoyo F., Gimenez-Mendez J.P., Castro-Cels A., Castro-Llorens M. Closure of a complicated ductus arteriosus through the transpulmonary route using hypothermia: surgical considerations in one case. J Thorac Cardiovasc Surg 1975;69:698-702.[Medline]
- O’Donovan T.G., Beck W.B. Closure of complicated patent ductus arteriosus. Ann Thorac Surg 1978;25:463-465.[Abstract/Free Full Text]
- Pifarré R., Rice P.L., Nemickas R. Surgical treatment of calcified patent ductus arteriosus. J Thorac Cardiovasc Surg 1973;65:635-638.[Medline]
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Abstract
Introduction
