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Ann Thorac Surg 2000;70:1935-1937
© 2000 The Society of Thoracic Surgeons

Original article: cardiovascular

Operation for adult patent ductus arteriosus using cardiopulmonary bypass

Riichiro Toda, MDa, Yukinori Moriyama, MDa, Masafumi Yamashita, MDb, Yoshifumi Iguro, MDa, Hitoshi Matsumoto, MDa, Gouichi Yotsumoto, MDa

a Second Department of Surgery, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
b National Minami Kyushu Chuoh Hospital, Kagoshima, Japan

Accepted for publication March 29, 2000.

Address reprint requests to Dr Toda, Second Department of Surgery, Faculty of Medicine, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan
e-mail: toda{at}med6.kufm.kagoshima-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Surgical repair of adult patent ductus arteriosus is more hazardous than when performed on young patients.

Methods. Nine adult patent ductus arteriosus patients underwent surgical repair between January 1986 and December 1998. There were 3 male and 6 female patients (mean age 55.0 years). The ratio of pulmonary blood flow to systemic flow was 2.40 ± 0.95, and pulmonary arterial pressure was 56.0 ± 26.4 mm Hg. The operation was performed using transpulmonary approach under total cardiopulmonary bypass. Balloon occlusion method was also utilized.

Results. Direct closure was made in 5 and patch closure in 4 patients. Cardiopulmonary bypass and balloon occlusion were safely established. Cardioplegic arrest was not required in the 2 most recent patients. No operative death has occurred. Pulmonary arterial systolic pressure decreased to 35.3 ± 6.6 mm Hg at 6 months after operation. The mean follow-up period for all patients is 55 months. To date, neither recannalization of the ductus nor pseudoaneurysm has been recognized.

Conclusions. Cardiopulmonary bypass with balloon occlusion provides a safe operation for adult patients with complicated patent ductus arteriosus.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The majority of patent ductus arteriosus (PDA) patients undergo a surgical correction in childhood. However, some situations retard the operation until adulthood. If the ductus is short, the tissues friable, and the orifice heavily calcified, division or closure in continuity may not be practical. Utilization of cardiopulmonary bypass (CPB) might facilitate closure of the ductus. Nine adult PDA patients have been treated using CPB in our institute. We focused on an operation for adult PDA patients using CPB.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Between January 1986 and December 1998, 9 adult PDA patients were operated on with CPB support at Kagoshima University Hospital and National Minami Kyushu Chuoh Hospital. There were 3 male and 6 female patients, with a mean age of 55.0 years (range, 35 to 74 years).

The ratio of pulmonary blood flow to systemic flow (Qp/Qs) was 2.40 ± 0.95 (mean ± SD) (range 1.44 to 4.18), the ratio of pulmonary pressure to systemic pressure (Pp/Ps) was 0.42 ± 0.23 (range 0.18 to 0.91), and pulmonary arterial systolic pressure (PAP) was 56.0 ± 26.4 mm Hg (range 27 to 109 mm Hg). Calcification around the ductus was noted on roentogenogram and/or computed tomographic scan in 4 patients. Electrocardiogram (ECG) showed atrial fibrillation (AF) in 2 and sinus regular rhythm in 7 patients. All 9 patients were New York Heart Association (NYHA) functional class II (Table 1).


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  		Table 1. Preoperative Patient Characteristics

 
Operative procedure
The heart was exposed through a median sternotomy. After aortic cannulation on the ascending aorta and bicaval cannulation, CPB was established under mild hypothermia. For 7 of 9 patients, cold blood cardioplegia was infused through the aortic root in the usual fashion. The most recent 2 patients were operated on under electrical ventricular fibrillation or with the heart beating without cardioplegia. Under total CPB, the pulmonary trunk was longitudinally opened. Direct or patch closure was performed using balloon occlusion method. A 20-F or 24-F Foley catheter was used for occlusion, and Dacron patch was available for patch closure. The balloon itself was passed through the center of the patch after purse-string suture using 4-0 polypropylene when patch closure was performed. The patch was sutured on the orifice of the ductus using a running suture of 3-0 or 4-0 polypropylene. When direct closure was performed, 3-0 polypropylene was available. No reduction of the pump flow was required in this maneuver (Fig 1).



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  		Fig 1. Schema of the balloon occlusion method. The balloon was passed through the center of the patch with a purse-string suture. It was inserted into the ductus through the opened pulmonary trunk (PDA = patent ductus arteriosus).

 
Data were expressed as mean ± SD. Statistical analysis was performed with analysis of variance. Dependent t test was used to compare preoperative and postoperative-pulmonary arterial systolic pressure (PAP) value.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Five of 9 patients underwent direct closure of the ductus, and the remaining 4 patients received patch closure using CPB. The balloon occlusion method was utilized in all 9 patients. Patch closure was mandatory for a case with a large and/or calcified orifice of the ductus. CPB time was 76.7 ± 36.6 minutes (range 34 to 147 minutes); aortic cross-clamp time, required in 7 patients, was 37.4 ± 19.4 minutes (range 11 to 68 minutes); and the lowest esophageal temperature during CPB was 30.9 ± 3.44°C (27°C to 35°C) (Table 2). The operation was performed under electrical ventricular fibrillation or with the heart beating without cardioplegia in the 2 most recent patients. No complication regarding CPB and the balloon occlusion method was seen. No operative death has occurred among 9 patients.


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  		Table 2. Intraoperative Factors

 
No residual shunt was found by echocardiogram, and the value of PAP decreased significantly from 56.0 ± 26.4 mm Hg to 35.3 ± 6.6 mm Hg at 6 months after the operation. AF still remained in 2 patients, and NYHA functional class improved to grade I in 2 patients at 6 months after the operation (Table 3). Postdischarge follow-up was conducted by a review of the hospital outpatient records and contact with patients or their physicians. The mean follow-up period for all patients is 55 months (range 6 to 165 months). They have been all doing well during the follow-up period. A follow-up echocardiography was performed annually after the operation. To date, neither recannalization of the ductus nor pseudoaneurysm has been recognized. No development of other significant clinical events has been noted in all 9 patients.


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  		Table 3. Postoperative (6 Month) Patients Characteristics

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
By the age of 30 years, about 20% of PDA patients will have died. From the fourth decade onward, mortality rises from 2.5% to 4% a year by 60 years of age. After the age of 60 years, about 10% of the remaining patients will have died [1]. Furthermore, the surgical management in the elderly can be complicated by a presence of calcification around the ductus, pulmonary hypertension associated with aging, endarteritis, and friability. These complications would make the operation more hazardous than when undertaken in the young patients.

A number of operative procedures, including using internal prosthetic shunts, CPB, or hypothermia with circulatory arrest, have been reported for adult complicated PDA patients [2–6]. We have argued the usefulness of CPB for them since the report by Taira and Akita [7–10]. Most cardiothoracic surgeons consider that CPB provides for a safe operation; however, they may have hazardous experiences, including bleeding from injured ductus or the aorta in division or ligation of the ductus. It is not necessary to take the risk that division or ligation of the ductus sometimes makes the surgery hazardous. In case 2 of our series, whom Matsumoto and associates described in 1989, calcified ductus disturbed our approach. Patch closure with balloon occlusion method was successfully performed using CPB [8]. Since then, we have believed that CPB support would provide a safer operation, especially in the complicated adult PDA patients. With CPB used, direct closure using transpulmonary approach was initially considered. However, patch closure has been chosen for the patient with a large and/or calcified ductus orifice [7]. The balloon occlusion method has been used since Bhati and associates reported [5, 6]. We have been using the balloon occlusion method, in which the balloon itself was passed through the center of the patch [7–10]. This maneuver has the advantage that patch closure can be made without reducing the pump flow or circulatory arrest. An appropriate operative field can be also obtained by using the center of the patch (Fig 1). For 2 recently treated patients (cases 8 and 9), the operation was performed under electrical ventricular fibrillation or with the heart beating. Though it took a long CPB time in case 8, it was 48 minutes in case 9. Therefore, we currently believe that cardioplegic arrest is not required for direct or patch closure using transpulmonary approach under CPB. Moreover, the lowest esophageal temperature could be maintained at 33°C. It was considered that CPB could be maintained even at normothermia.

The possibility remains that recanalization and/or aneurysmal change of PDA occurs in the late postoperative course in the patch closure procedure through the pulmonary trunk [1–3]. To date, neither recanalization nor aneurysmal change of the ductus was noted in our series. However, echocardiography will be annually mandatory for prompt detection of these odious complications. We emphasize that CPB can be established even at normothermia, and closure of the ductus can be made safely using the balloon occlusion method without cardioplegic arrest.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968;30:4-13.[Free Full Text]
  2. Stanley J., Muralidharan S., Jairaj P.S., et al. The adult ductus. J Thorac Cardiovasc Surg 1981;82:314-319.
  3. Bell-Thomson J., Jewell E., Ellis F.H., Schwaber J.R. Surgical technique in the management of patent ductus arteriosus in the elderly patient. Ann Thorac Surg 1980;30:80-83.[Abstract]
  4. Wernly J.A., Amerison J.L. Intra-aortic closure of the calcified patent ductus: a new operative method not requiring cardiopulmonary bypass. J Thorac Cardiovasc Surg 1980;80:206-210.[Abstract]
  5. Bhati B.S., Nandakumaran C.P., Shatapathy P., John S., Cherian G. Closure of patent ductus arteriosus during open heart surgery. J Thorac Cardiovasc Surg 1972;63:820-826.[Medline]
  6. Omari B.O., Shapiro S., Ginzton L., Milliken J.C., Baumagartner F.J. Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion. Ann Thorac Surg 1998;66:277-278.[Abstract/Free Full Text]
  7. Taira A., Akita H. Patch closure of the ductus arteriosus: An improved method. Ann Thorac Surg 1976;21:454-455.[Abstract]
  8. Matsumoto H., Morishita Y., Hashiguchi M., Taira A. Surgical treatment of the aged patient with patent ductus arteriosus. Kyobu-Geka 1989;42:933-935.
  9. Umebayashi Y., Taira A., Morishita Y., Arikawa K. Abrupt onset of patent ductus arteriosus in a 55-year-old man. Am Heart J 1989;118:1067-1069.[Medline]
  10. Toda R., Moriyama Y., Taira A. Balloon use for patent ductus arteriosus closure with cardiopulmonary bypass. Ann Thorac Surg 1999;67:1215.[Free Full Text]

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