Ann Thorac Surg 2003;76:271-273
© 2003 The Society of Thoracic Surgeons
Case report
Calcified patent ductus arteriosus diagnosed following aortic valve replacement
Gareth J. Morgan-Hughes, MRCPa*,
Jamie Villaquiran, MDC-Thb,
Carl A. Roobottom, FRCRc,
Nick J. Ring, FRCRc,
James Kuo, MD, FRCS, (CTh)b,
Andrew J. Marshall, MD, FRCPa
a Department of Cardiology, United Kingdom
b Department of Cardiothoracic Surgery, , United Kingdom
c Department of Radiology, Plymouth NHS Trust, Plymouth, United Kingdom
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Morgan-Hughes, SpR Cardiology, Cardiology Department, SWCC, Plymouth NHS Trust, Derriford, Plymouth PL6 8DH, United Kingdom
e-mail: gareth.morgan-hughes{at}phnt.swest.nhs.uk
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Abstract
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A 71-year-old woman underwent aortic valve replacement for severe, symptomatic aortic stenosis. The left ventricle filled rapidly when the left ventricular vent was switched off and postoperatively she was slow to recover with bilateral pleural effusions. These findings prompted early reinvestigation, initially with echocardiography and subsequently with multi-detector row computed tomography. Using a retrospectively electrocardiographic-gated acquisition, adapted from a noninvasive coronary angiography protocol, a calcified, persistently patent ductus arteriosus was identified as the cause for her perioperative and postoperative condition. The defect has since been closed successfully using a transcatheter technique.
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Introduction
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Persistently patent ductus arteriosus in adults is rare. Coexistence with severe aortic stenosis is exceedingly rare with only 11 cases previously reported in the English language literature [1–3]. Here we describe just such a case in which the patent ductus arteriosus passed unrecognized before aortic valve replacement. We discuss the role of multi-detector row computed tomography in the evaluation of adult patent ductus arteriosus and reflect on how the information obtained relates to the therapeutic options available.
A 71-year-old woman was referred to our institution for aortic valve replacement. Her original presentation had been with recent onset exertional dyspnea and audible systolic and diastolic murmurs on auscultation. Assessment with transthoracic echocardiography suggested a diagnosis of severe mixed aortic valve disease, presumed degenerative in etiology. Selective coronary angiography indicated no significant coexistent coronary artery disease and she therefore went forward to aortic valve replacement. At surgery, initial inspection of the heart confirmed good left ventricular function. Cardiopulmonary bypass was established using an aortic cannula inserted into the ascending aorta and a two-stage venous cannula, inserted into the right atrial appendage. The aorta was opened through an oblique aortotomy and the aortic valve was found to be tricuspid and severely calcified. The aortic valve was replaced with a 21-mm Mosaic bioprosthesis (Medtronic, Inc, Mineapolis, MN). Suspicion of an unrecognized left-to-right shunt arose when rapid flooding of the left ventricle occurred as the left ventricular vent was switched off.
Although bypass was discontinued without difficulty she had a slow postoperative recovery characterized by pulmonary edema and persistent bilateral pleural effusions. The presence of a postoperative murmur audible throughout the cardiac cycle emphasized the need for early reinvestigation. Transoesophageal echocardiography did not reveal any abnormalities of prosthetic valvular function. However, abnormal high velocity flow could be detected in the main and right pulmonary artery on Doppler. A persistently patent ductus arteriosus was suspected. Further evaluation was carried out using multi-detector row computed tomography (CT). In order to reduce cardiac motion artifact the study was acquired using retrospective electrocardiographic-gating. This enabled subsequent selection of the optimal diastolic reconstruction window. Given the similarity in size of patent ductus arteriosus to a coronary artery the acquisition protocol was adapted from a CT coronary angiography protocol (collimation 4x1.0 mm, gantry rotation 500 msec). This provided maximal image resolution for an image volume covering the aortic arch and pulmonary trunk. The multi-detector row CT was initially evaluated using standard axial reconstructions. These provided clear diagnostic images of a calcified persistently patent ductus arteriosus. The duct measured 2.0 mm at the pulmonary insertion point. Subsequent three-dimensional reconstruction using volume rendering techniques produced excellent visualization of the duct morphology and adjacent structures (Fig 1).
The patient made gradual but steady progress postoperatively and was discharged on postoperative day 10. Successful transcatheter closure of the patent ductus arteriosus was carried out 2 months after the aortic valve replacement surgery.
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Fig 1. Three-dimensional reconstruction of multi-detector row computed tomographic (CT) scan. The extensive calcification of the aortic arch and dilated proximal portion of the patent ductus arteriosus are demonstrated. This type of CT reconstruction provides excellent visual information before transcatheter or surgical closure procedures.
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Comment
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The hemodynamic effect on each other of coexisting patent ductus arteriosus and aortic stenosis has already been reported in children [4]. It seems likely that in our patient the "dominant" lesion, the severe aortic stenosis, "masked" the second lesion, the patent ductus arteriosus. Certainly the traditional clinical signs were not apparent preoperatively, although with the benefit of hindsight a funnel-shaped area of aortic arch calcification was apparent on angiographic review. The observations of Glower and coworkers [1] that "successful diagnosis (of coexisting patent ductus arteriosus in the adult with concurrent aortic stenosis) requires careful observation at catheterization" certainly holds true. Clear noninvasive diagnostic imaging in adult patent ductus arteriosus is notoriously difficult. Although assessment of patent ductus arteriosus size and morphology can be predicted using Doppler echocardiography in children, this is not often possible in adults [5]. Previously it has not been possible to size adult patent ductus arteriosus noninvasively. This has required traditional angiography or balloon sizing. Size remains a relevant factor in the evolution of the technique of transcatheter closure. It was not until 1998 that it was reported that transcatheter closure of moderate and large ducts was possible with an acceptably low complication and failure rate [6]. However, not every duct is suitable for transcatheter closure, and surgery may also be considered if there is a coexistent pathology. Accurate noninvasive sizing of the duct has relevance not only to device selection but also to mode of closure in the first place. Both duct morphology and calcification are important considerations if surgery is an option. Heavy calcification and distorted or aneurysmal changes are unfavorable characteristics for surgery [7]. Surgical closure over 60 years of age carries a significant risk [8]. Under circumstances, such as the existence of a coexistent pathology requiring cardiac surgery, reliable noninvasive demonstration of these characteristics is invaluable. Certainly knowledge of duct anatomy and relationship to the trachea is potentially useful information before transcatheter closure, bearing in mind the role of the tracheal air shadow as a fixed landmark during the procedure.
In our patient’s case the multi-detector CT findings, with respect to the morphology and degree of calcification of the duct, suggested that the preferred mode of closure would be transcatheter. Therefore, earlier diagnosis of the coexistent defect would not have changed the procedures performed, but the order in which they were conducted. This report serves to remind us to remain alert to the possibility of coexistent cardiac pathologies. It also demonstrates the advance that retrospectively electrocardiographic-gated multi-detector row CT represents as a complementary technique in the imaging of persistently patent ductus arteriosus in adults.
The authors are undertaking research into the clinical applications of cardiac computed tomography.
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References
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- Glower D., Bashore T., Spritzer C. Congenital aortic stenosis and patent ductus arteriosus in the adult. Ann Thorac Surg 1992;54:368-370.[Abstract]
- Whitlark J., Lajos T., Visco J. Combined aortic valve replacement and closure of patent ductus arteriosus in the elderly. J Card Surg 1994;9:85-88.[Medline]
- Bhutani A., Dev K., Koppala M., et al. Congenital aortic stenosis and patent ductus arteriosus in the adult. Ann Thorac Surg 1993;56:1003.
- Bruckheimer E., Bulbul Z., Love J., Kleinman C., Hellenbrand W. Aortic stenosis and patent ductus arteriosus: pressure gradients pre- and posttranscatheter ductal occlusion. Pediatr Cardiol 1998;19:428-430.[Medline]
- Zamora R., Donnerstein R. Can colour Doppler predict the narrowest patent ductus arteriosus diameter for the purpose of coil occlusion?. J Noninvasive Cardiol 1998;2:7-10.
- Masura J., Kevin P., Thanopoulos B., et al. Catheter closure of moderate- to large-sized patent ductus arteriosus using the new Amplatzer Duct Occluder: immediate and short-term results. J Am Coll Cardiol 1998;31:878-882.[Abstract/Free Full Text]
- Roques F., Hennequin J., Sanchez B., et al. Aortic stent graft for patent ductus arteriosus in adults: the exclusion technique. Ann Thorac Surg 2001;71:1708-1709.[Abstract/Free Full Text]
- Celermajer D., Sholler G., Hughes C., Baird D. Persistent ductus arteriosus in adults. A review of surgical experience with 25 patients. Med J Aust 1991;155:233-236.[Medline]
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Abstract
Introduction
