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Ann Thorac Surg 2003;76:1421-1428
© 2003 The Society of Thoracic Surgeons
a division of Thoracic and Cardiovascular Surgery, All Children's Hospital/University of South Florida College of Medicine, St. Petersburg, Florida, USA
b division of Pediatric Cardiology, All Children's Hospital/University of South Florida College of Medicine, St. Petersburg, Florida, USA
c Division of Pediatric Cardiac Surgery, Miami Children's Hospital, Miami, Florida, USA
* Address reprint requests to Dr Jacobs, Division of Thoracic and Cardiovascular Surgery, All Children's Hospital, University of South Florida School of Medicine, Cardiac Surgical Associates, 603 Seventh St South, Suite 450, St. Petersburg, FL 33701, USA.
e-mail: jeffjacobs{at}msn.com
Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
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Abstract |
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METHODS: One hundred patients underwent 102 cardiac catheterizations. Forty-five children underwent VATS. The entire cohort of patients is 141 because 4 patients underwent both catheterization and VATS.
RESULTS: Successful PDA coil occlusion occurred in 91 patients (91 of 100; 91%); 8 had unsuccessful attempts at coil occlusion and 1 was referred for surgical ligation after catheterization without any attempt at coil placement. Thirty-nine children had successful VATS PDA closure. Six children required conversion to thoracotomy because of inadequate exposure during VATS. Hospital stay for children more than 45 days of age was as follows: VATS median stay, 1 day, mean, 1.4 days; thoracotomy median stay, 4 days, mean, 4.6 days. One patient treated with PDA coil occlusion developed a recurrent PDA and required reembolization. Three children underwent initial catheterization without successful coil placement with subsequent successful VATS. All VATS patients left the operating theater with echocardiography documenting no residual PDA. Two children who underwent successful VATS with no residual PDA at hospital discharge were found on outpatient follow-up to have developed tiny recurrent PDAs and both were successfully coil occluded; 1 of these 2 children is 1 of the 3 children initially evaluated by catheterization and then referred for VATS.
CONCLUSIONS: Video-assisted thoracoscopic surgery and coil occlusion represent complementary techniques for PDA treatment. A rationale for selection of the appropriate treatment modality can be based upon the size and age of the patient and the size and morphology of the PDA.
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Introduction |
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Before 1991 the standard operative approach to the PDA was through a posterolateral thoracotomy. Over the past several years VATS has been assuming an expanded role in the management of cardiothoracic disease. In 1991 VATS approaches to PDA ligation were concurrently developed in Paris by Laborde [2, 3] and in Boston by Burke [4]. In 1993 Laborde published a VATS approach to PDA utilizing two 5-mm thoracostomies and one or two 1-mm retractor openings. Burke's technique uses four 2-mm to 4-mm trocars and allows two-handed dissection.
In 1992 Cambier and associates [5] published their experience with 4 patients (aged 0.5 to 6 years) with PDAs less than 2.5 mm. Three of the four PDAs were successfully occluded with a single Dacron (C. R. Bard, Haverhill, PA) stranded stainless steel coil. In this early series, three PDAs were successfully closed and in a fourth PDA, the coil embolized to left pulmonary artery and was retrieved with no further attempts made.
In June 1994, Lloyd and associates [6] at the University of Michigan created a PDA Coil Registry that collected data on coil embolization of PDAs using the World Wide Web. By March 1995 they had collected data on 535 procedures for 523 patients with a median age of 3.4 years (range, 15 days to 71 years) using single or multiple coils depending on the size of the PDA (< 1 mm to 7 mm) [6]. This and other experiences stimulated the application of the coil occlusion technique to an increasing population of children with PDAs. In 1996 Hijazi and associates [7] reported their experience with 19 patients with a median age of 3.8 years (range, 15 days to 34 years) in which successful closure of large PDAs (
4 mm) were accomplished using multiple coils. As data accumulated, the coil embolization technique became the preferred method of interruption for a significant proportion of affected children with PDAs. At most centers it has replaced surgical intervention for patients with small to moderate PDAs and under some circumstances, large PDAs (Fig 1)
[6–10].
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Material and methods |
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Although VATS PDA ligation has been performed in the operating theater, the procedure certainly could be performed either in the open warmer of the neonatal intensive care unit or in an attached "minioperating room," depending on institutional preferences.
Interventional cardiology coil occlusion
A cardiac catheterization is performed in all patients with a pediatric anesthesiologist providing either conscious sedation or a general anesthetic. Arterial and venous access, preferably from the femoral vessels, is obtained in all cases. Typically a 4F sheath is placed into the artery and a 6F sheath into the vein. Heparin and antibiotic prophylaxis are given as the case progresses. A standard heart catheterization is then performed and the echocardiographic findings confirmed. An internal diameter estimate of the PDA is obtained by angiography, calibrated to externally placed markers, and the ductus classified into small (< 1 mm), small to moderate (1 to 2 mm) and moderate (2 to 3 mm). If the ductus is larger than 3 mm, particularly in the smaller child, the catheterization is ended and the child referred for surgery. In the older child or in the child with a large ductal ampulla, PDA occlusion is attempted if it is thought that multiple coils will not protrude significantly into either the junction of the main pulmonary artery and left pulmonary artery or the descending aorta and the mass of coils is likely to sit in the ductal ampulla. For the smaller duct, a single 0.035-inch Gianturco coil (Cook Inc, Bloomington, IN) measured to be 1.5 to 2 times the size of the "neck" of the PDA is used. It is delivered from the aortic side with one loop placed in the pulmonary side of the PDA and the remaining loops in the ampulla. If needed, the PDA is recrossed with care and a second coil placed. For the larger duct, the ductus is cannulated from the pulmonary and aortic side simultaneously. A detachable coil is placed from the pulmonary side and a 0.035-inch Gianturco coil placed from the aortic side. Further coils are used as necessary to effect complete closure. A reasonable effort is made to insure that all patients have complete closure and that no residual leaks are left. After closure is documented, hemostasis is obtained by hand pressure and a sterile pressure bandage is placed. Typically, the child is discharged home on the same day of the procedure and monitored as an outpatient with documentation of permanent ductal closure by echocardiography at 6 months after the procedure.
Patients
A registry and database (a component of the CardioAccess International Clinical Outcomes Database: Comprehensive Cardiovascular and Thoracic Module, CardioAccess Inc., Saint Petersburg and Fort Lauderdale, Florida) has been prospectively maintained on all patients and has been utilized for data collection and analysis. Informed consent was obtained in all cases. Surgical informed consent included consent for both VATS PDA ligation and potential conversion to open thoracotomy.
This series reviews 45 consecutive children undergoing VATS PDA ligation. Patient age ranged from 13 days to 15.4 years (median, 0.80; mean, 1.83). Patient weight ranged from 625 g to 70 kg (median, 8.0 kg; mean, 10.0 kg).
This series also reviews one hundred consecutive patients who underwent 102 cardiac catheterizations for PDA therapy. A total of 100 patients were selected by clinical and echocardiographic criteria for an attempt at coil embolization of the PDA in the catheterization laboratory. Ages ranged from 0.7 to 20.1 years (median, 3.3; mean, 4.6). Ductal size ranged from less than 1 mm to more than 3 mm. Of the total, 45% were less than 1 mm, 25% were 1 to 2 mm, 29% were 2 to 3 mm, and 1% were more than 3 mm (Fig 4).
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Results |
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Of the 9 patients who underwent catheterization without successful coil embolization, 8 were referred for surgical ligation—5 of these occurred before our VATS program and 3 of these were sent for VATS. All 3 patients sent for VATS underwent successful PDA closure with echocardiography before leaving the operating theater documenting no residual ductal flow. In 1 of these 3 patients, a recurrent PDA developed and was documented during outpatient echocardiography; it was successfully coil embolized at a subsequent catheterization.
Only 2 of the 100 consecutive patients (2%) who underwent 102 cardiac catheterizations for PDA therapy were infants (less than 1 year in age). One of these was successfully embolized and 1 had a PDA measuring 2.5 to 3.0 mm that could not be embolized. At our institution infants are now typically referred for surgical PDA closure, usually by VATS when appropriate, as described in the Comment section.
There were no deaths (0% mortality) among the coil embolization patients. One patient treated with PDA coil occlusion developed a recurrent PDA and required reembolization. In 1 patient a coil left indwelling in the subcutaneous tissue of the groin caused no adverse sequelae. In our series all coils that embolized to the lungs were successfully percutaneously removed during the same cardiac catheterization without any adverse sequelae besides some extra fluoroscopy time. No patients in this series (coil, VATS, or thoracotomy) required blood transfusion. No patients treated with PDA coil occlusion required stay in the intensive care unit; all coil patients went from the cardiac catheterization laboratory to the recovery room to home. No patients required operative intervention for arterial or venous bleeding complications; furthermore, no patients in this series have required surgical intervention on peripheral blood vessels.
Video-assisted thoracoscopic surgery
Thirty-nine children had successful VATS PDA closure. Six children required conversion to a limited muscle-sparing thoracotomy. All 39 children with successful VATS PDA closure had echocardiography before leaving the operating theater documenting no residual ductal flow. Conversion to thoracotomy was necessary in all 6 cases due to inadequate visualization to allow for safe dissection. Conversion to thoracotomy is not considered a complication but rather the exercise of good surgical judgment. Families are informed of the possibility of conversion during the preoperative discussion. In this series, conversion to thoracotomy because of bleeding has not been necessary.
Three children underwent initial catheterization without successful coil placement with subsequent successful VATS. All VATS patients left the operating theater with echocardiography documenting no residual PDA. Two children who underwent successful VATS with no residual PDA at hospital discharge were found on outpatient follow-up to have developed tiny recurrent PDAs; both were successfully coil occluded. One of these 2 children is 1 of the 3 children initially evaluated with catheterization and then referred for VATS. This 1 child initially was evaluated with catheterization and thought to have a PDA too large for coil occlusion. The child then underwent successful VATS PDA ligation with no residual PDA at hospital discharge; outpatient follow-up identified a tiny recurrent PDA successfully occluded with a coil. Thus a total of 4 patients underwent both catheterization and VATS and are counted in both the VATS and coil groups (4 of 141; 2.84%).
Among surgical patients hospital stay for the 35 patients more than 45 days of age was as follows: VATS median stay, 1 day, mean, 1.4; thoracotomy median stay, 4 days, mean, 4.6.
Operative mortality was zero. Any child with clinical suspicion of vocal cord dysfunction was evaluated with bronchoscopy and 1 neonate was found to have left vocal cord dysfunction. Diaphragm paresis developed in 2 neonates (1 aged 19 days, weight 1.55 kg; and 1 aged 13 days, weight 2.8 kg). We have since modified our technique of lung retraction to prevent this complication. On all children less than 4,000 g in size we no longer utilize the expanding metal lung retractor. Instead we use cotton swabs for lung retraction in infants less than 4,000 g. We believe that phrenic nerve dysfunction may have been caused by a stretch injury to the phrenic nerve secondary to lung retraction with the expanding metal lung retractor. No cases of nerve injury have occurred since our lung retraction technique has been modified. No patients had residual PDAs because all 39 children with successful VATS PDA closure had echocardiography before leaving the operating theater documenting no residual ductal flow.
A learning curve exists as documented by our rate of conversion to open thoracotomy. In our first 16 cases, we had 3 conversions (3 of 16; 18.75%) whereas in our next 19 cases, we had 1 conversion (1 of 19; 5.26%). Closer examination of the data supports the concept of this learning curve: in our first 19 cases we had 4 conversions (4 of 19; 21.05%); in our next 26 cases we had 2 conversions (2 of 26; 7.69%)
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Comment |
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Video-assisted thoracoscopic surgery PDA ligation offers the important advantage of decreased chest wall trauma. Proper chest wall and spine mechanics depend on a delicate balance of neural function, ligamentous support and muscular forces [12–16]. By avoiding muscle division and rib spreading, VATS minimizes the risk of nerve injury (associated with postthoracotomy pain syndromes [15]) and rupture of intercostal ligaments (associated with scoliosis [12–14]). In adults, VATS pulmonary wedge resection has been associated with improved early postoperative respiratory function and chest wall compliance compared with conventional open thoracotomy technique [16]. Postthoracotomy scoliosis and shoulder muscle dysfunction may be more pronounced in the pediatric population in whom rapid growth could exaggerate thoracotomy-induced imbalances in chest wall mechanics.
One criticism of VATS surgery is that it may cause decreased visualization of the operative field. In reality, the VATS camera and optics allow improved visualization compared with the limited exposure seen in a minithoracotomy [17]. Figures 2 and 3 demonstrate the ease of identifying the vagus and recurrent laryngeal nerves during VATS PDA ligation.
As instrumentation and experience increase, VATS is being applied to treat smaller patients. A recent multi-institutional report described the successful application of VATS PDA to treat 34 low birth weight infants undergoing VATS interruption of PDA (low birth weight is defined as less than 2,500 g) [18]. Median age at surgery was 15.5 days (range, 1 to 44). Median weight at surgery was 930 g (range, 575 to 2,500 g). Twenty patients weighed less than 1 kg (very low birth weight is defined as less than 1,000 g) and 13 weighed less than 750 g.
For elective patients, VATS PDA ligation may be applied to all patients with PDA, with no contraindications related to patient size. Video-assisted thoracoscopic surgery is contraindicated in patients with calcified ducts, severe pleural scarring, and short, wide, window-like ducts. Patients with short, wide, window-like ducts can often be treated with classic Potts ductus clamps but may require median sternotomy and PDA interruption on cardiopulmonary bypass, especially if the PDA is calcified. No patients in this series had calcified ducts, severe pleural scarring, or short, wide, window-like ducts, and no patients in our institution during the time of this study required PDA closure on cardiopulmonary bypass.
Coil embolization of PDAs commonly has replaced surgical techniques in older infants, children, and adults because it is a minimally invasive method associated with very low morbidity and minimal mortality. It is applicable to the great majority of PDAs outside of the neonatal period. Endotracheal intubation is not required in most patients with conscious sedation sufficient. Coil embolization is an "outpatient" procedure and a hospital stay is typically not required in the absence of complications. Patients are ambulatory within 6 hours and postprocedural pain is either minimal or nonexistent.
The single most important factor in the decision for or against coil embolization is dependent on size and morphology of the PDA. For effective embolization, a "neck" is required to "trap" the body of the coil. The larger PDAs tend not to have a significantly constricting neck. In addition, larger PDAs are likely to require multiple coils, which may protrude into the lumen of the left pulmonary artery or descending aorta and cause a flow disturbance in the left pulmonary artery or rarely a coarctation of the aorta [19]. This phenomenon is likely to be exaggerated in the smaller child with the larger ductus. In a follow-up study of 53 patients with multiple-plane angiographic evidence of intraaortic coil loops after coil occlusion of aortopulmonary collateral vessels or patent ductus arteriosus, all patients with adequate follow-up angiography demonstrated 0.5 mm separating the coil and aortic contrast column suggesting endothelial coverage of the intraaortic coil loop. The authors concluded that "although coil occlusion of aortopulmonary collateral vessels or patent ductus arteriosi may produce intraaortic coil loops, endothelialization appears routine" [20].
Large PDAs are also more likely to have a residual leakage [6] that may predispose the patient to a second coil embolization procedure (or possibly a surgical intervention) to effect complete closure and eliminate the risk of endocarditis. In some cases hemolysis has been associated with residual leakage due to the turbulent flow across the mass of coils with disruption of red blood cells [21]. This hemolysis may necessitate placement of additional coils [21] or even surgical coil removal and ductal closure on cardiopulmonary bypass (personal communication, Carl Lewis Backer, September 12, 2002; surgical case, September 9, 2002, Children's Memorial Hospital, Chicago, Illinois). Finally, large PDAs are also more likely to predispose to embolization of coils, typically into the pulmonary circulation with a risk of mechanical embolic complications if percutaneous retrieval is unsuccessful. In some cases, patients have had to undergo a surgical procedure in order to remove the coils from the circulation [22].
Indomethacin therapy, VATS PDA ligation, open thoracotomy ligation, and transcatheter coil occlusion all represent complementary treatment modalities for PDA. Each technique has advantages and limitations. The proper treatment modality must be matched to the clinical situation at hand. Based on our experience reported in this manuscript, we make the following four management recommendations concerning the role of VATS PDA ligation in the management of PDA.
First, multi-institutional collaborative research has demonstrated that effective treatment for the hemodynamically significant PDA in small premature infants involves initial anticongestive treatment followed by indomethacin; an operation is utilized when indomethacin therapy is ineffective or contraindicated [23]. When surgery is indicated, small premature infants may be treated with VATS PDA ligation or open thoracotomy ligation. We use an open muscle-sparing minithoracotomy for small premature infants with hemodynamic instability, inotrope requirement, oscillating ventilator requirement, high ventilatory pressure requirement, or coagulopathy. For patients weighing less than 2,000 g, we selectively use VATS PDA ligation if the above risk factors are absent.
Second, full-term otherwise healthy infants (less than 1 year of age) are best treated with VATS PDA ligation. A large infant greater than 10 kg might be a candidate for coil occlusion; however, in smaller infants we utilize VATS because of the potential of arterial complications with coil occlusion.
Third, older children and adults can be treated with VATS PDA ligation, open surgical ligation (through thoracotomy or sternotomy), or transcatheter coil occlusion depending on the situation. As the ratio of PDA size to patient size increases, transcatheter coil occlusion becomes more cumbersome. At some point this ratio is large enough that VATS PDA ligation represents a better option than transcatheter coil occlusion. This decision is best made with the joint input of the interventional cardiologist and the cardiac surgeon. Echocardiography can provide useful data about PDA size.
Our current approach utilizes the following echocardiographic criteria: (1) To be considered for coil occlusion or VATS, the patient can not have a short, wide, window-like PDA. (2) For children more than 10 kg, if the PDA is less than 2.5 mm, we tend to favor coil occlusion. (3) Any PDAs between 2.5 and 3.0 mm are judgment calls based on patient size and ductal morphology. The ideal PDA for coil occlusion has length (not short and window-like) and a ductal ampulla with a narrowing at the pulmonary artery side of the PDA. (4) If the PDA is greater than 3.0 mm, we typically recommend VATS. In an older and larger patient, a large ductal ampulla might facilitate coil occlusion in a PDA greater than 3 mm. Nevertheless, as our experience and confidence with VATS grew, we were less likely to aggressively approach larger PDAs in the cardiac catheterization laboratory. Larger PDAs closed with coils often necessitate the use of multiple coils and result in a huge mass of coils with potential protrusion of coils into the aorta and left pulmonary artery with subsequent risk of aortic coarctation or left pulmonary artery stenosis.
This protocol has evolved over time as available instrumentation has improved. A cooperative team effort between the interventional cardiologist and the cardiac surgeon proves that these techniques are complementary rather than competitive. For all patients in whom both coil occlusion and surgical ligation are reasonable options, our team utilizes a true team approach. Even in patients with small PDAs, patients and their families, when appropriate, are given the informed choice of coil occlusion and surgical ligation, either open or through VATS.
Our fourth management recommendation concerning the role of VATS PDA ligation is that patients with calcified ducts, severe pleural scarring, or short, wide, window-like ducts who require surgery, are not candidates for VATS. When in need of surgery, these patients are best treated with open surgical techniques. When open surgery is required, the PDA is most commonly ligated through a muscle-sparing left posterolateral thoracotomy. Patients with short, wide, window-like ducts can often be treated with classic Potts ductus clamps but may require median sternotomy and PDA interruption on cardiopulmonary bypass, especially if the PDA is calcified.
In conclusion, both VATS PDA ligation and coil occlusion techniques are safe, effective, and minimally traumatic. These techniques allow PDA interruption without the muscle cutting or rib spreading of a standard thoracotomy. Video-assisted thoracoscopic surgery PDA ligation and coil occlusion represent complementary techniques for PDA treatment. A rationale for selection of the appropriate treatment modality can be based upon the size and age of the patient and the size and morphology of the PDA.
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Discussion |
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One is, our approach has been with VATS because we think it is not only equal but better but there is something inherently curious to me about an indication to close a ductus in older kids is to prevent endocarditis. Filling in the ductus with a foreign body is unsettling, and I don't think they have ever shown—as much as they have shown the ability to close the ductus— I don't think it has ever been well proven that that reduces the risk of endocarditis to the baseline level whereas with surgery we have shown that it does; we have been doing that since the 1950s. So we have some concerns about the coil and although it has not been published, there have been some reports of endocarditis on coils, and I think that is a concern you could comment on.
The second thing is, is this really a complementary or a competitive technique and who is really deciding? Are you deciding in a joint conference which ones go where or is the patient offered both or are you getting the ones the cardiologists don't want?
We presented and published our data with 1-year follow-up in the VATS technique and found 1 child to have a small ductus that we termed a missed residual rather than a recurrence. While the coil relies on almost occluding the ductus and then having the rest cut off, the VATS technique relies on occluding it with a clip permanently and completely. We did find one child who came back that we reapproached with the VATS and could only demonstrate the residual ductus in the supine position with transthoracic echo, and when we put the child on the side with a TEE and couldn't see it, we think we missed that. Now on all our kids we turn them and do a surface echo as well and subsequently found another child.
We think that is a missed residual rather than a recurrence because these clips—if you follow them up on chest x-ray— do not open back up. I guess theoretically you could think that the distal end of the ductus closed and opened up overnight or over the next couple of days. I would like to get your comments on that.
DR JACOBS: Thank you. Those are all quite good questions. I certainly would compliment you on your series that you just presented of 100 small babies who had excellent results with this VATS-PDA procedure.
First, I would like to comment on the role of preventing endocarditis. I think I agree with a lot of your concerns about endocarditis in coils. I think that the likelihood of endocarditis after a VATS-PDA ligation is probably zero, and probably, after coil placement, there is some incidence of it which is unknown and most likely quite low. I would agree that, given the choice, I would probably VATS all of these patients, but that is not really our option. These patients usually don’t come directly to us; they come through cardiology. Therefore, we have tried to develop a cooperative approach.
And that brings us to your second question: "Is this really a complementary or a competitive technique?" I think in our institution it is not a competitive approach at all. It is a very cooperative approach. The decisions are made with a joint discussion with us and the cardiologists. In our program, we have two cardiologists who place coils and we have three surgeons that perform the VATS-PDA procedure. We look at these patients together based on the four recommendations that I gave at the end of my presentation. In some patients, the cardiologists feel the PDA is a little bit too big for a coil. The cardiologists then discuss the patient with the surgeons. The patient and family are sent to our office and we talk about it and decide if we should use VATS for them. We don’t think it is a competitive situation at all; instead, it is a cooperative approach that we are taking.
Finally, I would like to address your last comment about whether to view, as missed residuals versus recurrences, our two VATS cases found on outpatient follow-up to have a small PDA present. All of our VATS patients left the operating theater after intraoperative echocardiography documented no residual PDA; so, technically these are classified as recurrences; however, you could very well be correct that these cases may actually represent missed residuals. I have no way to know for sure whether the two that did have recurrences were actually missed residuals. I think your point about doing echocardiography in a variety of positions probably is a good idea.
DR KAMAL A. MANSOUR (Atlanta, GA): I do not have much to do with pediatric cardiac surgery but as a general surgeon we have seen clips falling off. Have you ever experienced such a mishap? And for that reason why don’t you use two clips instead of one? Both you and Dr Hines put one clip right close to the aorta and Dr Hines mentioned that he experienced one clip that did not include the whole width of the ductus. Why don’t you use two for safety?
DR JACOBS: Again, that is a good question.
First of all, I have never had one of these clips fall off, and I am pretty happy about that. Sometimes, I have placed two clips. I didn’t have pictures in my presentation today where I showed that. When we are doing this procedure on a small premature baby, we typically would place only one clip because we want to stay well away from the recurrent laryngeal nerve; however, on the larger children, we have several instances in our series where we placed two clips. Our two largest children were 56.2 and 70 kg. In these larger patients, we often actually dissect out the PDA completely because it is too big for the clip initially. We get around the PDA with a tie, tie an extracorporeal knot, and push the knot down with a knot-pusher. The tie might not completely occlude the PDA, but it would make it small enough to endoscopically place a clip. We would then completely occlude the PDA with one or two clips. That seems like a lot of work, but if you ask a teenager if they’d rather have that or a thoracotomy, they will take the minimally invasive VATS approach any day.
Thank you.
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References |
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4 mm) with multiple gianturco coils: immediate and mid-term results. Heart 1996;76:536-540.This article has been cited by other articles:
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  M. Kahrom and H. Kahrom Esophageal Stethoscope in Thoracoscopic Interruption of Patent Ductus Arteriosus Asian Cardiovasc Thorac Ann, August 1, 2008; 16(4): 288 - 291. [Abstract] [Full Text] [PDF]
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 A. M. Gaca, J. J. Jaggers, L. T. Dudley, and G. S. Bisset III Repair of Congenital Heart Disease: A Primer--Part 2 Radiology, July 1, 2008; 248(1): 44 - 60. [Abstract] [Full Text] [PDF]
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 M. H. Nezafati, G. Soltani, and A. Vedadian Video-Assisted Ductal Closure With New Modifications: Minimally Invasive, Maximally Effective, 1,300 Cases Ann. Thorac. Surg., October 1, 2007; 84(4): 1343 - 1348. [Abstract] [Full Text] [PDF]
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C. R. Zamfir, M. Vernet, M. F. de la Vega, and E. Sapin Patent Ductus Arteriosus Ligation: The LigaSure System May Be Unreliable Ann. Thorac. Surg., June 1, 2007; 83(6): 2228 - 2230. [Abstract] [Full Text] [PDF]
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