Ann Thorac Surg 2005;80:1976-1977
© 2005 The Society of Thoracic Surgeons
Correspondence
Reply
Vladimiro L. Vida, MD,
Aldo R. Castañeda, MD, PhD
Unidad de Cirugía Cardiovascular Pediatrica de Guatemala (UNICARP), 9 Avenida, 8-00 Zona 11, Guatemala City, Guatemala
(Email: vladimirovida{at}interfree.it).
To the Editor:
Dr Sersar, thank you for your comments [1]. It has been previously documented that late complications of minimally invasive thoracotomies are less common in comparison with conventional surgical transpleural approaches [2–5].
Moreover, the incidence of postoperative bleeding after a surgical extrapleural (SEP) approach in our series was only 0.9%; therefore routine use of chest tubes is not necessary and also decreases the discomfort to patients and the cost of the procedure.
Regarding triple occlusion of the patent ductus arteriosus (PDA), two ligatures and a titanium clip between them proved feasible in 99% of our patients and should be considered an option. Early in our experience, we only doubly ligated a large PDA In 2 patients, and both required secondary coil closure for a small residual shunt.
Even though a calcified PDA does represent an additional surgical risk, we have neither seen a calcified PDA in our pediatric surgical patients nor in the 3 adult patients included in this report. Regarding a rare window-type PDA, clearly, division and suture of the PDA is imperative [6].
We agree that transcatheter closure with a coil is recommended for small PDAs (less than 3-4 mm in diameter) [4–6]; but the length of the PDA was not a selection criteria in our series. For PDAs with a diameter larger than 4 mm, transcatheter occlusion offers similar results to surgical closure [3]. However the use of an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) or the need for multiple coils does not prove cost effective when compared with surgical ligation in a low-income country like Guatemala. For these reasons the minimally invasive SEP approach for PDA closure continues to be favored in our institution.
The aim of this study was to provide data concerning cost-effectiveness, comparing percutaneous occlusion with surgical closure of a PDA in a low-income country. Countries such as Guatemala, where health-care resources are limited, are in need of this information to formulate institutional policies and to judiciously allocate resources to be able to effectively treat the largest number of patients.
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References
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- Sersar SI, Mooty HA, Hafez MM, Ismail MF. PDA ligationtrans or extrapleural approach (letter). Ann Thorac Surg 2005;80:1976.[Free Full Text]
- Rothenberg SS, Pokorny WJ. Experience with a total muscle-sparing approach for thoracotomies in neonates, infants, and children J Pediatr Surg 1992;27:1157-1160.[Medline]
- Leon-Wyss J, Vida VL, Veras O, et al. Modified extrapleural ligation of patent ductus arteriosusa convenient surgical approach in a developing country. Ann Thorac Surg 2005;79:632-635.[Abstract/Free Full Text]
- Yan D, Xie Q, Zhang Z, Gu C, Kawada S. Surgical treatment of patent ductus arteriosus (PDA) through mini subaxillary extrapleural approach Ann Thorac Cardiovasc Surg 1999;5:233-236.[Medline]
- Vicente WAV, Rodriguez AJ, Ribeiro PJF, et al. Dorsal minithoracotomy for ductus arteriosus clip closure in premature neonates Ann Thorac Surg 2004;77:1105-1106.[Abstract/Free Full Text]
- Vida VL, Veras O, Leon-Wyss J, Vides I, Castañeda AR. The right-sided window ductus: a rare anatomical entity. Ann Thorac Surg (in press)..
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