Ann Thorac Surg 2010;90:e46-e48. doi:10.1016/j.athoracsur.2010.06.071
© 2010 The Society of Thoracic Surgeons
How To Do It
Adult Patent Ductus Arteriosus Closure With a Pedicled Pulmonary Arterial Patch
Go Kataoka, MDa,*,
Yoshitsugu Nakamura, MDa,
Osamu Tagusari, MDa,
Mitsugi Nagashima, MDb
a Department of Cardiovascular Surgery, NTT Medical Center Tokyo, Tokyo, Japan
b Department of Surgery, Stroke and Cardiovascular Center, Ehime University Hospital, Ehime, Japan
Accepted for publication June 10, 2010.
* Address correspondence to Dr Kataoka, Department of Cardiovascular Surgery, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan (Email: goca{at}dnh.twmu.ac.jp).
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Abstract
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The vascular wall of patent ductus arteriosus in adults is usually fragile due to atherosclerosis with calcification. In adults, surgical treatment, such as direct or patch closure, is sometimes required for a wide, short, or calcified patent ductus arteriosus. We present a novel technique for patent ductus arteriosus closure with a pedicled patch created from the wall of a dilated pulmonary artery. We believe that this technique, in which only an autologous tissue is used, is safe and has excellent durability.
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Introduction
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Less-invasive catheter treatment is currently used for most patients with patent ductus arteriosus (PDA). However, this treatment is difficult to perform for adults with a calcified and wide PDA. Here, we describe a modification of the conventional direct closure technique through a transpulmonary route by using a pedicled patch created from the wall of a dilated pulmonary artery (PA) to treat adult PDA.
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Technique
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A 56-year-old woman with New York Heart Association class II heart failure was referred to our institution. Transthoracic echocardiography showed a PDA with left-to-right shunting, and the left ventricular diameter was 70 mm at end-diastole and 50 mm at end-systole. The maximal PDA diameter was 12 mm, and calcification around the ductus was noted on a contrast-enhanced computed tomography (CT) scan. The PA was dilated to 47 mm on a sagittal CT scan (Fig 1A).
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Fig 1. Sagittal computed tomography images obtained (A) preoperatively and (B) postoperatively show the pulmonary artery diameters (double-headed arrows), which were 47 preoperatively and 34 mm postoperatively. The patent ductus arteriosus was occluded in the postoperative computed tomography scan.
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Right and left heart catheterization was performed. The pulmonary-to-systemic flow ratio was 1.88. The left-to-right shunt was 51.2%. Because the PDA was considered too large for coil embolization, we decided to perform direct closure by using cardiopulmonary bypass. Written informed consent to undergo this procedure was obtained from the patient.
The operation was performed through the median sternotomy approach. Cardiopulmonary bypass was established under normothermia by aortic and bicaval cannulation. An incision was made from the dilated PA trunk to both the right and left PA without cardioplegia. An 8F Foley catheter was inserted into the PDA to control the back flow. The ductal orifice was carefully closed with two 4-0 polypropylene mattress sutures with an autologous pericardium pledget to obtain rough hemostasis. The Foley catheter was removed before the sutures were tied.
The cranial end of the PA wall was trimmed to create a triangular pedicled patch. The pedicle was folded and sutured around the PDA to reinforce the direct closure and to reduce the diameter of the dilated PA by using 4-0 polypropylene running sutures. The pulmonary arteriotomy incision was closed with 4-0 polypropylene sutures after its edge was trimmed for the PA plication. The patient was weaned from bypass (Fig 2). The total time of cardiopulmonary bypass was 63 minutes. The intraoperative time was 159 minutes.
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Fig 2. (A) The main pulmonary trunk was incised to the left and right pulmonary arteries (PAs). (B) An 8F Foley catheter was inserted into the patent ductus arteriosus through the pulmonary trunk. The patent ductus arteriosus orifice was tied using two 4-0 polypropylene mattress sutures with an autologous pericardial pledget. (C) The pedicled PA wall was folded to cover the patent ductus arteriosus, and the redundant PA was trimmed. (D) The pulmonary arteriotomy incision was closed, and the PA was plicated with 4-0 polypropylene sutures.
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The patient was discharged on postoperative day 9. Intraoperative transesophageal echocardiography before discharge showed successful closure of the ductus. The left ventricular diameter at end-diastole and at end-systole improved to 55 and 44 mm, respectively, and no residual shunt was observed. Sagittal CT imaging showed the maximum diameter of the PA had reduced from 47 to 34 mm (Fig 1B). At 7 months after discharge, the absence of a residual shunt was confirmed and the left ventricular diameter at end-diastole and at end-systole were 52 and 35 mm, respectively, as revealed by echocardiography.
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Comment
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There are various treatments for PDA, and the risk of recanalization or aneurysmal change in PDA has been reported after direct or patch closure of PDA through the PA trunk [1–5]. In the present patient, we chose surgical closure of PDA through the PA trunk because coil embolization was not indicated owing to the PDA anatomy, and we performed both direct and patch closure of PDA to reduce the risk associated with these techniques. Inaba and coworkers [6] reported that the PA of adults with PDA was usually dilated and that the orifice of the ductus on the pulmonary side was located at the end of a straight line from the right ventricle. Fukuda and coworkers [7] reported that PA aneurysm contributed to pulmonary hypertension or cystic mucoid degeneration of the PA wall. They presented an adult with PDA in whom aneurysmorrhaphy was performed for the PA aneurysm to prevent PA rupture. From these findings, we considered it very reasonable to reinforce the closure of PDA with a pedicled patch from the PA wall and to simultaneously plicate the dilated pulmonary trunk. In our present patient, the maximum diameter of the PA in the sagittal CT image reduced from 47 to 34 mm.
A pedicled patch created from the PA wall is a viable and autologous tissue. To date, various materials have been used as patch material for reconstruction in cardiac operations for establishing pulmonary circulation. Viable autologous tissue is superior to other patch materials in biocompatibility, durability, growth potential, antithrombogenicity, and resistance to infection [8]. We believe that the viable pedicled PA wall patch is a good patch material for PDA closure.
Our technique has several limitations. It cannot be applied to all patients with PDA. Specifically, we consider that our technique is not suitable for the treatment of children with PDA and patients with no dilated PA. Although no complications were observed in our patient in 24 months after the operation, long-term outcomes of our method are unknown; therefore, we need to follow-up to check for complete occlusion of the PDA.
In conclusion, this technique is a novel method of using a viable autologous PA wall patch. Further, the dilated PA can be plicated. We believe that this technique is a simple, safe, and effective method for the treatment of wide, short, or calcified PDA in adults with a dilated PA.
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References
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- Omari OB, Shapiro S, Ginzton L, Milliken JC, Baumgartner FJ. Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion Ann Thorac Surg 1998;66:277-278.[Abstract/Free Full Text]
- Toda R, Moriyama Y, Yamashita M, et al. Operation for adult patent ductus arteriosus using cardiopulmonary bypass Ann Thorac Surg 2000;70:1935-1938.[Abstract/Free Full Text]
- Hosono M, Suehiro S, Shibata T, et al. Surgical treatment for patient ductus arteriosus in an aged patient J Jpn Assn Thorac Surg 1996;44:2200-2204.
- Saito N, Toma M, Sasaki K, et al. Transcatheter closure of patent ductus arteriosus with the Inoue single-branched stent graft J Thorac Cardiovasc Surg 2005;130:1203-1204.[Free Full Text]
- Lai Y-Q, Xu S-D, Li Z-Z, et al. Thoracic endovascular aortic repair of adult patent ductus arteriosus with pulmonary hypertension J Thorac Cardiovasc Surg 2008;135:699-701.[Free Full Text]
- Inaba H, Higuchi K, Koseni K, et al. Surgical closure of adult patent ductus arteriosus using a pursestring suture Asian Cardiovasc Thorac Ann 2008;16:59-61.[Abstract/Free Full Text]
- Fukuda S, Suma H, Furuta S, et al. Surgical treatment of PDA in the elder patient accompanied with the aneurysm of the main pulmonary artery Kyobu Geka 1991;44:579-582.[Medline]
- Shinoka T, Shum-Tim D, Ma PX, et al. Creation of viable pulmonary artery autografts through tissue engineering J Thorac Cardiovasc Surg 1998;115:536-546.[Abstract/Free Full Text]
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Abstract
Introduction
