The objective of this article is to present by illustration the surgical options in neonatal PDA closure with emphasis on clip application.peer-reviewe

Nosál, M

Omeje, IC

Poruban, R

Valentík, P

Šagát, M

PubMed

Omeje, Ikenna C.

Poruban, Rudolf

Valentik, Pavel

Sagat, Michal

Nosal, Matej

OAR@UM

P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   27  IMAGES  in PAEDIATRIC CARDIOLOGY  Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.  PMCID: PMC3232578 Surgical closure of patent ductus arteriosus in pre-term babies P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál Department of Cardiac Surgery, The Slovak Children's Heart center, Limbova 1, 833 51 Bratislava, Slovakia. Contact information: Matej Nosál, Department of Cardiac Surgery, The Slovak Children's Heart center, Limbova 1, 833 51 Bratislava, Slovakia. Tel: +421 (2) 59371327 Fax: +421 (2) 54775766 ; Email: nosal@dkc-sr.sk  Copyright : © Images in Paediatric Cardiology This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.  Abstract  Objectives: To present by illustration the surgical options in neonatal PDA closure with emphasis on clip application.  Methods: Photo/video-documentation of surgical closure of PDA in a neonate by clip application coupled with free-hand drawings showing PDA closure by ligation and division. Review of 38 neonates undergoing surgical PDA closure in our institution between 1998 and 2006.  Results: Overall survival following surgery was 100%. There was one case of residual PDA and three postoperative complications – 2 cases of pneumothorax and one chylothorax.  Conclusion: The outcome of surgical closure of PDA in neonates is very good with zero mortality in our series and only few postoperative complications. MeSH: patent arterial duct, surgery P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   28  Introduction Patent ductus arteriosus (PDA) accounts for about 10% of all congenital heart anomalies.1 Its incidence is highest in premature babies and twice more frequent in females than in males.2 The clinical manifestation of PDA depends on the volume of blood shunt through it, which in turn is determined by the diameter and length of the ductus and the pulmonary vascular resistance. Untreated PDA can lead to obstructive pulmonary diseases and heart failure. In pre-term babies initial treatment is usually pharmacological. Surgical options are considered when the duct fails to close following treatment with drugs. In older infants treatment options also include percutaneous closure using coil embolization or by devices. Video assisted closure (VATS) of PDA - a less invasive alternative to posterolateral thoracotomy has been used in some centres.3 Here we present by illustration the surgical closure of PDA in a pre-term baby through a left lateral thoracotomy.  Surgical approach The patient is in a lateral position with the left side up (Fig. 1). Surgical approach is through a left thoracotomy performed in the third or fourth intercostal space, as in the case of surgery for isolated coarctation of the aorta.  Figure 1 Patient position (All images are shown from the surgeon's view with the patient's head to the right).    A curved incision is made starting at the anterior axillary line and extending posteriorly (Fig. 2). The serratus anterior is mostly preserved while the fourth intercostal space is identified and opened. P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   29 The rib spreader is inserted and opened in stages to avoid rib fractures (Fig. 3). The lung is retracted anteriorly and the mediastinal pleura opened over the aorta. Stay sutures may be placed along each side of the pleural incision. The ductus is partially mobilised with the aid of a dissector (Fig. 4,5).  Figure 2 Incision      Figure 3 Left thoracotomy  P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   30  Figure 4 Dissection of the ductus   P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   31 Figure 5 Anatomy   Surgical Techniques 1. PDA closure by clip - single or double After the ductus has been dissected, a clip of appropriate size is placed around it and closed by applying gentle pressure on the clip holder (Fig. 6,7).  P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   32 Figure 6 Position of the clip    Figure 7 Position of the clip    Care should be taken to avoid injury to the recurrent laryngeal nerve. The position of the clip is reviewed before closing the chest (Fig. 8).    P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   33 Figure 8 Position of the clip     A second clip can be placed to ensure the ductus is completely closed. The entire procedure is shown on the attached video (Fig. 9). P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   34   2. PDA ligation: The ductus is mobilized; a ligature is passed around it and gently tied down. Double ligation technique involving ligatures on the pulmonary and aortic ends of the ductus has also been widely used (Fig. 10).4,5 Purse-string sutures may be used in place of simple ligatures. A metal clip may be placed for additional security. 3. Ligation and Division: This method is rarely used for the closure of isolated PDA. It entails placing two 6/0 prolene purse-string sutures around the ductus, tying and dividing the ductus as shown in Fig. 11. In coarctation patients a single purse-string suture is used, hence the aortic end of the ductus is completely excised prior to coarctation repair.        Figure 10 Ligation   P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   35 Figure 11 Ligation and division    Surgical Closure of PDA in Pre-term Babies – Our Experience We conducted a retrospective study of 38 pre-term neonates who underwent surgical PDA closure in our centre between 1998 and 2006. Of these, 24 were females and 14 males. The average age of gestation was 30 weeks (range: 24 – 37 wks), the median birth weight was 1200g (range: 670 – 3580g). The median age at operation was 34 days (range: 10 – 130days). 66% of patients weighed less than 1500g at the time of surgery; median weight at operation was 1430g (range: 730 – 4170g). 84% of all procedures were performed in the operating room; the remaining cases were done in the neonatal intensive care unit. In 71% of cases, PDA closure was achieved by use of single or double clip. One patient had PDA ligation only, while 10 patients (26%) had both ligation and clip. The mean time of surgical procedure was 58min ± 20 (27-101). There was zero mortality in our series and only few procedure-related complications. 2 patients (5%) had pneumothorax, while one patient (2.6%) had chylothorax requiring surgical revision. There was only one case of residual PDA on immediate postoperative echo, which on follow-up examination was discovered to have spontaneously closed. P Valentík, IC Omeje, R Poruban, M Šagát, and M Nosál. Surgical closure of patent ductus arteriosus in pre-term babies. Images Paediatr Cardiol. 2007 Apr-Jun; 9(2): 27–36.   36  Comments Despite the advance on pharmacological and other less invasive procedures, surgery still plays a vital role in the treatment of patients with persistent arterial duct. The surgical procedures are quite straight-forward, postoperative complications are few with near-zero mortality in recent years.6 Our preferred surgical technique for ductal closure in pre-term neonates is clip application. A single clip will always suffice, but where in doubt, the surgeon may place a second clip to achieve complete closure. This method is relatively simple and entails minimal dissection around the friable ductal tissue unlike ligation. Hence, it is a safer procedure with very low risk of ductal tissue tear and consequent life-threatening bleeding.6  References 1. Hillman ND, Mavroudis C, Backer CL. Patent ductus arteriosus. In: Mavroudis C, Backer CL, editors. In: Pediatric Cardiac Surgery. Philadelphia: Mosby; 2003. pp. 223–233. 2. Haas G. Patent ductus arteriosus and aortopulmonary window. In: Baue AE, editor. In: Glenn's thoracic and Cardiovascular Surgery. Appleton and Lange, Stamford; 1996. pp. 1137–1161. 3. Villa E, Eynden FV, Le Bret E, Folliguet T, Laborde F. Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases. Eur J Cardiothorac Surg. 2004;25:387–393.[PubMed: 15019665] 4. Brandt B, Marvin WJ, Ehrenhaft JL, # Heintz S, Doty DB. Ligation of patent ductus arteriosus in premature infants. Ann Thorac Surg. 1981;32:166–72.[PubMed: 7259356] 5. Ghosh PK, Lubliner J, Mogilnar M, Yakirevich V, Vidne BA. Ligation of patent ductus arteriosus in very low birthweight premature neonates. Thorax. 1985;40:533–537. [PMCID: PMC460127][PubMed: 4035621] 6. Mandhan PL, Samarakkody U, Brown S, Kukkady A, Maoate K, Blakelock R, Beasley S. Comparison of suture ligation and clip application for the treatment of patent ductus arteriosus in preterm neonates. J Thorac Cardiovasc Surg. 2006;132:672–674.[PubMed: 16935125] 7. Jonas RA. In: Comprehensive Surgical Management of Congenital Heart Disease. London: Arnold; 2004. Patent ductus arteriosus, aortopulmonary window, sinus of Valsalva fistula, aortoventricular tunnel; pp. 187–206.       © Images in Paediatric Cardiology (1999-2012)   

English

Comparison of suture ligation and clip application for the treatment of patent ductus arteriosus in preterm neonates.

In: Comprehensive Surgical Management of Congenital Heart Disease.

Ligation of patent ductus arteriosus in premature infants. Ann Thorac Surg.

Ligation of patent ductus arteriosus in very low birthweight premature neonates.

Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases.

Patent ductus arteriosus and aortopulmonary window.

Patent ductus arteriosus.

Surgical closure of patent ductus arteriosus in pre-term babies

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/4082/Surgical%20closure%20of%20patent%20ductus%20arteriosus%20in%20pre-term%20babies.pdf?sequence=1&isAllowed=y

Surgical closure of patent ductus arteriosus in pre-term babies

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