Patch closure of the ductus arteriosus: an improved method

Intermediate- and long-term follow-up of device closure of patent arterial duct with severe pulmonary hypertension: factors predicting outcome

BACKGROUND

In patients with large patent arterial ducts and severe pulmonary hypertension, the natural history of progression of pulmonary hypertension is very variable. Whether to close or not to close is often a difficult decision, as there are no established haemodynamic parameters predicting reversibility.

OBJECTIVES

The objectives of this study were to evaluate the results of device closure of large patent arterial ducts with severe pulmonary hypertension after 2 years of age and to determine haemodynamic variables associated with its regression during long-term follow-up.

METHODS

A total of 45 patients, with median age of 10 (2-27) years, with large patent arterial ducts and severe pulmonary hypertension, were considered. Haemodynamic variables were assessed in air, oxygen, and after occlusion. The follow-up was performed to assess regression of pulmonary hypertension.

RESULTS

Device closure was successful in 43 (96%) patients. Pulmonary artery systolic and mean pressures decreased from 79 to 67 mmHg and from 59 to 50 mmHg, respectively (p25% (both in oxygen) (p=0.007).

CONCLUSIONS

Device closure of large patent arterial ducts with severe pulmonary hypertension is safe and effective. Pulmonary vascular resistance index and systolic and mean pulmonary artery pressures in oxygen are the key prognostic variables predicting regression of pulmonary hypertension.

Large patent ductus arteriosus in an adult complicated by pulmonary endarteritis and embolic lung abscess

Patent ductus arteriosus in the adult is an extremely rare clinical phenomenon. We report the case of a 34-year old man who developed pulmonary endarteritis and subsequent embolic lung abscess secondary to a large patent ductus arteriosus. This brief report also provides an overview of the natural history, potential complications, optimal therapy, and diagnostic dilemmas associated with this persistent congenital cardiac defect in adults.

Operation for adult patent ductus arteriosus using cardiopulmonary bypass

BACKGROUND

Surgical repair of adult patent ductus arteriosus is more hazardous than when performed on young patients.

METHODS

Nine adult patent ductus arteriosus patients underwent surgical repair between January 1986 and December 1998. There were 3 male and 6 female patients (mean age 55.0 years). The ratio of pulmonary blood flow to systemic flow was 2.40 +/- 0.95, and pulmonary arterial pressure was 56.0 +/- 26.4 mm Hg. The operation was performed using transpulmonary approach under total cardiopulmonary bypass. Balloon occlusion method was also utilized.

RESULTS

Direct closure was made in 5 and patch closure in 4 patients. Cardiopulmonary bypass and balloon occlusion were safely established. Cardioplegic arrest was not required in the 2 most recent patients. No operative death has occurred. Pulmonary arterial systolic pressure decreased to 35.3 +/- 6.6 mm Hg at 6 months after operation. The mean follow-up period for all patients is 55 months. To date, neither recannalization of the ductus nor pseudoaneurysm has been recognized.

CONCLUSIONS

Cardiopulmonary bypass with balloon occlusion provides a safe operation for adult patients with complicated patent ductus arteriosus.

Surgical closure of the patent ductus arteriosus with an intravascular prosthesis: clinical experience

The authors developed a new prosthesis for patent ductus arteriosus (PDA) closure, using a delivery device inserted through the main pulmonary artery (MPA) avoiding ductal dissection and use of cardiopulmonary bypass. The prosthesis was inserted in 19 consecutive patients between 1985 and 1992. They have been followed for a mean of 4.8 years (minimum 30 days, maximum 7.5 years). There were 14 women (72%) and the average age was 11 years (16 months to 38 years). All patients presented with pulmonary hypertension (4 severe, 5 moderate, and 10 mild). Simultaneous surgical procedures for congenital heart disease were performed in two cases. One patient had a diffuse calcified PDA. The average diameter of the inserted prosthesis was 7.5 mm (3.5 to 12.5 mm). Neither hemorrhage nor prosthesis dislocation/embolization occurred during the implantation or in the postoperative period. In a newborn (30 days) with severe cardiomegaly and thin MPA, we decided to ligate the ductus. Chronic cor pulmonale contributed to death in one patient 3.7 years after operation. The remaining patients recovered well, without clinical evidence of residual shunt. Therefore, we recommend the use of this new prosthesis for PDA closure in cases of large ductus or ductus complicated with calcification, pulmonary hypertension, and when associated open heart surgery is required.

Combined aortic valve replacement and closure of patent ductus arteriosus in the elderly

Two cases of patent ductus arteriosus (PDA) and aortic stenosis are presented. Both were diagnosed at routine cardiac catheterization and significant aortic gradient was concomitantly encountered. The first patient had subacute bacterial endocarditis due to B. cereus infection. Eventually it was proven to be localized on the PDA on the pulmonary artery side. Both patients underwent closure of PDA through endopulmonary closure and aortic valve replacement. Postoperative courses were uneventful. These cases demonstrated the technically easy closure of the PDA in the elderly. The literature has documented only six cases including our two cases.

Patent ductus arteriosus in the elderly

Patent ductus arteriosus presenting in an elderly patient is unusual. This report describes the oldest patient (72 years) to undergo successful surgical interruption of a patent ductus arteriosus with a unique clinical presentation of typical angina pectoris with normal coronary anatomy. A possible pathophysiologic mechanism for this previously unreported presenting symptom is proposed. The natural history of patent ductus arteriosus and the role of surgery in the elderly patient are discussed.

Patent ductus arteriosus in patients more than 50 years old

At the Mayo Clinic, from 1945 through 1983, a definitive diagnosis of patent ductus arteriosus was first made in 38 patients when they were more than 50 years old. Of the 29 patients who had cardiac catheterization, 14 had a small left-to-right shunt, 7 had a moderate shunt, and 8 had a large shunt. Five patients, including 2 with right-to-left shunts through the ductus, had pulmonary systolic pressures greater than 75 mm Hg. Thirty procedures were done in 29 patients: ductal ligation in 7, division and suture in 13, transaortic patch closure in 3, and closure via median sternotomy with extracorporeal circulation in 7. There was one intraoperative death (operative mortality, 3.3%). Although technically more challenging, surgical repair is associated with low mortality and excellent follow-up survival. The patients who benefit most from surgical correction are those with Qp/Qs greater than 1.5 and pulmonary artery systolic pressure less than 75 mm Hg.

Persistence of ductus arteriosus with left to right shunt in the older patient

Eight hundred and four patients with persistence of the ductus arteriosus were seen in Edinburgh between 1940 and 1979. Thirty-seven of them reached the age of 50 years, and in 32 the shunt was exclusively from left to right. Fifteen of the 32 were subsequently treated surgically. None of the 32 was lost to follow-up. Duration of clinical observation averaged 17 years and extended to over 30 years in eight patients. Their features have been correlated with those from reports of 48 comparable patients in an attempt to clarify the management of the persistent ductus in the older patient. Impairment of left ventricular function is shown as the major risk, even when the ductus is small. Bacterial endarteritis is infrequent. Surgical treatment carries greater risk than in childhood and early adult life but usually reduces heart size and restores exercise tolerance. Left ventricular dysfunction, however, occasionally vitiates the benefits; symptoms are then incompletely relieved and death from heart failure may occur months or years after operation. Experience in older patients thus emphasises the value of elective operation in childhood, however well the child, however trivial the shunt. It is concluded that in older patients, the presence or the development of symptoms or cardiac enlargement are almost always indications for surgical treatment. As age increases, especially by the eighth decade, medical treatment may be preferable. Continued follow-up of symptomless patients without cardiomegaly is important because increase in heart size usually precedes further deterioration which can then be prevented by timely surgical treatment.

Surgical technique in the management of patent ductus arteriosus in the elderly patient

The successful surgical treatment of a patent ductus arteriosus in a 68-year-old man is presented. A review of current methods for repair is discussed, with emphasis on the simple and safe technique described here.

Closure of the complicated patent ductus arteriosus

A technique for closure of the complicated ductus arteriosus is described which has proved both simple and safe. The technique embodies the use of profound hypothermia, low flow, and direct suture of the pulmonary end of the ductus arteriosus through a pulmonary arteriotomy. No operative deaths have occurred among 4 patients so treated, and no complications from air embolism or hemorrhage have been encountered.