Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants

Evaluation of postoperative complications for patent ductus arteriosus in extremely-low-birthweight infants

BACKGROUND

Patent ductus arteriosus (PDA), which disrupts the hemodynamics early after birth, causes intraventricular hemorrhage and neonatal necrotizing. Unlike medical treatment for hemodynamically significant PDA, there are institutional disparities in the criteria for surgical treatment METHODS: We aimed to clarify the postoperative indications of surgery for hemodynamically significant PDA and the postoperative complications associated with surgery.

RESULTS

Thirty-six extremely-low-birthweight infants (median gestational age 25.2 weeks, median birthweight 699 g) required video-assisted thoracoscopic surgery for PDA (VATS-PDA). The treatment indication of VATS-PDA was resistance to medical treatment in 17 cases, relapsed PDA in 15 cases, and no additional administration of indomethacin because of severe side effects in four cases. Complications with VATS-PDA occurred in eight of 36 cases. There were three cases of pneumothorax, two of thoracotomy transition, two of pulmonary hemorrhage, and four of post-ligation cardiac syndrome (PLCS). VATS-PDA-related death occurred in two cases due to PLCS. The frequency of four or more administrations of indomethacin, with or without postoperative complications, was 88% vs. 39%, respectively (P = 0.04).

CONCLUSIONS

All postoperative deaths were caused by PLCS, which had the highest risk of poor prognosis. VATS-PDA should be considered for unclosed PDA after one course of indomethacin administration.

Patent ductus arteriosus: From pharmacology to surgery

Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.

Short-Term Complications Associated with Surgical Ligation of Patent Ductus Arteriosus in ELBW Infants: A 25-Year Cohort Study

OBJECTIVE

This article aims to determine the incidence of short-term complications of surgical patent ductus arteriosus (PDA) ligations, the factors associated with those complications, and whether complications are associated with poor long-term outcomes.

STUDY DESIGN

Retrospective cohort study of all extremely low birth weight (ELBW, < 1,000 g) infants who underwent surgical PDA ligation at a single-center neonatal intensive care unit from 1989 to 2015. Demographic, clinical, and laboratory data were reviewed. The primary outcome was development of a short-term (< 2 weeks from ligation) surgical complication. Secondary outcomes include bronchopulmonary dysplasia (BPD), length of stay, and mortality.

RESULTS

A total of 180 ELBW infants were included; median gestational age and birth weight was 24 weeks and 683 g, respectively, and 44% of infants had at least one short-term complication. Need for vasopressors (33%) was the most common medical complication and vocal cord paralysis (9%) was the most common surgical complication. Younger corrected gestational age at time of repair was associated with increased risk for complications. Mortality, length of stay, and BPD rates were similar between infants with and without complications.

CONCLUSION

Serious complications were seen in a minority of infants. Additional research is needed to determine if short-term complications are associated with long-term adverse outcomes.

Optimal timing of video-assisted thoracoscopic surgery for patent ductus arteriosus in preterm infants born at ≤ 28 weeks of gestation

BACKGROUND

Video-assisted thoracoscopic surgery for patent ductus arteriosus (VATS-PDA) is an alternative surgical procedure to open chest surgery, even in premature infants. This study investigated whether the timing of VATS-PDA has a prognostic impact in premature infants whose operative indication was determined according to the symptomatic PDA and the ineffectiveness of or contraindication to indomethacine therapy.

METHODS

We studied 49 infants born at or before 28 weeks of gestation who were admitted to the neonatal intensive care unit between January 2004 and June 2016, and who underwent VATS-PDA. The patients were divided into two groups according to median age at the time of surgery (early group, 24 infants who underwent surgery at ≤ 24 days of life; late group, 25 infants who underwent surgery at ≥ 25 days of life).

RESULTS

No significant differences were found in bodyweight at 30 days of age and 40 weeks of corrected gestational age between the groups. The timing of surgery did not affect the operative procedure or postoperative complications. In addition, no differences were observed between the early and late groups in terms of complications associated with prematurity, including intraventricular hemorrhage, incidence and severity of bronchopulmonary dysplasia, and necrotizing enteropathy.

CONCLUSION

Video-assisted thoracoscopic surgery for patent ductus arteriosus can be safely performed in premature infants without a preferential timing for the intervention, suggesting that this procedure allows for an elective basis approach after heart failure management with conservative and/or drug therapy in premature infants with PDA.

Descriptive review of patent ductus arteriosus ligation by video-assisted thoracoscopy in pediatric population: 7-year experience

Background

Less invasive procedures such as video-assisted thoracoscopic surgery (VATS) are desirable for patent ductal artery (PDA) ligation when pharmacologic or conservative approaches fail. Studies done on VATS-PDA ligation showed better outcomes when compared to open thoracotomies, however, complication rates remain conflicting. Learning curve can be a postulated reason which may also precludes the acceptability. We therefore sought to report our single centered 7-year experience of PDA closure with VATS.

Methods

Single centered retrospective study of 127 patients who underwent PDA ligature with VATS from February 2012 to October 2018. The cohort was divided into two groups, i.e., 2012-2014 (early phase) and 2015-2018 (late phase) and were further compared. Early and late outcomes, including mortality and morbidity, were analyzed.

Results

The included patients had a mean age of 1.7 years. Among them, preterm infants accounted for 38.6%, there was no operative mortality. Six deaths (4.7%) occurred during in-hospital stay, predominantly in the neonatal intensive care unit (NICU) due to massive cerebral bleeding and cardiopulmonary failure. Overall conversion rate to thoracotomy was 16.5%. It decreased from 20% in early phase to less than 5% in late phase. Fifty patients (39.4%) required transfer to the NICU. The mean in-hospital stay for the remainders was only 2.2±1.6 days. All but two patients discharged home survived follow-up period without any adverse events and nobody among non-converted cases expressed concerns regarding chest deformity. A 5-year probability of survival estimated according to the Kaplan-Meier curve was 93.6%.

Conclusions

VATS is a safe as well as efficient method for closure of PDA that ensures satisfactory late cosmetic results. Postoperative mortality and extended hospital stay may be attributed to prematurity. Although learning curve exists it does not affect the safety and late outcomes.

[Thoracoscopic clipping of patent ductus arteriosus: position of surgery in the era of transcatheter procedures]

AIM

To describe single-center evolution of the procedure and to evaluate the results of thoracoscopic clipping of patent ductus arteriosus (PDA) with diameter over 3,0 mm in term infants weighting over 4,0 kg.

MATERIAL AND METHODS

Thoracoscopic clipping of PDA has been performed in 140 patients for the period from March 2012 to March 2018 in Meshalkin National Medical Research Center. Mean age was 4.0 years (range 3 months - 13 years), mean body mass index - 15.4±2.2 kg/m².

INCLUSION CRITERIA

PDA size 3.5-10 mm, Qp/Qs >1,3/1,0, weight 4.0-40 kg. Mean PDA size was 4.6±0.9 mm (range 3.5-8.0 mm), mean pulmonary artery pressure - 34.3±5.8 mm Hg, mean systemic/pulmonary flow Qp/Qs - 1.6±0.3. All patients underwent successful PDA closure through four-port technique under endotracheal general anesthesia and no need for pleural drainage.

RESULTS

Mean procedure time was 24.5±15.5 min. In 29 (20,7%) cases we used titanium clips, in 11 (79.3%) - polymer locking ligating clips. There was 1 conversion to mini-thoracotomy. There were no deaths, bleeding or any other life-threatening complications. 94 (67.1%) patients were weaned from ventilator within operating theatre, in other 46 (32.9%) patients mean ventilation time in ICU was 1.3±1.0 hours. In-hospital postoperative complications: pneumothorax - 2 (1.4%) cases, recurrent laryngeal nerve dysfunction - 1 (0.7%), false croup - 1 (0.7%). There were 2 residual leakages in 2 (1.4%) patients in 10 and 6 months after titanium clip deployment. Both of them underwent transcatheter closure using the coil. Considering these cases all following patients underwent PDA closure by polymer locking ligating clips with no cases of residual leakage.

CONCLUSION

Thoracoscopic PDA closure by polymer locking ligating clip is safe and effective technique for surgical management of PDA with diameter over 3.0 mm in term infants weighting over 4.0 kg.

Incidence, Risk Factors, and Comorbidities of Vocal Cord Paralysis After Surgical Closure of a Patent Ductus Arteriosus: A Meta-analysis

Surgical closure of a patent ductus arteriosus (PDA) is considered standard treatment for symptomatic neonates refractory to medical therapy. Sometimes, iatrogenic injury to the left recurrent laryngeal nerve during the procedure can result in vocal cord paralysis (VCP). This study aimed to estimate the incidence of VCP in patients after surgical PDA closure and to identify any associated risk factors and morbidities associated with VCP in the preterm infant population. A thorough search of the major electronic databases was conducted to identify studies eligible for inclusion into this meta-analysis. Studies reporting data on the incidence of VCP (primary outcomes) or risk factors and morbidities associated with VCP in premature infant population (secondary outcomes) were included. A total of 33 studies (n = 4887 patients) were included into the analysis. Overall pooled incidence estimate of VCP was 7.9% (95%CI 5.3-10.9). The incidence of VCP after PDA closure was significantly much higher in premature infants (11.2% [95%CI 7.0-16.3]) than in non-premature patients (3.0% [95%CI 1.5-4.9]). The data showed that VCP was most common after surgical ligation and in studies conducting universal laryngoscopy scoping. The risk factors for postoperative VCP in preterm infants included birth weight and gestational age. In addition, VCP was significantly associated with the occurrence of bronchopulmonary dysplasia, gastrostomy tube insertion, and increased duration of mechanical ventilation. Vocal cord paralysis remains a frequent complication of surgical closure of a PDA, especially in premature neonates, and is associated with significant post-procedural complications.

Conversion to thoracotomy of video-assisted thoracoscopic closure of patent ductus arteriosus

Introduction

Posterolateral thoracotomy was the access of choice in surgical treatment of patent ductus arteriosus (PDA) for many years before the introduction of video-assisted thoracoscopic surgery (VATS). The latter is thought to reduce postoperative pain and improve musculoskeletal system status. However, it carries a potential risk of conversion to thoracotomy.

Aim

To evaluate the rate, reasons and outcomes of VATS conversion to thoracotomy in surgical PDA patients.

Material and methods

From 2012 to 2017, 112 children were qualified for VATS closure of symptomatic PDA. Among them, 19 (16.9%) with the median age of 19.4 months required conversion to thoracotomy. The predominant reasons for conversion, early mortality and morbidity as well as late survival were evaluated.

Results

The overall conversion rate was 16.9% with an evident learning curve as it decreased significantly from more than 20% at the beginning to approximately 10% in the last 2 years. The predominant reasons were incomplete PDA closure (n = 6; 31.6%) followed by ductal bleeding after clip application (n = 5; 26.3%) and inadequate visualization (n = 5). One child died 48 h after the surgery due to acute cardiopulmonary failure (mortality 5.9%). All patients required postoperative chest tube insertion, and two of them developed postoperative pneumothorax. Neither deaths nor severe adverse events were noted throughout the follow-up period.

Conclusions

The rate of VATS PDA closure conversion to standard thoracotomy features a learning curve. Although it must be considered as a serious complication, probably it does not negatively affect either early the mortality rate or long-term survival.

Thoracoscopy Versus Open Surgery for Persistent Ductus Arteriosus and Vascular Ring Anomaly in Neonates and Infants

BACKGROUND

The aim of our study was to report our experience in thoracoscopy in infants and neonates for vascular surgical conditions in neonates and infants and to compare our results to open surgery regarding the short-term outcome.

PATIENTS AND METHODS

We retrospectively reviewed all the patients operated in a single institution from 1997 to 2016 for persistent ductus arteriosus (PDA) and vascular ring (VR) anomalies. We compared our thoracoscopic series to a historical control group operated by open surgery. Data collection from charts and office notes included age and weight at surgery, cardiac ultrasound data for PDA, preoperative clinical symptoms for VR, type of surgery, operating time, analgesic treatment requirements, ventilation status during postoperative course, and early complications.

RESULTS

The thoracoscopic group included 13 PDA (median age and weight at surgery: 34 days and 1800 g) and 11 VR (median age and weight at surgery: 8 months and 7000 g). The thoracoscopic group did not differ in preoperative symptoms and work-up, operating time, ventilation status, length of hospital-stay, and postoperative complications with the group operated on by thoracotomy, for either PDA or VR.

CONCLUSION

Our short-term results in thoracoscopic PDA closure and VR anomalies surgery in neonates and infants are comparable to open surgery. Thoracoscopy seems to provide less pain especially for neonates and premature babies and allows to decrease the risk for postoperative chest wall deformities. Long-term outcome is mandatory to confirm these preliminary results.

Minimally invasive thoracoscopic closure versus thoracotomy in children with patent ductus arteriosus

BACKGROUND

Patent ductus arteriosus (PDA) is one of the most common congenital heart defects. Once diagnosed, an immediate pharmacologic or invasive treatment should be performed. The purpose of this work was to evaluate the safety and efficacy of surgical PDA ligation in children using video-assisted thoracoscopic surgery (VATS) in comparison with a conventional muscle-sparing posterolateral thoracotomy technique (MSPLT).

MATERIALS AND METHODS

In this single-center, retrospective study 173 children qualified for surgical PDA closure were enrolled. Patients were divided according to their weight and type of surgery performed. The groups consisted of patients operated through thoracotomy (54%) or VATS (46%). Operative characteristics, cosmetic effect, postoperative complications and long-term survival were evaluated.

RESULTS

Regardless of weight, fewer complications were noted in children after thoracoscopic clipping. Fifteen VATS patients required intraoperative conversion to thoracotomy; however, adverse sequelae were not observed. Aesthetics seemed to be the major complaint after conventional surgery. We did not observe any statistically significant differences in the long-term survival between both groups.

CONCLUSIONS

Both techniques were shown to be safe and effective. Unsuccessfully performed thoracoscopic surgeries were safely converted to conventional thoracotomy. VATS, being a less invasive approach, leads to a better aesthetic effect and lower surgical complication rate.

Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether thoracoscopic patent ductus arteriosus (PDA) closure is superior to conventional surgery. Altogether 821 papers were found using the reported search, 11 of which represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Eleven studies included in the analysis consisted of two prospective and three retrospective, non-randomized studies and six case series. Four included studies focused only on preterm infants, three studies enrolled neonates and the other four analysed all age groups from neonates to older children or young adults. There were no differences in mortality between video-assisted thoracoscopic surgery (VATS) and conventional surgery. Two studies suggested that VATS offers shorter operative times. Two papers observed shorter hospital stay, although the other two noted no significant difference. A large prospective trial found VATS to be associated with a lower number of postoperative complications in neonates and infants, whereas other studies suggested no significant differences in short-term postoperative complications. There is little evidence to suggest better musculoskeletal status and cosmesis in neonates following VATS. Conversion from thoracoscopy to thoracotomy described in six papers was seldom and it did not lead to any additional complications. All observational studies confirmed that both techniques are free from major adverse cardiovascular complications and these two techniques can be safely used in all patients qualified for surgical PDA closure. Two studies compared cost-effectiveness between the two techniques; one of them described VATS as significantly more cost-efficient, whereas the other study observed no difference. However, it should be noted that data were provided from different countries and time periods. The results presented suggest that there are no significant differences in early clinical outcomes between VATS and thoracotomy in all age groups. However, where differences have been shown, such as pain, postoperative complications, length of hospital and ICU stay and cost, these favour the VATS approach.

Effect of surgical subspecialty training on patent ductus arteriosus ligation outcomes

PURPOSE

Surgical outcomes data for patent ductus arteriosus (PDA) ligation come primarily from single institution case series. The purpose of this study was to evaluate national PDA ligation trends, and to compare outcomes between pediatric general (GEN) and pediatric cardiothoracic (CT) surgeons.

METHODS

The Pediatric Health Information System database was queried to identify neonates who underwent PDA ligation from 2006 through 2009. Outcomes evaluated included surgical morbidity, in-hospital mortality, length of stay, and total charges. Outcomes were compared between pediatric general and pediatric cardiothoracic surgeons.

RESULTS

The records of 1,482 neonates who underwent PDA ligation were identified and analyzed. Overall mean gestational age was 26 ± 3 weeks and birth weight was 888 ± 428 g. The majority of patients among both surgeons had birth weights of ≤1,000 g (77.2%) and were born at ≤27-week gestation (81.5%). Most of the PDA ligations were performed by pediatric CT surgeons (n = 1,196, 80.7%). The mortality rate did not differ by surgeon subspecialty training (GEN = 5.2%, CT 7.9%, p = 0.16). Neonates in the cardiothoracic surgeon cohort showed lower length of stay (p < 0.001-0.05) and total hospital charges (p < 0.05) among patients with birth weight ≤1,200 g. Proxy measures of surgical morbidity-gastrostomy, fundoplication, and tracheostomy-showed no significant differences between the two surgical subspecialists overall or across birth weight subgroups (p > 0.05).

CONCLUSION

These data provide a contemporary snapshot of PDA ligation outcomes at American children's hospitals. Pediatric general surgeons achieve comparable outcomes performing PDA ligation compared to pediatric cardiothoracic surgeons.

Outcomes of thoracoscopic clipping versus transcatheter occlusion of patent ductus arteriosus: randomized clinical trial

AIM

To compare outcomes of thoracoscopic clipping (TC) versus transcatheter occlusion (TO) for patent ductus arteriosus (PDA).

PATIENTS AND METHODS

One hundred patients were enrolled in the study from May 2010 to December 2011. Those patients were randomized into 2 groups: group one received TC, group two received TO.

RESULT

There were no significant differences concerning width or length of the ductus (P>0.05). However the median age and median weight of patients in the TO group were greater than in the TC group (P<0.05). Mean operative time was 32 ± 12 min in the TC group versus 20 ± 3 min in the TO group (P<0.05). There were no deaths in either group. There were no complications in the TC group whereas three patients in the TO group had complications and required subsequent operation. Median postoperative stay was 3.5 days (IQR: 3.0-4.3) in the TC group versus 3 days (IQR: 2.0-4.0) in the TO group (P<0.05). There was no residual shunting in either group. Average cost for one patient was $645 ± 232 in the TC group versus $1,260 ± 204 in the TO group (P<0.001).

CONCLUSION

Thoracoscopic clipping is safer than transcatheter occlusion for PDA repair, with the same effectiveness and lower cost.

Patent ductus arteriosus in preterm infants: do we have the right answers?

Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.

Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants

BACKGROUND

A patent ductus arteriosus (PDA) with significant left to right shunt increases morbidity and mortality in preterm infants. Early closure of the ductus arteriosus may be achieved pharmacologically or by surgery. The preferred initial treatment of a symptomatic PDA, surgical ligation or treatment with indomethacin, is not clear.

OBJECTIVES

To compare the effect of surgical ligation of PDA versus medical treatment with cyclooxygenase inhibitors (indomethacin, ibuprofen or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA.

SEARCH METHODS

For this update we searched The Cochrane Library 2012, Issue 2, MEDLINE, EMBASE, CINAHL, Clinicaltrials.gov, Controlled-trials.com, Proceedings of the Annual Meetings of the Pediatric Academic Societies (2000 to 2011) (Abstracts2View(TM)) and Web of Science on 8 February 2012.

SELECTION CRITERIA

Randomised or quasi-randomised trials in preterm or low birth weight neonates with symptomatic PDA and comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA.

DATA COLLECTION AND ANALYSIS

The authors independently assessed methodological quality and extracted data for the included trial. We used RevMan 5.1 for analyses of the data.

MAIN RESULTS

One study reporting on 154 neonates was found eligible. No significant difference between surgical closure and indomethacin treatment was found for in-hospital mortality, chronic lung disease, necrotising enterocolitis, sepsis, creatinine level or intraventricular haemorrhage. There was a significant increase in the surgical group in the incidence of pneumothorax (risk ratio (RR) 2.68; 95% confidence interval (CI) 1.45 to 4.93; risk difference (RD) 0.25; 95% CI 0.11 to 0.38; number needed to treat to harm (NNTH) 4 (95% CI 3 to 9)) and retinopathy of prematurity stage III and IV (RR 3.80; 95% CI 1.12 to 12.93; RD 0.11; 95% CI 0.02 to 0.20; NNTH 9 (95% CI 5 to 50)) compared to the indomethacin group. There was a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group (RR 0.04; 95% CI 0.01 to 0.27; RD -0.32; 95% CI -0.43 to -0.21, number needed to treat to benefit (NNTB) 3 (95% CI 2 to 4)). No new trials were identified for inclusion in the 2012 update.

AUTHORS' CONCLUSIONS

There are insufficient data to conclude whether surgical ligation or medical treatment with indomethacin is preferred as the initial treatment for symptomatic PDA in preterm infants.

Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants

This study was designed to compare the long-term clinical outcomes and costs between video-assisted thoracic surgery (VATS) and posterolateral thoracotomy (PT) in neonates and infants. This study enrolled 302 patients with isolated patent ductus arteriosus (PDA) from January 2002 to 2007 and followed them up until April 2010. A total of 134 patients underwent total VATS (VATS group), and 168 underwent PDA closure through PT (PT group). The two groups were compared according to clinical outcomes and costs. The demographics and preoperative clinical characteristics of the patients were similar in the two groups. No cardiac deaths occurred, and the closure rate was 100% successful in both groups. The operating, recovery, and pleural fluid drainage times were significantly shorter in the VATS group than in the PT group. Statistically significant differences in length of incision, postoperative temperature, and acute procedure-related complications were observed between the two groups. The cost was $1,150.3 ± $221.2 for the VATS group and $2415.8 ± $345.2 for the PT group (P < 0.05). No cardiac deaths or newly occurring arrhythmias were detected in either group during the follow-up period. Statistically significant differences in the rate of residual shunt and scoliosis were observed between the two groups. The left ventricular end-diastolic diameter and the pulmonary artery diameter could be restored to normal in the VATS group but not in the PT group. The study confirmed that VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in neonates and infants.

Esophageal stethoscope: an old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for closure of a patent ductus arteriosus (PDA), but is associated with a minute rate of residual or recurrent duct patency. This study aims to analyze the efficacy of intraoperative esophageal stethoscopic monitoring in reducing the incidence of residual ductal flow during PDA clipping by VATS.

METHODS

Between June 1997 and October 2009, we retrospectively assessed 2000 consecutive patients with PDA who underwent VATS. During the procedure, heart sounds were monitored by the anesthesiologist through an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded before and after the PDA clipping and were confirmed to disappear completely. Color flow Doppler echocardiography was performed immediately before discharge, and patients were followed monthly for 3, 6, and 12 months and then annually to confirm the absence of residual or recurrent shunt.

RESULTS

Mean age was 6.0 years (range, 1 month-35 years), mean weight was 11.1 kg (range, 6-65 kg), and mean PDA diameter was 5.5 mm (range, 3-9 mm). Ninety-two percent of patients showed no ductal flow after a single clipping. In the other 8% of patients, residual flow was detected intraoperatively after a single clipping, but was eliminated by the second clipping. Twelve patients (0.6%) presented with residual ductal flow immediately after the operation (detected by color Doppler echocardiography), which was eliminated by thoracotomy before discharge. All patients left the hospital with echocardiography documenting no evidence of residual PDA. At follow-up, the incidence of residual patency was 0.2% (4 of 2000).

CONCLUSIONS

Our results demonstrate that the intraoperative esophageal stethoscope provides a remarkably effective technique for monitoring and evaluating PDA ligation by VATS, thus avoiding reintervention and the complications associated with residual ductal flow in most cases.

Uncommon congenital and acquired aortic diseases: role of multidetector CT angiography

State-of-the-art multidetector computed tomographic (CT) technology has replaced invasive angiography for evaluation of patients suspected to have aortic disease. Although most aortic disease is associated with atherosclerosis (ie, aneurysms and dissection), the spectrum of aortic disease is vast and includes various congenital and acquired entities. Radiologists should also be familiar with uncommon aortic diseases, which are divided into those that are congenital in origin and acquired disorders, and with their findings at multidetector CT. The first group includes patent ductus arteriosus, aortic hypoplasia, aortic coarctation, interrupted aortic arch, aortopulmonary window, common arterial trunk, supravalvular aortic stenosis, and vascular rings. The acquired disorders include aortic dissection due to extension of a coronary artery dissection, Marfan syndrome, large-vessel vasculitis such as Takayasu arteritis, and mycotic aneurysms. Finally, specific conditions associated with therapeutic maneuvers--such as recoarctation, stent-graft rupture, and endoleaks--can also be assessed with multidetector CT. Multidetector CT is an alternative tool helpful in establishing the primary diagnosis, defining anatomic landmarks and their relationships, and identifying associated cardiovascular anomalies. It is also an adjunct in the evaluation of complications during follow-up.

Patent ductus arteriosus closure in prematurities weighing less than 1 kg by subaxillary mini-thoracotomy

The surgical closure of patent ductus arteriosus (PDA) is provided more frequently in extremely low birth weight babies who are usually deemed unsuitable for pharmacological closure. We have adopted subaxillary mini-thoracotomy in order to lessen surgical trauma in these babies; and its clinical results were analyzed. From April 2004 to August 2008, out of 50 babies at the neonatal intensive care unit who underwent the surgical closure of PDA, 22 premature babies weighing less than 1 kg at operation were included in the study. Eleven babies were males and mean gestational age was 27 weeks ranging from 23(+3) to 30(+2) weeks. Mean body weight at operation was 816 g ranging from 490 to 989 g and average age at operation was 17.9+/-11.9 days. Of them, 17 babies (72%) were ventilator dependent preoperatively, as compared with 13 out of 28 (46%) babies that weighed more than 1 kg (P<0.05). Four babies did not survive to discharge. Among 28 babies who were heavier than 1 kg, there were only one death. However, the mortality difference was not statistically significant (P=0.11). All mortalities were caused by inherent problems of prematurity and co-morbidities. Out of 17 babies who had been ventilator dependent preoperatively, 13 weaned off successfully at 17.0+/-23.9 days after the operation. The baby patients heavier than 1 kg weaned at 6.0+/-5.3 days (P=0.27). Surgical outcome of simple and less invasive subaxillary mini-thoracotomy was satisfactory; the surgery is highly recommended for ductal closure in extremely low weight premature babies.

Acute hemodynamic decompensation following patent ductus arteriosus ligation in premature infants

INTRODUCTION

Patent ductus arteriosus (PDA) ligation can lead to postoperative hemodynamic instability requiring inotropic support, termed hemodynamic decompensation. The purpose of this study was to prospectively determine the incidence, predictors, and clinical impact of hemodynamic decompensation after PDA ligation in preterm infants.

METHODS

All infants undergoing PDA ligation were eligible for this prospective cohort study. After undergoing ligation, patients were followed until 30 days after successful extubation, discharge from the NICU, or death. Data collection included perinatal and preoperative clinical information, operative details, postoperative course, and outcome.

RESULTS

Ninety-six preterm infants were enrolled and underwent PDA ligation. Hemodynamic decompensation occurred in 27 patients (28%). Overall in-hospital mortality rate was 18%. Mortality was significantly higher among infants that developed hemodynamic decompensation (33% vs 11%, p = .012). Hemodynamic decompensation was associated with an adjusted odds ratio (OR) for death of 3.1 (95% confidence interval: 1.0-9.5, p = .05). Lower estimated gestational age, lower corrected age, and higher rate of preoperative mechanical ventilation were significant predictors of hemodynamic decompensation.

CONCLUSION

Hemodynamic decompensation occurred in 28% of patients after PDA ligation, resulting in a significantly higher mortality. Younger patients requiring higher ventilator support are most likely to develop hemodynamic decompensation.

Patent ductus arteriosus in preterm neonates

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.

Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) with significant left to right shunt in preterm infants increases morbidity and mortality. Early closure of the ductus arteriosus may be achieved pharmacologically using cyclooxygenase inhibitors or by surgery. The efficacy of both treatment modalities is well established. However, the preferred initial treatment of a symptomatic PDA in a preterm infant, surgical ligation or treatment with indomethacin, has not been well established.

OBJECTIVES

To compare the effect of surgical ligation of PDA vs. medical treatment with cyclooxygenase inhibitors (using indomethacin, ibuprofen, or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included search of electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - July 2007), CINAHL (1982 - July 2007), EMBASE (1980 - July 2007); and hand search of abstracts of Pediatric Academic Societies annual meetings published in Pediatric Research (1990 - April 2002) or on line from May 2002 -July 2007. No language restrictions were applied.

SELECTION CRITERIA

All trials 1) using randomized or quasi-randomized patient allocation, 2) in preterm infants < 37 weeks gestational age or low-birth-weight infants (< 2500 grams) with symptomatic PDA in the neonatal period (< 28 days) and 3) comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA.

DATA COLLECTION AND ANALYSIS

Assessment of methodological quality and extraction of data for included trials was undertaken independently by the authors. RevMan 4.1 was used for analysis of the data.

MAIN RESULTS

Only one study, trial B in the report of Gersony 1983, was found eligible. No additional studies were identified in the literature searches performed in July 2007. The trial compared the effect of surgical ligation of PDA vs. medical treatment with indomethacin, each used as the primary treatment. No trials comparing surgery to other cyclooxygenase inhibitors (ibuprofen, mefenamic acid) were found. Trial B of Gersony 1983 enrolled 154 infants. The study found no statistically significant difference between surgical closure and indomethacin treatment in mortality during hospital stay, chronic lung disease, other bleeding, necrotizing enterocolitis, sepsis, creatinine level, or intraventricular hemorrhage. There was a statistically significant increase in the surgical group in incidence of pneumothorax [RR 2.68 (95% CI 1.45, 4.93); RD 0.25 (95% CI 0.11, 0.38); NNH 4 (95% CI 3, 9)] and retinopathy of prematurity stage III and IV [RR 3.80 (95% CI 1.12, 12.93); RD 0.11 (95% CI 0.02, 0.20), NNH 9 (95% CI 5, 50] compared to the indomethacin group. There was as expected a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group: [RR 0.04 (95% CI 0.01, 0.27); RD -0.32 (95% CI -0.43, -0.21), NNT 3 (95% CI 2, 4)].

AUTHORS' CONCLUSIONS

The data regarding net benefit/harm are insufficient to make a conclusion as to whether surgical ligation or medical treatment with indomethacin is preferred as initial treatment for symptomatic PDA in preterm infants. It should be noted that three recent observational studies indicated an increased risk for one or more of the following outcomes associated with PDA ligation; chronic lung disease, retinopathy of prematurity and neurosensory impairment . It is possible that the duration of the "waiting-time" and transport to another facility with surgical capacity to have the PDA ligated could adversely affect outcomes, as could the perioperative care.

Evolution of strategies for management of the patent arterial duct

Persistent patency of the arterial duct represents one of the most common lesions in the field of congenital cardiac disease. The strategies for management continue to evolve. In this review, we focus on management beyond the neonatal period. We review the temporal evolution of strategies for management, illustrate the currently available the techniques for permanent closure of the patent arterial duct, review the expected outcomes after closure, discuss the current controversy over the appropriate treatment of the so-called "silent" duct, and provide recommendations for the current state of management of patients with persistent patency of the arterial duct outside of the neonatal period.At the Congenital Heart Institute of Florida, we now recommend closure of all patent arterial ducts, regardless of their size. Before selecting and performing the type of procedure, we explain the natural history of the persistently patent arterial duct to the parents or legal guardian of the child. Particular emphasis is placed on the risks of endocarditis, including the recognition that many cases of endocarditis may not be preventable. The devastating effects of endocarditis, coupled with the perception of more anecdotal reports of endocarditis with the silent duct, as well as the low risk of interventions, has led us to recommend closure of the patent arterial duct in these situations. We now recommend intervention, after informed consent, for all patients with a patent arterial duct regardless of size, including those in which the patent duct is "silent". We recognize, however, that this remains a controversial topic, especially given the new recommendations for endocarditis prophylaxis from American Heart Association. Since 2003, our strategy for closure of the patent arterial duct has changed subsequent to the availability of the Amplatzer occluder. This new device has allowed significantly larger patent arterial ducts to be closed with interventional catheterization procedures that in the past would have been closed at surgery. During the interval between 2002 and 2006 inclusive, the overall surgical volume at our Institute has been stable. Over this period, the number of patients undergoing surgical ligation of the patent arterial duct has decreased, with this decline in volume most notable for the subgroup of patients weighing more than five kilograms. This decrease has been especially notable in thoracoscopic procedures and is attributable to the increased ability to close larger ducts using the Amplatzer occluder. For infants with symptomatic pulmonary overcirculation weighing less than 5 kilograms, our preference is for the surgical approach. For patients who have ductal calcification, significant pleural scarring, or "window-like" arterial ducts, video-assisted ligation is not an option and open surgical techniques are used. When video-assisted ligation is possible, the approach is based on family and surgeon preference. When open thoracotomy is selected, we usually use a muscle-sparing left posterolateral thoracotomy. For patients weighing more than 5 kilograms, we currently recommend percutaneous closure for all patent arterial ducts as the first intervention, reserving surgical treatment for those cases that are not amenable to the percutaneous approach. For symptomatic infants weighing greater than 5 kilogram with large ducts, we prefer to use the Amplatzer occluder. In rare instances, the size of the required ductal occluder is so large that either encroachment into the aorta or pulmonary arteries is noted, and the device is removed. The child is then referred for surgical closure. We can now often predict via echocardiography that a duct is too large for transcatheter closure, even with the Amplatzer occluder, and refer these patients directly to surgery. For patients with an asymptomatic patent arterial duct, we prefer to wait until the weight is from 10 to 12 kilograms, or they are closer to 2 years of age. If the patent arterial duct is greater than 2.0 to 2.5 millimetres in diameter, our preference is to use the Amplatzer occluder. For smaller ducts, we typically use stainless steel coils. Using this strategy, we close all patent arterial ducts, regardless of their size.

Minimally invasive neonatal surgery

Minimally invasive surgery is now an option to patients as light as 1.2 kg, extending the benefits of small incisions, faster recoveries, decreased pain, and more precise procedures in critically ill neonates. This article provides a review of the historical development of minimally invasive surgery and an overview of the equipment involved, identifies the roles of the neonatal and perioperative nurse, and briefly describes several minimally invasive surgery procedures currently performed in the neonatal population.

Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques

OBJECTIVE

To review our 12-year experience in video-assisted thoracoscopic surgery (VATS) for patent ductus arteriosus.

METHODS

VATS was performed in 743 patients. Three groups were compared: 24 low-birth-weight infants (LBWIs), 676 children between 2.5-25 kg and 43 boys > 25 kg. A diameter of > 8 mm was the main contraindication. For 85 consecutive patients, hospital stay underwent cost analysis.

RESULTS

Median age was 1.6 years (range 5 days-33 years) and median weight 9.0 kg (range 1.2-65 kg). Mortality was nil. Median operative time was 20 min and hospital stay 2 days. Residual patency at discharge was 0% in LBWIs, 0.7% in children, and 4.7% in boys (P = NS) and 0, 0.3, and 4.7% at follow-up (P = 0.001). Persistent recurrent laryngeal nerve dysfunction was recorded in 4.2% of LBWIs, 0.3% of children and 0% of boys (P = 0.012). Total mean cost was Euro 5954 +/- 2110.

CONCLUSIONS

The success rate of VATS clipping compares favorably with the thoracotomic approach but without chest wall trauma and it may have a very favorable cost-effective therapeutic balance compared to transcatheter techniques.

Consequences of Delayed Surgical Closure of Patent Ductus Arteriosus in Very Premature Infants

BACKGROUND

Surgical closure of ductus arteriosus is commonly indicated in premature newborns. The aim of this study was to assess short-term and mid-term effects of delayed surgical closure of the ductus arteriosus on respiratory and digestive outcome in extremely preterm infants.

METHODS

We retrospectively studied 58 infants less than 28 weeks gestational age who underwent surgical closure of ductus arteriosus between January 1997 and December 2002. Nine infants with intrauterine growth restriction and major congenital malformation were excluded from the study. Criteria for surgical closure of ductus arteriosus were: (1) medical treatment failure (ie, indomethacin or ibuprofen) and (2) hemodynamically patent ductus arteriosus: systemic arterial pressure less than gestational age in mm Hg, heart failure, left atrial-aortic root ratio greater than 1.6, mean velocity in the left pulmonary artery greater than 0.6 m/s, and ductus arteriosus diameter greater than 3 mm. Infants were divided into two groups: (1) the early group who had surgery before 21 days of life (n = 31), and (2) the late group who had surgery after 21 days of life (n = 27). Preoperative and postoperative criteria were compared between the two groups (ie, gestational age, birth weight, hemodynamic, ventilatory, and echographic [left atrial-aortic root ratio, mean velocity in the left pulmonary artery] parameters).

RESULTS

Preoperative gestational age and birth weight did not differ between the two groups. In the early group, gestational age was 26 weeks (range, 23 to 28 weeks and birth weight was 800 g (range, 630 to 1,240 g). In the late group, gestational age was 26 weeks (range, 24 to 28 weeks) and birth weight was 840 g (530 to 1,130 g). Hemodynamic, ventilatory, and echographic parameters were similar in both groups. Rate of bronchopulmonary dysplasia was similar in both groups. However, at 24 hours post surgery, median FiO2 was higher in the late group (28% [range, 21% to 65%]) than in early group (21% [range, 21% to 60%]) (p < 0.05). Furthermore, full oral feeding was acquired later in the late group (57 days of life [range, 30 to 136 days]) than in the early group (37 days of life [range, 27 to 84 days]) (p < 0.01), and body weight at 36 weeks of post-conceptional age was higher in the early group at 1,800 g (range, 1,250 to 2,750 g) than in the late group at 1,607 g (1,274 to 2,200 g) (p < 0.05).

CONCLUSIONS

Our findings show that early surgical closure of the ductus arteriosus (< 3 weeks of life) is associated with shortened delay for full oral feeding and improved body growth when compared with late surgical closure (> 3 weeks of life).

Surgeons should provide minimally invasive approaches for the treatment of congenital heart disease

The basis for pursuing techniques for less invasive surgery on children with congenital heart disease is to reduce the known long-term morbidities of thoracotomy and sternotomy. In addition, rapid return to normal activities, reduced length of stay, and better pain control may be achieved. Several congenital lesions have been successfully treated with innovative minimally invasive techniques; however, further technique and technology development is required to accomplish repair of the more complex defects safely and effectively.

Minimally Invasive Patent Ductus Arteriosus Occlusion in 5 Dogs

OBJECTIVE

To report a technique for minimally invasive occlusion of patent ductus arteriosus (PDA) and outcome in 5 dogs.

STUDY DESIGN

Clinical cases.

ANIMALS

Five, 4-6-month-old, dogs with PDA.

MATERIALS AND METHODS

Titanium ligating clips were used for PDA closure in all dogs. Three dogs had video-enhanced mini-thoracotomy PDA occlusion. Two other dogs had thoracoscopic PDA occlusion using a custom-designed thoracoscopy clip applicator.

RESULTS

Thoracoscopic PDA occlusion was successful in both dogs in which it was attempted. Complete PDA closure was achieved in 4 dogs. Three months after surgery, the largest dog had residual ductal flow that hemodynamically was insignificant.

CONCLUSIONS

Although technically demanding, minimally invasive PDA occlusion is a safe and reliable technique in dogs. Preoperative measurement of the diameter of the PDA is crucial to determine if complete closure with metal clips can be achieved.

CLINICAL RELEVANCE

Minimally invasive PDA occlusion should be considered as an alternative to occlusion via conventional thoracotomy.

Minimally invasive surgery in the neonate: review of current evidence

Minimally invasive surgery has been one of the most important surgical advances in the last 15 years. The development of smaller instruments has allowed pediatric surgeons to apply this rapidly evolving technology to neonates. Congenital neonatal deformities including tracheoesophageal fistula, patent ductus arteriosus, duodenal atresia and anorectal malformations are now being managed with minimally invasive surgery. This article summarizes the status of these techniques in neonates.

Video-assisted ductal ligation in premature infants

BACKGROUND

Video-assisted thoracic surgery has been shown to be a safe and effective method of closing the patent ductus arteriosus in infants and children. We have applied this technique in low birth weight premature infants and now report our experience.

METHODS

Since 1996, we have used video-assisted thoracic surgery ligation as the treatment of choice for all patent ductus arteriosus, including 100 performed on premature infants (23 to 31 weeks' gestation, mean 25.6 weeks; 0.420 to 1.5 kg, mean 0.859 kg). A modification of our previously described technique was used with a three-port approach. All patients had some degree of symptoms of congestive failure with failure to wean from ventilatory support or oxygen dependency. Five infants had associated patent foramen, and 1 had a small ventricular septal defect.

RESULTS

All 100 procedures were performed in the operating room. One infant was found to have a coarctation, and the procedure was aborted. The remaining 99 were successfully ligated, although three were converted to an open procedure (3%) because of coagulopathy, poor pulmonary compliance, or hemodynamic instability. There were no procedure-related deaths; however, 15 infants subsequently died of complications of prematurity, including enterocolitis, sepsis, and late respiratory failure. Six infants had chest tubes left in place for coagulopathy, effusions, suspected air leak, and existing empyema. There were six residual pneumothoraces, four requiring treatment.

CONCLUSIONS

Video-assisted thoracic surgery is a safe and effective technique for patent ductus arteriosus ligation in premature infants, including those with very low and extremely low birth weight.

The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional cardiology coil occlusion

BACKGROUND

In an effort to analyze our experience and develop treatment guidelines, we reviewed all our patients with patent ductus arteriosus (PDA) treated with video-assisted thoracoscopic surgery (VATS) or interventional cardiology coil occlusion.

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.

Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) with significant left to right shunt in preterm infants increases morbidity and mortality. Early closure of the ductus arteriosus may be achieved pharmacologically using cyclooxygenase inhibitors, or by surgery. The efficacy of both treatment modalities is well established. However, the preferred initial treatment of a symptomatic PDA in a preterm infant, surgical ligation or trial of indomethacin, has not been well established.

OBJECTIVES

To compare the effect of surgical ligation of PDA versus medical treatment with cyclooxygenase inhibitors (using indomethacin, ibuprofen, or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included search of electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2002), MEDLINE (1966 - December 2002), CINAHL (1982 - December 2002), EMBASE (1980 - December 2002); and hand search of abstracts of Pediatric Academic Societies annual meetings published in Pediatric Research (1990 - April 2002). No language restrictions were applied.

SELECTION CRITERIA

All trials 1) using randomized or quasi-randomized patient allocation, 2) in preterm infants < 37 weeks gestational age or low-birth-weight infants (< 2500 grams) with symptomatic PDA in the neonatal period (< 28 days) and 3) comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA.

DATA COLLECTION AND ANALYSIS

Assessment of methodological quality and extraction of data for included trials was undertaken independently by the authors. RevMan 4.1 was used for analysis of the data.

MAIN RESULTS

Only one study, trial B in the report of Gersony 1983, was found eligible. The trial compared the effect of surgical ligation of PDA versus medical treatment with indomethacin, each used as the primary treatment. No trials comparing surgery to other cyclooxygenase inhibitors (ibuprofen, mefenamic acid) were found. Trial B of Gersony 1983 enrolled 154 infants. The study found no statistically significant difference between surgical closure and indomethacin treatment in mortality during hospital stay, chronic lung disease, other bleeding, necrotizing enterocolitis, sepsis, creatinine level, or intraventricular hemorrhage. There was a statistically significant increase in the surgical group in incidence of pneumothorax [RR 2.68 (95% CI 1.45, 4.93); RD 0.25 (95% CI 0.11, 0.38); NNH 4 (95% CI 3, 9)] and retinopathy of prematurity grade III and IV [RR 3.80 (95% CI 1.12, 12.93); RD 0.11 (95% CI 0.02, 0.20), NNH 9 (95% CI 5, 50] compared to the indomethacin group. There was as expected a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group: [RR 0.04 (95% CI 0.01, 0.27); RD -0.32 (95% CI -0.43, -0.21), NNT 3 (95% CI 2, 4)].

REVIEWER'S CONCLUSIONS

The data regarding net benefit/harm are insufficient to make a conclusion as to whether surgical ligation or medical treatment with indomethacin is preferred as initial treatment for symptomatic PDA in preterm infants.

Advances in fetal and neonatal surgery for gastrointestinal anomalies and disease

The last decade has seen considerable improvement in the understanding and treatment of neonatal surgical disorders. Translation of basic molecular biology research to clinical practice has directly improved the understanding and treatment of a number of congenital, developmental disorders, such as Hirschsprung's disease and congenital hyperinsulinism. Miniaturized instruments and improved optics have permitted increased use of videoscopic and minimally invasive techniques to even the smallest infants. Continued improvements in prenatal imaging will permit enhanced understanding of the prenatal natural history of congenital structural disorders and the development of more specific therapies. Finally, rigorous clinical research tools have begun to be applied to rare pediatric surgical disorders with the use of organized multicenter trials. It is an exciting time for all involved in the care of neonates.

Patent ductus arteriosus in preterm neonates

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.

Reducing the trauma of congenital heart surgery

While describing the circulatory system in De Moto Cordis, in 1628, William Harvey developed precepts for investigation, which could be modified slightly to guide the adoption of new technology and technique in the twenty-first century. Harvey might suggest (1) careful and accurate observation and description of a new technique, (2) a tentative explanation of how the technique improves on existing techniques, (3) a controlled testing of the hypothesis, and (4) conclusions based on the results of the experiments. Also, he might admonish surgery today, with its massively enhanced capabilities for information management, to rigorously test the validity of these conclusions with quantitative reasoning. In the future, precise measurement of the "trauma" of surgery, or even an individual surgeon, may be possible, and the long-term impact of a chest wall incision on a patient's self-esteem may be predictable. Absent such objective measures, justifications for "minimally invasive" deviations from conventional technique in surgery for CHD lack substance. Morbidity, mortality, and physiological endpoints will continue to form the foundation for therapeutic plans; however, the potential for emerging technology to reduce the trauma of these plans remains tantalizing.

Late follow-up after thoracoscopic ductal ligation

Interventional catheterization and minimally invasive surgical techniques offer the real possibility of a reduction in cost and morbidity when compared with the traditional surgical approach to patent ductus arteriosus. Video-assisted thoracoscopic surgery may prove to be a superior technique because of its application to a wider range of patients needing ductal closure, a lower incidence of residual shunting, no evidence for recurrent shunting, and the absence of intravascular foreign bodies.

Congenital Heart Surgery Nomenclature and Database Project: patent ductus arteriosus, coarctation of the aorta, interrupted aortic arch

The extant nomenclature for patent ductus arteriosus (PDA), coarctation of the aorta (CoAo), and interrupted aortic arch (IAA) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. PDA is subclassified by origin, insertion, and patient weight. CoAo is subclassified into isolated CoAo, CoAo with ventricular septal defect, and CoAo with complex intracardiac anomalies. IAA is subclassified into anatomic types A, B, and C based on the location of the interruption. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.