The Current Role of Surgery in Treating Adult Patients with PatentDuctus Arteriosus

Bosko P. Djukanovic, MD, PhD, Slobodan Micovic, MD, Ivan Stojanovic, MD, PhD,Dragana Unic-Stojanovic, MD, Sinisa Birovljev, MD, and Petar M. Vukovic, MD, PhD

Department of Cardiac surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia

A B S T R A C T

Objective. Surgical closure of patent ductus arteriosus (PDA) is still required in selected adult patients. We analyzedthe morphology of the anomaly and coexisting pathological findings in adult patients who were recently referred toour institute for surgical PDA repair.Patients and Interventions. Six adult PDA patients who were not considered candidates for percutaneous closureunderwent surgical PDA correction. In three patients with isolated PDA, computed tomographic scan revealedshort, wide, and distorted ductus. In the remainder three patients, concomitant heart or aortic disease was found.Transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest was performed.Results. In all patients, a Dacron patch was used to close the duct. The balloon occlusion technique with normo-thermic cardiopulmonary bypass was performed in four patients. In one of these patients, the balloon occlusion wasnot feasible because of unfavorable ductal anatomy, and PDA was closed in short hypothermic circulatory arrest. Intwo patients with aortic aneurysm, PDA closure and aortic reconstruction were performed in deep hypothermiccirculatory arrest. No significant complications occurred during postoperative course. After the mean follow-upperiod of 48 months, neither ductal reopening nor aneurysmal degeneration of remnant ductal tissue was found.Conclusion. Surgical PDA closure in adults remains the treatment of choice in wide, deformed PDAs unsuitable forpercutaneous closure and PDAs associated with surgical aortic or heart disease.

Key words. Congenital Heart Disease; Patent Ductus Arteriosus; Surgery

Introduction

Various medical and interventional strategiesare currently applied to treat pediatric

patients with patent ductus arteriosus (PDA).1–4

Significant defects are generally closed in earlychildhood, and PDA correction in adulthood israrely required.

In the past, open surgical closure was the treat-ment of choice in adult PDA patients.5–7 In recentyears, less invasive treatments evolved and becamethe preferred therapeutic option. However, surgi-cal closure of PDA is still required in selected adultpatients. We analyzed the morphology of theanomaly and coexisting pathological findings inadult patients who were recently referred to ourinstitute for surgical PDA correction. Thisresearch was conducted to provide an insight inthe current role of surgery in treating adult PDApatients, with no intention to promote a new sur-gical technique.

Methods

Six adult PDA patients, who were not consideredcandidates for percutaneous closure, were oper-ated in the period from January 2003 to May 2013.There were two male and four female patients,with median age 50 years (range, 23–60 years;Table 1).

In three patients with isolated PDA, computedtomographic scan revealed short, wide, and tortu-ous ductus, unsuitable for percutaneous coil occlu-sion. In two patients, severe calcifications aroundthe duct were seen on CT scan (Figure 1).

In the remainder three patients, concomitantaortic or heart valve disease was found: Severeaortic stenosis was diagnosed in one patient,whereas two patients (Figures 2 and 3) had theascending aortic aneurysm (one of the patients hadthe aneurysm extending into the proximal arch).

Pulmonary to systemic blood flow ratio (Qp/Qs) was 2.27 ± 0.49 (range 1.73 to 3.12), and

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pulmonary arterial systolic pressure (PAP) was52.2 ± 15.1 mm Hg (range 34–78 mm Hg). Allpatients were New York Heart Association(NYHA) functional class II.

Operative ProcedureTransesophageal echocardiography (TEE) wasperformed in the operating theater to visualizethe duct. The heart was approached throughmedian sternotomy. Normothermic cardiopulmo-

nary bypass (CPB) was established with bicavalcannulation, and cold blood antegrade and retro-grade cardioplegia were delivered. The branchpulmonary arteries were temporarily occluded tomaintain adequate perfusion pressures and toprevent pulmonary overflow. The pulmonarytrunk was longitudinally opened under total CPB.Balloon occlusion of the PDA was achieved usinga 20F Foley catheter. The catheter was insertedinto the duct and then inflated. A Dacron patchwas used to close the duct. Pledgeted 4-0 polypro-pylene sutures were placed around the circumfer-

Table 1. Preoperative Characteristics

Case Age (Years) GenderConcomitantAortic Disease LVEF Qp/Qs PAP (mm Hg)

1 23 M + 0.55 1.73 422 60 M + 0.45 2.41 573 47 F − 0.6 3.12 784 60 F + 0.35 1.92 345 53 F − 0.4 2.38 536 34 F − 0.6 2.07 49Mean + SD 46.2 ± 14.9 0.49 ± 0.11 2.27 ± 0.49 52.2 ± 15.1

F, female; LVEF, left ventricular ejection fraction; M, male; PAP, pulmonary artery pressure; Qp/Qs, pulmonary to systemic blood flow ratio; SD, standard deviation.

Figure 1. Wide and deformed patent ductus arteriosus sur-rounded with severe calcifications of the aorta.

Figure 2. The ascending aortic aneurysm extending intothe proximal arch associated with the calcified patentductus arteriosus (PDA) (CT angiogram, coronal view). Thearrow denotes the PDA. Ao, aorta; PA, pulmonary artery.

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ence of the orifice and then passed through thepatch. Patch was brought to the orifice of the ductusing parachute technique, and the sutures weretied. Last two sutures were tied after deflation andremoval of the catheter. The pulmonary arteri-otomy was closed.

In patients with aortic aneurysm, the aorticreconstruction was performed with the use of deephypothermic circulatory arrest. Patients weregradually cooled to 18°C, and hypothermic circu-latory arrest was established. First, the aortic aneu-rysm (including the proximal hemiarch whenneeded) was resected. The area around the duct(the distal arch) was not excised. Then, PDA wasclosed using transpulmonary approach. The pul-monary artery was sutured. Tubular Dacron graftwas distally anastomosed with the residual aorticarch. The aortic cannula was placed into the graft,and CPB was reestablished. Aortic reconstructionwas completed with CPB.

Before weaning from CPB, TEE was used toassess the residual shunt after PDA closure.

Results

In all patients, a Dacron patch was used to closethe duct. The operative details are summarized inTable 2.

The balloon occlusion technique with normo-thermic CPB was performed in four patients. Inone of these patient (case no. 5, Table 2), theballoon occlusion was not feasible because of unfa-vorable ductal anatomy, and PDA was closed inshort hypothermic circulatory arrest.

Two patients had aortic aneurysm (cases no. 1and 2, Table 2). In these patients, the aortic recon-struction and PDA closure were performed indeep hypothermic circulatory arrest, and ante-grade cerebral perfusion was applied.

TEE performed by the end of operationshowed no residual shunt.

No death nor significant complicationsoccurred during postoperative hospitalization.

After surgery, patients underwent an echocar-diographic control. The mean follow-up was 48months (range 7–87 months). No major adversecardiovascular or other significant clinical eventswere recorded during follow-up period. Two outof six patients improved their NYHA functionalclass to grade I. Neither ductal reopening noraneurysmal degeneration of remnant ductal tissuewas recorded on echocardiographic control. PAPdecreased significantly on control (37.3 +8.5 mm Hg).

Discussion

In adult patients with significant PDA, the deci-sion whether to close the defect with percutaneousdevices or to perform surgical closure depends onmultiple factors including the morphology of theanomaly and concomitant heart and aortic dis-eases. Our results indicate that, in recent years,

Figure 3. Patent ductus arteriosus (PDA) in patient withascending aortic aneurysm (CT angiogram, axial view). Thearrow denotes the PDA. Ao, aorta, PA, pulmonary artery.

Table 2. Operative Data

CaseConcomitantProcedure

CPB Time(min)

AorticClampTime (min)

CirculatoryArrestTime (min)

1 Bentall op 123 52 49*2 SAR 111 96 36*3 — 63 41 —4 AVR 89 72 —5 — 91 57 106 — 47 33 —Mean + SD 87.3 ± 28.5 58.5 ± 22.8

*Antegrade cerebral perfusion.AVR, aortic valve replacement; Bentall op, Bentall operation; CPB, cardiopul-monary bypass; SAR, supracoronary aortic replacement; SD, standarddeviation.

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surgical closure was reserved for (1) short, wide,and deformed PDAs unsuitable for percutaneousclosure and (2) PDAs associated with surgicalaortic or heart diseases.

Current therapeutic options for PDA closurein adults include transcatheter occlusion or deviceclosure, video-assisted thoracoscopic surgery(VATS) ligation, and open surgical correction.

VATS ligation of PDA and transcatheter occlu-sion are minimally traumatic and complementarytechniques for PDA treatment.2,3

These techniques are applicable to the greatmajority of isolated PDAs outside of the neonatalperiod. However, patients with large PDAs maylack a PDA “neck” required for coil occlusion.Residual shunting, coil emboliazation, andreopening after successful coil occlusion are morelikely in large PDAs. On the other hand, VATS iscontraindicated in patients with calcified ducts,severe pleural scarring, or short, wide, window-like ducts.2 There is an agreement that patientswith short, wide, window-like ducts are not candi-dates for coil occlusion or VATS.2 These patientsrequire surgery. Furthermore, PDAs too large fordevice closure or with distorted ductal anatomyincluding aneurysm or postendarteritis are con-traindicated for percutaneous occlusion.8 Inad-equate exposure during VATS or uncontrollablebleeding indicates conversion to thoracotomy.Rarely, urgent surgical management for embolizedcoils and occluder devices is needed.9

Various techniques for surgical correction ofPDA were described. PDA was approachedthrough thoracothomy or sternotomy, with orwithout the use of CPB. Left heart bypass and ashunt from the left subclavian artery to thedescending thoracic aorta were also reported.10,11

The duct was simply ligated, or divided and sub-sequently ligated. PDA was closed directly, or thepatch closure was performed.

Left posterolateral thoracothomy with crossclamping of the aorta was reported in elderlypatients.5 The ductus was divided, and both sideswere over-sewn with running suture. However,direct aortic closure may be complicated by fragileaortic wall and severe calcification around theductus which often occur in adults. Therefore, anumber of surgeons rely on sternotomy, CPB, andtranspulmonary approach. This method enablessafe PDA correction in cases with complicatedanatomy of the duct. A patch closure is performedwhen needed.

Omari and associates reported successful use ofFoley catheter balloon occlusion to repair the

short, wide PDA in adults during normothermicCPB.6 The method was effective for both directand patch repairs.12 The authors emphasized thatwith careful technique, balloon rupture did notoccur. We applied this technique in patients withisolated PDA. No balloon rupture was recorded,but in one patient, unfavorable ductal anatomydisabled proper Foley catheter placing, and we hadto perform the correction in short circulatoryarrest.

Robinson and associates reported the use ofdeep hypothermia and circulatory arrest in treat-ing adult patients with PDA.7 During the years,this technique proved to be effective.13

We applied this technique in patients withaneurysmatic dilatation of the arch and/or ascend-ing aorta. When longer arrest was expected, ante-grade cerebral perfusion was established. Thistechnique has several advantages. As there is nobackbleeding from the aorta through the duct, itenables excellent visualization of the anomaly. Thecorrection of wide, distorted, or calcified ductuscan be effectively performed. During suturing,no care is taken to avoid Foley catheter balloondisplacement and rupture.

Obviously, all side effects associated with deephypothermia may occur when circulatory arrestis used: coagulopathy, organ dysfunction, andextended CPB time needed for cooling andrewarming.14 We did not observe prolonged ICUstay because of organ dysfunction, and there wasno rethoracotomy because of coagulopathy andexcessive bleeding. However, these complicationscan be expected in larger series.

Just recently, a novel stent graft was successfullyapplied to close the aneurysm evolving from PDAtissue.15 More reports will bring better insight ineffectiveness and safety of stent graft placement inadult PDA patients.

Surgical PDA closure in adults remains thetreatment of choice in wide, deformed PDAsunsuitable for percutaneous closure and PDAsassociated with surgical aortic or heart diseases.

Author Contributions

B.D. designed the study; B.D., S.M., I.S., and S.B. per-formed the operations and wrote the sections of the manu-script; D. U.S. collected data; P.V. is the correspondingauthor and made a critical revision of article.

Corresponding Author: Petar M. Vukovic, MD, PhD,Department of Cardiac surgery, Dedinje Cardiovascu-lar Institute, Milana Tepica 1, Belgrade 11040, Serbia.

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Tel: (+381) 11-3601647; Fax: (+381) 11-3547856;E-mail: petarvuk@eunet.yu

Conflict of interest: No conflict of interest, grants, orother financial support.

Accepted in final form: December 16, 2013.

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