Clinical experiences in the surgical treatment of 143 patients with patent ductus arteriosus

Clinical Treatment

Experiences in the Surgical of 143 Patients with Patent Ductus Arteriosus IIERCCHEL

From

the Department

of

E. ~~IOZEN,

Surgery,

University School 0s Medicine and pilals oj Cleveland, Cleveland, Ohio.

Western Re.
M.D.,

Cleveland, Ohio

Figure I is the original illustration which ac. companied their article. It is evident that surgeons have considered closure of the patent ductus for a long time before the actual performance of the operation. (Fig. I .j The first attempt to ligate a patent ductus was reported by Graykiel, Strieder and Boyer [3]. On March 16, 1937, the operation Ivas performed on a patient with subacute bacterial endocarditis due to Streptococcus viridans. Because of technical diffrcuIties during the operation, the ductus was cIosec1 only partially with pIicating sutures. The patient died on the fourth postoperative day due to acute gastric diIatation. Autopsy revealed that the pulmonary artery- contained numerous soft, friable, endothelial vegetations.

s early as 1907, Munro of Boston [I] described his observations in a group of patients with cardiac disability due to a patent He made the following ductus arteriosus. “its Iigation must he prophetic statement, foIlowed by instant and permanent restoration of the lungs and heart to a normal function.” In 1927, Cutler and Beck [2] wrote, “it seems reasonable to assume that if this communication were Iigated at operation, the heart \vouIcl be relieved of the handicap. Technical Iigation of this persisting anomaly should not be These surgeons tried to secure cliff&It.” patients for operation hut were not successful.

A

K,,qt

IB IA FIG. I. This iIIustration and caption were published eleven years before the operation was actuaIly performed. A, drawing of the heart of a three day old child, illustrating the patent ductus artcriosus. Ligation of a patent ductus arteriosus is proposed for the relief of cases uncomplicated by other congenital anomaIies. B, sketch of the circulation showing the short circuit of bIood through the patent ductus arteriosus. (From: CUTLER, E. C. and BECK, c. s. [2].)

361

American Journal of Surgery,

Volume 93, March. ,957

.\lozen The

nest

patient

to Iw selected

four months old. A significant number ol patients were in the fourth decade of life at the time of operation. If there were no other contraindications to surgery-, age had no infIuence in the decision to operate. It is a coincidence that the oldest patient \vas thirty-nine years old. Gross has reported the sectioning of a patent ductus in a fifty--one year old Ivoman, “with great benefit.” The majority of patients were white. Kate. The reason for this racial disproportion is unknown. (TabIe I.)

Ihr operation

~vas a seven

year old girl with early cardiac failure. She \vas operated upon successfully b? Dr. Robert Gross of Boston in August, 1938 [J]. Since then, several thousand similarly successful operations have fleen performed by man) TABLE

Distribution

I

I i

Sex : Female. MaIe.. Age (yr.):

o-10.......... IO-20.....

20-30. 30-40....... Over4o.. .,. Race : White. Negro..........

Per cent

N 0. of Cases

96 47

67,1 32.9

89

62.2

25

17.5 ‘3.3 7.0

‘9 IO 0

. . . . . . ...’

The accurate diagnosis of patent ductus arteriosus is easier to make than that of any other congenita1 CardiovascuIar anomaly. Gross has noted that the diagnosis was estabIished by simpIe cIinica1 examination in more than 94 per cent of his cases. History. The history is important and shouId be taken carefully. Precise questioning is necessary in order to evaIuate the subtle symptoms of earIy cardiac failure. In a Iarge number of cases, however, the patient is truly asymptomatic. In this series, 41.3 per cent of the patients had no symptoms. In these cases the presence of a murmur was the only complaint. Operation is safer anti easier to perform before the late complications of patent ductus have occurred. Therefore, operation is advised in an asvmptomatic patient, w-hen the diagnosis is made. The histories of all patients nere studied for evidence of cardiac failure. Such evidence was present in 42.0 per cent. Fatigue or sIight shortness of breath may be the only evidence of earlv failure. Since these symptoms are improved by cIosure of the patent ductus, they must be due to the weakness of an overburdened heart. The physioIogic effects of a patent ductus arteriosus are the same as those of an arteriovenous fistuIa. Large quantities of blood are shunted from the high pressure systemic arterial tree into the low pressure pulmonary vascular bed. This flow has been estimated to he 5 to 19 L. per minute. This results in a strain on the Ieft ventricIe which must pump this increased voIume of blood. This strain may Iead to a high output cardiac failure. The large additiona pulmonary inflow may resuIt in pulmonary hypertension with reversa1 of the shunt flow.

0 96.5

138

5

DIAGNOSIS

I

3’5

surgeons in different centers. The demonstration of the fact that this congenital anomaly can be cured by operation was an important stimulus for many investigations into other congenital and acquired cardiovascular abnormalities. Today, there is scarcely anv pathologic condition of the heart and great vessels which is beyond the scope of possible correction by operation. During the fifteen-year period between 1940 anti June, 1955, 143 patients August, with patent ductus arteriosus were operated upon by Dr. Claude S. Beck. These experiences in diagnosis, treatment and follow-up observation are the flases of this report. DISTRIBUTION

OF

PATIENTS

Sex. In aImost all of the reported series of cases of patent ductus arteriosus the fact is emphasized that the condition is much more common in females. There is no explanation for this sex discrepancy. In the present series, 67.1 per cent of the patients were females. This corresponds to the figure of 70 per cent which was reported by Gross. Age. The age distribution of the patients is typica of any large group of similar cases. As expected, the majority of operations were performed on chiIdren. The youngest patient was 362

Patent

Ductus

Many children with patent ductus faif to grow and devefop normaffy. This w-as noted in 22.4 per cent of the patients in this series. The farge aort!c “run-off” into the pufmonar\ vascular bed results in a deficient peripheral circulation. This leads to poor somatic cfevelopment lvhich is particularly &dent as a failure to gain a-eight. The most serious complication of patent ductus nrteriosus is a blood stream infection due to Str. viridans, i.e., subacute bacterial cncfocarditis. Such an infection \cas noted in the histories of 4.2 per cent of all patients ~.ho under\vent operation. In some cases it w-as present at the time of operation. Abbott reportetf that more than 25 per cent of the c!eaths in a series of ninety--two cases of patent ductus \vere clue to this complication. IVhen there is a bacterial endocarditis, there ma,v be friable vegetations on the pulmonic vafve. These may extend up the pulmonary artery and through the ductus into the aorta. One of the operative deaths in this series was due to an embofus of bacterial vegetations which occluded a cerehraf nrterq-. Prior to the use of antibiotics, surgical closure of a patent ductus was performed as a desperate treatment for subacute bacterial endocarditis. Today-, the bfoocf stream is sterilized with the proper antibiotics before operation. Frequencyof respiratory infections \vas a common complaint. It was noted in the history of 31.5 per cent of the patients studied. In most cases of patent ductus there is no cyanosis. However, \vhen an infant or child strains or cries, the pulmonar\- pressure may he elevated markedly. When an open communication is present between the aorta and the pulmonary artery, this elevation of pufmonary pressure may cause a temporary reversal of the shunt ffow. In such a situation there is transient cyanosis Episodes of cyanosis were noted in the histories of 10.5 per cent of the patients in the present series. Ph,vsical Examination. Except for the cardiovascular findings, the physical examination of a patient with patent ductus arteriosus ma) reveaf no abnormalities. Evidence of asthenia and poor nutrition was found in 22.4 per cent of the patients in this series. A wide pulse pressure usuaffy is present. This is due principaffy to a low diastolic pressure. A typical bfood pressure reading in a child with a patent ductus is roo/qo mm. Hg. When the ductus is 363

Arteriosus cfamped during operation, there is a prompt narrowing of the pufse pressure. None of the patients in this series had clubbing of the fingers or toes. Physical examination revealed cardiac enlargement in 53.8 per cent of the patients \vho were studied. The most important factor in the proper cliagnosis of patent ductus arteriosus is careful auscultation of the heart. The murmur which is present in this condition is characteristic. Once it has been heard, it is easy to recognize. It is a continuous murmur lvhich is hearcf throughout the cardiac cycle. There usually is systolic accentuation. The murmur sounds like the rumble of machinery, and is loudest and best heart1 in the left second intercostal space. Frequently, it radiates to the subclavicular area. P2 is loud and accentuated. When the cfuctus is very farge, the heart is usually enlarged. The apical thrust may be so forceful that the entire precordium heaves \q,ith each heartbeat. In infants under one year of age, the diastolic component of the murmur may be diminished or ahsent. It is usuaIfy present after this time, but may not appear until later. A typical “machiner?, murmur” was present in 93.0 per cent of the patients in this series. There was a palpable thrifl in 80.7 per cent. Laboratory Studies. Laboratory studies are accessories to the clinical examination. PoIycythemia is not present in patients with a patent ductus. The red ceff count and hematocrit usually are normal. The prothrombin time, bleeding time and clotting time were determined in almost all of the patients before operation, and were normal. Cardiac ffuoroscopy was performed during the preoperative stud)- of a11 patients. Cardiac enlargement, which was due to left ventricufar hypertrophy, was present in $6.6 per cent of the patients in this series. This enlargement \j’as slight to marked. The pufnlonary artery is prominent in an x-ray of a patient with patent ductus artcriosus. There usuaffy is an increase in the pulmonary vascular markings. There may be ffuoroscopic evidence of increased pulsations of the pufmonarv artery. This is the so-called “ hifar dance.” A normaf s-ra!- of the chest does not alter a cIinica1 diagnosis of patent ductus arteriosus. However, if there is right ventricular enlargement and decreased pufmonar?; vascular markings, this diagnosis is questionable. (Fig. 2.)

Mozen

FIG. 3. T,ypic:d clcctrocartliogr:l11~ and phonocardiogr:lm of :I patient rvith patent ductus arteriosus. Abnormally huge QKS complexes arc prcscnt. There is a continuous systolrc and di:lstolic murmur.

FIG. 2. X-ray of an eight year old girl with patent ductus artcriosus. Note the prominence of the pulmonar?artery at the base of the heart. There arc increased pulmonary vascuIar markings.

there is right ventricular Ii?-pertropfi)- ant1 pillThis causes unosymonar\- hypertension. genatec1 blood from the right ventricle to IIou from tJle pulmonary arter,v back through the ductus into tfle aorta. Holmnn has suggcsteci

Electrocardiograms and phonocnrdiograms \vere obtained during the preoperative period. There 1va.s evidence of Ieft ventricuIar hypertrophy in 14.0 per cent of the patients studied. High voltage complexes were frequent. Prolonged interventricular conduction time is more favorabIe for the diagnosis of interventricuIar septa1 defect. The phonocardiogram is a good visua1 record of the auscultation findings.

TABLE 11 OCCUKKENCE AND

PATENT

DUCTUS

VAKIOUS

FIM,,NGS

Clinical

(Fig. 3.1 Cardiac catheterization has heen of considerable help in establishing the diagnosis in cases of compIicated or atypicat patent ductus arteriosus. Since the clinical diagnosis is so accurate, tflis procedure has fleen necessary- in only tweIve patients with a typica ductus. (TabJe II.) COMPLICATED

01;

OX

SYMPTOMS PHYSICAL

IN TllE

HISTOKIES

EXAMlNATlONS

Per cent

Findings

Asymptomatic. hlyocardial failure. Failure of normal growth and development. Subacute bacterial endocarditis Frequent respiratory infections Cyanosis (transient or differential). Asthenia or malnutrition. Cardiac enlargement (physical examination). Typical “machinery-murmur”. ThriII......................... ._....... Cardiac enlargement (x-ray). Left ventricular hypertrophy iclcctrocnrdiogram).

AKTEKIOSUS

The probIem of the compIicated ductus with reversaf of the shunt fJow has received a great deal of attention. In this type of ductus, the patient has differentia1 cyanosis. The head and arms, which receive only oxygenated bIood from the Jeft ventricle, are normaJIy pink whiIe the trunk and Iower extremities, which receive mixed venous and arteria1 bIood, are cyanotic. This reversa1 of the shunt ffow may be a Jate stage in the evolution of the patent ductus. It usuaIIy occurs when the left ventricJe begins to fai1. It may be due to primary arterioscJerosis of the small vesseJs in the Lungs. In eitherzcase,

4’ .3 42.0 22.4

4.2 3’ .s ro.5 22.4

53.8 93.0 80.7 56.6

that the ductus is :I safety valve in these cases and that it wouId be dangerous to interrupt it. In this series, there were two patients with such a compIicated ductus. Both had severe pulmonary- hvpertension, reversa1 of the shunt Rot11 were flow and differential c\-anosis. remaIe anc1 both were in’their twenties. Both patients underwent operation for interruption of the patent ductus. In one case, temporary 364

Patent

Ductus

Arteriosus

FIG. 4. The “ball-dissector” designed by Dr. CI:lude S. BccL. This instrument is wluable during dissection of the patent ductus arteriosus.

occlusion of the ductus caused immecliate cardiac dilatation and arrest. The heartbeat was restored easily- and nothing further was done. The patient recovered. In the second case, the patient was ahIe to toIerate division of the ductus but died in acute heart faiIure six hours after the operation. This experience indicates that it is hazardous to interrupt a patent ductus when there is reversal of the shunt flow.

develop, requiring a second operation. In the last eighty-eight consecutive patients (61.5 per cent) the ductus was sectioned and sutured. In the earlier cases, the operation consisted of ligating and suturing the ductus. In one of these patients recanaIization developed. The ductus was sectionec1 and sutured during a seconcl operation, five years after the original one. In t\vo patients, expIoration alone was performed. One patient was a thirty-nine year old physician with an enormous patent ductus and dilatation of the aorta. At the time of operation (1941), it \vas beIieved to he inoperable. \Vith more experience and the availability of better instruments, this ductus could probabl\r be divided safely at the present time The second patient had a cardiac arrest during the mediastinal dissection. The heartbeat was restored and the operation Ivas discontinued.

OPERATION

Surgical interruption of the patent ductus arteriosus is recommended when the diagnosis is made. If there is no urgency to perform the operation, it is preferabIe to wait unti1 the infant or small child is four to six years oId. The important details of the operation have been discussed by numerous authors. One point of technic wiI1 be noted. It is essential that the tissues behind the ductus be cIearIy visualized and dividecl by sharp dissection. To facilitate this dissection, Dr. Beck has designed a specia1 instrument caIIec1 a “ baII-dissector.” This instrument has not been described previousIy. It consists of a small steel sphere which is mounted on a conveniently curved handle. This ha11 is passed behind the ductus and sweeps the posterior tissues upward into a more accessMe position for dissection. This instrument is aIso useful in operations for coarctation of the aorta, aortic aneurysm and arteriovenous f&da. (Fig. 4.) The question of bvhether to divicIe or ligate the patent ductus has received considerable comment. Ligation carries the risk of possible erosion and hemorrhage from the ductus. In in addition, in a small percentage of patients whom the ductus is ligated, recanalization will

OPERATIVE

hfORTALIT1

The mortality from operation has been low. in whom operation Three of the 143 patients was performed died in the operative period. The crude

immediate

post-

mortality rate is 2.14 per cent. Two of these three cleaths occurred in patients with a complicated patent ductus. In one patient there was severe pulmonary hypertension with reversal of the shunt flow. The other patient had subacute bacteria1 endocarditis at the time of operation. If these complicated cases are set aside, the corrected mortality rate for the simpIe patent ductus is 0.72 per cent. In the one uncomplicated case, death WRS due to the presence of a tenacious mucus plug which occludecl both and main stem bronchi. This caused anoxia 365

Mozen cardiac arrest. The heartbeat was restored, the patient died several hours Iater. POSTOPERATIVE

but

COMPLICATIONS

The average hospita1 stay was 10.4 days following the operation. The postoperative course was entirely uneventfu1 in the majoritv of patients and the number of notahIe complications was low. There were no instances of postoperative hemorrhage, empyema or serious wound infection. In three patients pleural fluid collections deveIoped which required thoracentesis. This has not occurred since a drainage tube has been used routinely. There was one case of severe postoperative atelectasis. In one patient postoperative Iaryngeal edema deveIoped and tracheotomy was necessary. Four patients had proIongecI periods of hoarseness foIIowing operation. In one case, there was drainage of Iymph from the chest. When this occurs it is often due to accidental division of an intercostal lymphatic vessel. Treatment consists of prompt reoperation and expIoration of the mediastinum. The divided Iymphatic vesse1 should be accurately Iigated. This was done in the case mentioned with excellent resuIts. A number of patients continue to have a soft to moderately Ioud systolic murmur after operation. Since this may occur even after the ductus has been compIeteIy divided, it is evidently not due to recanaIization. There may he a smaI1 projection of the aortic wall at the point of origin of the ductus. This region easily couId be the site of eddy currents which couId cause a murmur.

Two patients stiI1 have slight cardiac enlargement. In seventeen chiIdren with previous poor growth and deveIopment, exceIIent weight gains have been reported since operation. The folIowing is a typical reply to the question of the patient’s general condition: . . . “patient Jooks and feels like a different boy. Has absolutely no compIaints.” SUMMARY

Between 1940 and 1955 a group of 143 patients with patent ductus arteriosus were treated surgicaIIy on the cardiovascuIar surgica1 service of Dr. Claude S. Beck. The histories of these patients have been anaIyzed. Data concerning age, sex, race, occurrence of various symptoms, physical findings and Iaboratory studies of these patients are presented. The use of a new instrument, the “ha11-dissector,” is described. Operative mortality is presented and postoperative complications are discussed. Follow-up reports are described. Acknowledgment: Grateful acknowIedgment is made to Dr. Claude S. Beck for his permission to use his records for this study, and for his heIpfu1 and stimulating criticism during the preparation of this report. REFERENCES I.

z.

3.

FOLLOW-UP

The experiences in this report cover a period of fifteen years. AI1 patients have been folIowed up for at least nine months. Follow-up questionnaires have been sent to a11 patients, but onIy fifty-two replies have been received. There have heen no Iate postoperative deaths. In every case in which symptoms were present before operation, the patient reported compIete or aImost compIete reIief of symptoms. Five patients reported the continued presence of a systoIic murmur. The average bIood pressure following operation was 118/82 mm. Hg. The average puIse pressure was 36. Fifteen patients who had enlarged hearts before operation reported that the heart size decreased to normal.

4.

5.

6.

7.

8.

o.

J. C. Ligation of the ductus arteriosus. Ann. Suv., 46: 335 1907. CUTLER. E. C. and BECK. C. S. Suxerv of the heart and pericardium. In: Nelson’s Loose Leaf Surgery, chapt. 4, pp. 337-338. New York, 1927. Thos. Nelson and Sons. GRAYBIEL, A., STRIEDER, J. W. and BOI.ER, N. 11. An attempt to obliterate the patent ductus arteriosus in a patient with subacute bacterial endocarditis. Am. Heart J., rj: 621, 1938. Gross. R. E. and HUBBARD. J. P. Surgical ligation of a patent ductus arteriosus; report of first successful case. J. A. M. A., I 12: 729, 1939. GROSS, R. E. SurgicaI management of the patent ductus arteriosus with summary of four surgicalIy treated cases. Ann. Surg., I IO: 321, 1939. GROSS, R. E. and LONGINO,L. A. The patent ductus arteriosus: observations from 412 surgically treated cases. Circulation, 3: I 25, 193 I. GROSS, R. E. Surgery of Infancy and Childhood. Philadelphia and London, 1953. W. B. Saunders co. TOUROFF, A. S. W. Subacute bacteria1 endocarditis as a comptication of patent ductus arteriosus. J. A. M. zi., 115: ,270, ‘940. HULTGKEN. H.. SELZEK. A.. PURDY, A.. IIOLMAR., E. and GE~BO& F. Syndrome of patent d&us arteriosus with pulmonnry hypertension. Circuh&?I, 8: 15, 1953. hlusm,

L.

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