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Intra-aortic closure of the calcified patent ductus
J
THORAC CARDIOVASC SURG
80:206-210, 1980
Intra-aortic closure of the calcified patent ductus A new operative method not requiring cardiopulmonary bypass Diffuse and circumferential calcification of the patent ductus arteriosus is a rare finding frequently associated with severe pulmonary artery hypertension. Under this circumstance, closure of the patent ductus arteriosus by ligation in continuity or by division and suture is hazardous if not impossible. Endoaortic closure of the ductus with a prosthetic patch has been proposed as an alternate and safer procedure. This paper describes an improved operative technique for intra-aortic closure of a calcified patent ductus arteriosus employing a heparin-coated shunt to permit aortic cross-clamping and an intraluminal balloon catheter to control bleeding from the pulmonary artery. Extracorporeal circulation and systemic heparinization are avoided. Minimal manipulation of the ductus and pulmonary artery is required.
Jorge A. Wemly, M.D.,* and Jose L. Ameriso, M.D.,** Rosario, Argentina
Since the initial report by Gross and Hubbard I in 1939, surgical closure has been the accepted treatment for patent ductus arteriosus. When the operation is performed in asymptomatic patients in early childhood the surgical risk is hardly more than that of the anesthesia and the cure is complete. 2 When performed in older patients, however, the presence of complicating factors such as pulmonary hypertension, aneurysm, infection, or calcification of the ductus increases the operative risk markedly.v " Although partial calcification of the ductus and adjacent aorta is not unusual in adult patients," 7-9 diffuse and circumferential calcification of the ductal wall is a rare finding frequently associated with severe pulmonary hypertension. 6, 10. II Ligation in continuity or diFrom the Department of Surgery. Escuela de Medicina de la Universidad Nacional de Rosario, Rosario. Argentina. Received for publication Dec. 12. 1979. Accepted for publication Jan. 10. 1980. Address for reprints: Jorge A. Wernly, M.D.• Department of Cardiac Surgery. Michael Reese Hospital and Medical Center. 2929 S. Ellis Ave .. Chicago. Ill. 60616. *Instructor of Surgery. Division of Thoracic and Cardiovascular Surgery. **Associate Professor of Surgery and Chief. Division of Thoracic and Cardiovascular Surgery.
206
vision and suture is not possible in patients with a diffusely calcified ductus arteriosus. Currently only four reported patients with severe calcification of a patent ductus arteriosus and pulmonary artery hypertension have successfully undergone intra-aortic closure of the ductus.P: 10. 11 This report describes a new and simple operative procedure for intra-aortic closure of a calcified patent ductus with a tridodecylmethylammonium-chloride (TDMAC)-heparin bonded shunt to permit safe aortic cross-clamping and an intraluminal balloon catheter to control bleeding from the pulmonary artery. Extracorporeal circulation and systemic heparinization are thus avoided and minimal manipulation of the ductus and the pulmonary artery is required.
Case report A 54-year-old white woman was admitted to Universidad National de Rosario Hospital with a 2 106 year history of progressive exertional dyspnea, orthopnea, and palpitations. Blood pressure was 140170 mm Hg and the pulse was irregular with a rate of 100 beats/min. The neck veins were distended and the apical impulse was felt at the sixth left intercostal space. There was a marked parasternal lift. A Grade 5/6 systolic murmur was audible at the base of the heart and a Grade 2/6 blowing diastolic murmur was present along the left sternal border. There was no peripheral edema and the liver was palpable 4 ern below the costal margin. Elec-
0022-5223/80/080206+05$00.50/0 © 1980 The C. V. Mosby Co.
Volume 80 Number 2
Closure of calcified patent ductus
207
August, 1980
Fig. 1. Preoperative radiograph of the chest showing gross cardiomegaly , prominence of the pulmonary artery, and increased pulmonary vasculature . Fig. 2. Operative exposure and the placement of the heparin-coated shunt. The aorta is cross-clamped proximal and distal to the patent ductus . trocardiogram revealed atrial fibrillation and biventricular hypertrophy . Chest roentgenogram (Fig . I) showed gross cardiac enlargement, prominence of the main pulmonary artery , and increased pulmonary vasculature . Cardiac catheterization (Table I) demonstrated a pulmonary artery pressure of 75/35 mm Hg and a right ventricular pressure of 75/0 mm Hg. Aortic pressure was 125/90 mm Hg and there was no gradient across the aortic valve. The left ventricular angiogram showed a large cavity with mild hypokinesia of the inferior wall and no mitral insufficiency . Aortic root injection showed no aortic insufficiency, but the main pulmonary artery was immediately opacified through a widely patent ductus arteriosus . Exten sive calcification in the area of the ductus was readily apparent on flouroscopy . A left-to-right shunt into the pulmonary artery was demon strated by measurement of oxygen saturation . Calculated pulmonary-systemic flow ratio was 2 : I. At operation the chest was entered through the left fifth intercostal space. The distal aortic arch, the left subclavian artery, and the descending thoracic aorta were dissected free and tapes were placed around them . A large thrill was felt over the ductus. Extensive calcification of its walls and of the adjacent aorta was palpable . No attempts were made to mobilize the ductus or the pulmonary artery . The subclavian artery and the distal thoracic aorta were cannulated with a TDMAC -heparin bonded shunt (Fig. 2). The aorta was clamped proximal and distal to the ductus and was opened
Table I. Results of cardia c catheterization Position Right atrium Right ventricle Pulmonary artery Left ventricle Aorta
Pressure (mm Hg)
Oxygen sat. (%)
mean 6
55 53 75
75/3 75/35 125/0 125/90
91 91
longitudinally . The hemorrhage from the patent ductu s arteriosus was rapidly controlled with a finger. A venou s Fogart y catheter was advanced into the pulmonary artery and inflated. and the ductus was occluded by gentle traction on the catheter (Fig. 3). Its lumen was covered circumferentially with heavy calcified arteriosclerotic plaque s which extended into the aorta. The aortic orifice of the ductus was closed with a woven Dacron patch graft by means of interrupted mattress sutures (Fig . 4) . Because of extensive calci fication the sutures were placed I cm away from the ductal orifice . The balloon catheter was removed and the patch inspected for leaks (Fig . 5). The aortotomy was closed with a partial occlu sion clamp, and the aortic cross-clamps were released after 16 minutes of occlusion . The aorta was closed with a continuous suture and the shunt was removed. There wa s no thrill over the ductus ,
The Journal of
208
Wernly and Ameriso
(
Thoracic and Cardiovascular Surgery
--,, ...
Fig. 3. The Fogarty venous catheter occluding the pulmonary orifice of the patent ductus . Fig. 4. The ductu s is closed with a woven Dacron patch secured by interrupted mattress sutures. The Fogarty catheter occluding the patent ductus is not shown. Fig. 5. Completed patch closure of the ductal orifice. The Fogarty balloon is removed and the aortotomy is closed with a continuous suture. Fig. 6. Postoperative chest roentgenogram demonstrating reduction of the cardiac size and decreased pulmonary vasculature .
Volume 80 Number 2
Closure of calcified patent ductus
209
August. 1980
and the pulmonary pressure was reduced on palpation. The patient had an uneventful recovery and was discharged on the fifteenth postoperative day. She has been followed for 24 months since the operation; there is no murmurand, on chest roentgenogram (Fig. 6), the cardiacsilhouette and the pulmonary vasculature are markedly reduced. She continues to have atrial fibrillation but is asymptomatic. Comment
The surgical closure of the symptomatic patent ductus arteriosus in the adult population entails a higher risk than the elective repair in infancy. This is particularly true when pulmonary artery hypertension and calcification of the ductus are present. At operation, patients with patent ductus arteriosus and severe pulmonary artery hypertension are usually found to have a large, thin, friable pulmonary artery and a short, wide ductus. Attempting to place clamps and sutures or ligatures is a potentially dangerous maneuver that can lead to fatal intraoperative hemorrhage. The presence of calcification in the wall of a patent ductus arteriosus is an unusual finding thought to be secondary to arteriosclerosis or a sequelae of quiescent infection. In most of the cases reviewed" 7-9 only partial calcification of the ductus was present. The aortic end of the ductus was the site involved most frequently. Even though simple ligation" 8 of a partially calcified ductus arteriosus has been performed in some cases, several other procedures have been advised to permit ligation or suture division of a partially calcified ductus. Laustella and associates" ligated the ductus over Teflon felt using aortic cross-clamping and left heart bypass in two cases. Black and Goldman" divided and sutured the ductus under normothermic aortic crossclamping with controlled arterial hypotension in two cases. Furuse and colleagues':' reported one case in which a partially calcified patent ductus arteriosus was successfully divided under normothermic occlusion of the descending thoracic aorta with cerebrospinal fluid drainage. Calcification of the total length of a patent ductus arteriosus involving the bordering segments of the aorta and pulmonary artery, as seen in our patient, has only been reported at operation in five cases.": 10. 11 All these patients were women between 40 and 60 years of age and all had severe pulmonary artery hypertension. Surgical closure of the patent ductus in these cases is hazardous if not impossible, even with the aid of the techniques previously mentioned. Endoaortic closure of the ductus with a prosthetic patch has been proposed as an alternate and safer procedure. It was first done by Morrow and Chirk lo using total cardiopulmonary bypass. The ductus was approached through a left tho-
racotomy. A venous cannula was inserted in the outflow tract of the right ventricle, and arterial return lines were placed in the left subclavian and left femoral arteries. The main pulmonary artery and the thoracic aorta above and below the ductus were clamped to permit intra-aortic obliteration of the orifice of the ductus. Difficulties involved with this procedure are the necessity of extracorporeal circulation with systemic heparinization and the dissection and clamping of the ductus and the pulmonary artery. This procedure was done in two patients (one of whom died because of right ventricular failure) and was later used with success by Peiper and associates" in one case. Pifarre and colleagues!' reported two cases of calcified patent ductus arteriosus closed through the aorta without extracorporeal circulation. Distal circulation after cross-clamping of the descending thoracic aorta was maintained by means of a temporary arterial shunt with systemic heparinization. Hemorrhage from the pulmonary artery was avoided by a partial occlusion clamp placed over the pulmonary artery. Even though the risk of cardiopulmonary bypass was avoided, this procedure is technically difficult and dangerous, for it requires an extensive dissection of the patent ductus and adjacent pulmonary artery and the application of a vascular clamp over this fragile vessel. It is conceivable that patch closure of a patent ductus arteriosus through the transpulmonary approach with cardiopulmonary bypass could be employed to close a calcified patent ductus. This technique has been reported for the surgical closure of the patent ductus arteriosus in patients who have severe pulmonary hypertension 14 or who have had previous attempts at closure.!" Disadvantages of this technique are the use of extracorporeal circulation, the risk of air embolism, and the fact that the ductus remains connected to the systemic circulation. In our opinion, this technique should be utilized only when closure of the ductus has to be followed by an intracardiac repair. Our technique combines the use of a TDMACheparin shunt to permit safe cross-clamping of the descending thoracic aorta without systematic heparinization, with a balloon catheter passed through the ductus to prevent hemorrhage from the pulmonary artery. This provides the surgeon with a simple, rapid, and safe method to accomplish the transaortic closure of the patent ductus arteriosus. The risk of extracorporeal circulation is avoided and the dangerous dissection and manipulation of both the patent ductus and the pulmonary artery are unnecessary. No systemic anticoagulation is required. We recommend this method for closure of a totally calcified or complicated ductus arteriosus.
The Journal of
210
Wernly and Ameriso
Thoracic and Cardiovascular Surgery
REFERENCES
2
3
4 5
6
7 8
Gross RE, Hubbard JP: Surgical ligation of a patent ductus arteriosus. Report of first successful case. JAMA 112:729, 1939 Trusler GA, Arayangkoon P, Mustard WT: Operative closure of isolated patent ductus arteriosus in the first two years of life. Can Med Assoc J 99:879, 1968 Ellis FH, Kirklin JW, Callahan JA, Wood EH: Patent ductus arteriosus with pulmonary hypertension. J THORAC SURG 31:268, 1956 Keys A, Shapiro M1: Patency of the ductus arteriosus in adults. Am Heart J 25:158, 1943 Laustella E, Tala P, Halttunen P: Patent ductus arteriosus with pulmonary hypertension (A report of 25 operated cases.) J Cardiovasc Surg 17:245, 1968 Peiper HJ, Schramm G, Heberer G: Zur Anwendung eines totalen extrakorporalen Zirkulation fur Risikoeingroiffe beim ductus arteriosus apertus (Use of total extracorporeal circulation for surgery with particular risks in patent ductus arteriosus.) Thoraxchirurgie 18:102, 1970 Ruskin H, Samuel E: Calcification in the patent ductus arteriosus. Br J Radiol 23:710, 1950 Currarino G, Jackson 1: Calcification of the ductus arte-
9 10
11
12 13 14
15
riosus and ligamentum botalli. Radiology 94: 134-142, 1970 Pochaczevsky R, Dunst ME: Coexistent pulmonary artery and aortic arch calcification. AJR 116: 141, 1972 Morrow AG, Clark WD: Closure of the calcified patent ductus. A new operative method utilizing cardiopulmonary bypass. J THORAC CARDIOVASC SURG 51 :534, 1966 Pifarre R, Rice PL, Nemickas R: Surgical treatment of calcified patent ductus arteriosus. J THORAC CARDIOVASC SURG 65:635, 1973 Black LL, Goldman BS: Surgical treatment of the patent ductus arteriosus in the adult. Ann Surg 175:290, 1972 Furuse A, Mizuno A, Nohara F, Ito K, Saigusa M: Calcified patent ductus arteriosus. Jpn Heart J 9:316, 1968 Arai T: Surgical treatment of patent ductus arteriosus in elderly persons with huge pulmonary artery. Jpn J Thorac Surg 23:722, 1970 Goncalves-Estella A, Perez- Villoria J, Gonzalez-Reoyo F, Gimenez-Mendez JP, Castro-Cels A, Castro-Llorens M: Closure of a complicated ductus arteriosus through the transpulmonary route using hypothermia. Surgical considerations in one case. J THORAC CARDIOVASC SURG 69:698, 1975
THORAC CARDIOVASC SURG
80:206-210, 1980
Intra-aortic closure of the calcified patent ductus A new operative method not requiring cardiopulmonary bypass Diffuse and circumferential calcification of the patent ductus arteriosus is a rare finding frequently associated with severe pulmonary artery hypertension. Under this circumstance, closure of the patent ductus arteriosus by ligation in continuity or by division and suture is hazardous if not impossible. Endoaortic closure of the ductus with a prosthetic patch has been proposed as an alternate and safer procedure. This paper describes an improved operative technique for intra-aortic closure of a calcified patent ductus arteriosus employing a heparin-coated shunt to permit aortic cross-clamping and an intraluminal balloon catheter to control bleeding from the pulmonary artery. Extracorporeal circulation and systemic heparinization are avoided. Minimal manipulation of the ductus and pulmonary artery is required.
Jorge A. Wemly, M.D.,* and Jose L. Ameriso, M.D.,** Rosario, Argentina
Since the initial report by Gross and Hubbard I in 1939, surgical closure has been the accepted treatment for patent ductus arteriosus. When the operation is performed in asymptomatic patients in early childhood the surgical risk is hardly more than that of the anesthesia and the cure is complete. 2 When performed in older patients, however, the presence of complicating factors such as pulmonary hypertension, aneurysm, infection, or calcification of the ductus increases the operative risk markedly.v " Although partial calcification of the ductus and adjacent aorta is not unusual in adult patients," 7-9 diffuse and circumferential calcification of the ductal wall is a rare finding frequently associated with severe pulmonary hypertension. 6, 10. II Ligation in continuity or diFrom the Department of Surgery. Escuela de Medicina de la Universidad Nacional de Rosario, Rosario. Argentina. Received for publication Dec. 12. 1979. Accepted for publication Jan. 10. 1980. Address for reprints: Jorge A. Wernly, M.D.• Department of Cardiac Surgery. Michael Reese Hospital and Medical Center. 2929 S. Ellis Ave .. Chicago. Ill. 60616. *Instructor of Surgery. Division of Thoracic and Cardiovascular Surgery. **Associate Professor of Surgery and Chief. Division of Thoracic and Cardiovascular Surgery.
206
vision and suture is not possible in patients with a diffusely calcified ductus arteriosus. Currently only four reported patients with severe calcification of a patent ductus arteriosus and pulmonary artery hypertension have successfully undergone intra-aortic closure of the ductus.P: 10. 11 This report describes a new and simple operative procedure for intra-aortic closure of a calcified patent ductus with a tridodecylmethylammonium-chloride (TDMAC)-heparin bonded shunt to permit safe aortic cross-clamping and an intraluminal balloon catheter to control bleeding from the pulmonary artery. Extracorporeal circulation and systemic heparinization are thus avoided and minimal manipulation of the ductus and the pulmonary artery is required.
Case report A 54-year-old white woman was admitted to Universidad National de Rosario Hospital with a 2 106 year history of progressive exertional dyspnea, orthopnea, and palpitations. Blood pressure was 140170 mm Hg and the pulse was irregular with a rate of 100 beats/min. The neck veins were distended and the apical impulse was felt at the sixth left intercostal space. There was a marked parasternal lift. A Grade 5/6 systolic murmur was audible at the base of the heart and a Grade 2/6 blowing diastolic murmur was present along the left sternal border. There was no peripheral edema and the liver was palpable 4 ern below the costal margin. Elec-
0022-5223/80/080206+05$00.50/0 © 1980 The C. V. Mosby Co.
Volume 80 Number 2
Closure of calcified patent ductus
207
August, 1980
Fig. 1. Preoperative radiograph of the chest showing gross cardiomegaly , prominence of the pulmonary artery, and increased pulmonary vasculature . Fig. 2. Operative exposure and the placement of the heparin-coated shunt. The aorta is cross-clamped proximal and distal to the patent ductus . trocardiogram revealed atrial fibrillation and biventricular hypertrophy . Chest roentgenogram (Fig . I) showed gross cardiac enlargement, prominence of the main pulmonary artery , and increased pulmonary vasculature . Cardiac catheterization (Table I) demonstrated a pulmonary artery pressure of 75/35 mm Hg and a right ventricular pressure of 75/0 mm Hg. Aortic pressure was 125/90 mm Hg and there was no gradient across the aortic valve. The left ventricular angiogram showed a large cavity with mild hypokinesia of the inferior wall and no mitral insufficiency . Aortic root injection showed no aortic insufficiency, but the main pulmonary artery was immediately opacified through a widely patent ductus arteriosus . Exten sive calcification in the area of the ductus was readily apparent on flouroscopy . A left-to-right shunt into the pulmonary artery was demon strated by measurement of oxygen saturation . Calculated pulmonary-systemic flow ratio was 2 : I. At operation the chest was entered through the left fifth intercostal space. The distal aortic arch, the left subclavian artery, and the descending thoracic aorta were dissected free and tapes were placed around them . A large thrill was felt over the ductus. Extensive calcification of its walls and of the adjacent aorta was palpable . No attempts were made to mobilize the ductus or the pulmonary artery . The subclavian artery and the distal thoracic aorta were cannulated with a TDMAC -heparin bonded shunt (Fig. 2). The aorta was clamped proximal and distal to the ductus and was opened
Table I. Results of cardia c catheterization Position Right atrium Right ventricle Pulmonary artery Left ventricle Aorta
Pressure (mm Hg)
Oxygen sat. (%)
mean 6
55 53 75
75/3 75/35 125/0 125/90
91 91
longitudinally . The hemorrhage from the patent ductu s arteriosus was rapidly controlled with a finger. A venou s Fogart y catheter was advanced into the pulmonary artery and inflated. and the ductus was occluded by gentle traction on the catheter (Fig. 3). Its lumen was covered circumferentially with heavy calcified arteriosclerotic plaque s which extended into the aorta. The aortic orifice of the ductus was closed with a woven Dacron patch graft by means of interrupted mattress sutures (Fig . 4) . Because of extensive calci fication the sutures were placed I cm away from the ductal orifice . The balloon catheter was removed and the patch inspected for leaks (Fig . 5). The aortotomy was closed with a partial occlu sion clamp, and the aortic cross-clamps were released after 16 minutes of occlusion . The aorta was closed with a continuous suture and the shunt was removed. There wa s no thrill over the ductus ,
The Journal of
208
Wernly and Ameriso
(
Thoracic and Cardiovascular Surgery
--,, ...
Fig. 3. The Fogarty venous catheter occluding the pulmonary orifice of the patent ductus . Fig. 4. The ductu s is closed with a woven Dacron patch secured by interrupted mattress sutures. The Fogarty catheter occluding the patent ductus is not shown. Fig. 5. Completed patch closure of the ductal orifice. The Fogarty balloon is removed and the aortotomy is closed with a continuous suture. Fig. 6. Postoperative chest roentgenogram demonstrating reduction of the cardiac size and decreased pulmonary vasculature .
Volume 80 Number 2
Closure of calcified patent ductus
209
August. 1980
and the pulmonary pressure was reduced on palpation. The patient had an uneventful recovery and was discharged on the fifteenth postoperative day. She has been followed for 24 months since the operation; there is no murmurand, on chest roentgenogram (Fig. 6), the cardiacsilhouette and the pulmonary vasculature are markedly reduced. She continues to have atrial fibrillation but is asymptomatic. Comment
The surgical closure of the symptomatic patent ductus arteriosus in the adult population entails a higher risk than the elective repair in infancy. This is particularly true when pulmonary artery hypertension and calcification of the ductus are present. At operation, patients with patent ductus arteriosus and severe pulmonary artery hypertension are usually found to have a large, thin, friable pulmonary artery and a short, wide ductus. Attempting to place clamps and sutures or ligatures is a potentially dangerous maneuver that can lead to fatal intraoperative hemorrhage. The presence of calcification in the wall of a patent ductus arteriosus is an unusual finding thought to be secondary to arteriosclerosis or a sequelae of quiescent infection. In most of the cases reviewed" 7-9 only partial calcification of the ductus was present. The aortic end of the ductus was the site involved most frequently. Even though simple ligation" 8 of a partially calcified ductus arteriosus has been performed in some cases, several other procedures have been advised to permit ligation or suture division of a partially calcified ductus. Laustella and associates" ligated the ductus over Teflon felt using aortic cross-clamping and left heart bypass in two cases. Black and Goldman" divided and sutured the ductus under normothermic aortic crossclamping with controlled arterial hypotension in two cases. Furuse and colleagues':' reported one case in which a partially calcified patent ductus arteriosus was successfully divided under normothermic occlusion of the descending thoracic aorta with cerebrospinal fluid drainage. Calcification of the total length of a patent ductus arteriosus involving the bordering segments of the aorta and pulmonary artery, as seen in our patient, has only been reported at operation in five cases.": 10. 11 All these patients were women between 40 and 60 years of age and all had severe pulmonary artery hypertension. Surgical closure of the patent ductus in these cases is hazardous if not impossible, even with the aid of the techniques previously mentioned. Endoaortic closure of the ductus with a prosthetic patch has been proposed as an alternate and safer procedure. It was first done by Morrow and Chirk lo using total cardiopulmonary bypass. The ductus was approached through a left tho-
racotomy. A venous cannula was inserted in the outflow tract of the right ventricle, and arterial return lines were placed in the left subclavian and left femoral arteries. The main pulmonary artery and the thoracic aorta above and below the ductus were clamped to permit intra-aortic obliteration of the orifice of the ductus. Difficulties involved with this procedure are the necessity of extracorporeal circulation with systemic heparinization and the dissection and clamping of the ductus and the pulmonary artery. This procedure was done in two patients (one of whom died because of right ventricular failure) and was later used with success by Peiper and associates" in one case. Pifarre and colleagues!' reported two cases of calcified patent ductus arteriosus closed through the aorta without extracorporeal circulation. Distal circulation after cross-clamping of the descending thoracic aorta was maintained by means of a temporary arterial shunt with systemic heparinization. Hemorrhage from the pulmonary artery was avoided by a partial occlusion clamp placed over the pulmonary artery. Even though the risk of cardiopulmonary bypass was avoided, this procedure is technically difficult and dangerous, for it requires an extensive dissection of the patent ductus and adjacent pulmonary artery and the application of a vascular clamp over this fragile vessel. It is conceivable that patch closure of a patent ductus arteriosus through the transpulmonary approach with cardiopulmonary bypass could be employed to close a calcified patent ductus. This technique has been reported for the surgical closure of the patent ductus arteriosus in patients who have severe pulmonary hypertension 14 or who have had previous attempts at closure.!" Disadvantages of this technique are the use of extracorporeal circulation, the risk of air embolism, and the fact that the ductus remains connected to the systemic circulation. In our opinion, this technique should be utilized only when closure of the ductus has to be followed by an intracardiac repair. Our technique combines the use of a TDMACheparin shunt to permit safe cross-clamping of the descending thoracic aorta without systematic heparinization, with a balloon catheter passed through the ductus to prevent hemorrhage from the pulmonary artery. This provides the surgeon with a simple, rapid, and safe method to accomplish the transaortic closure of the patent ductus arteriosus. The risk of extracorporeal circulation is avoided and the dangerous dissection and manipulation of both the patent ductus and the pulmonary artery are unnecessary. No systemic anticoagulation is required. We recommend this method for closure of a totally calcified or complicated ductus arteriosus.
The Journal of
210
Wernly and Ameriso
Thoracic and Cardiovascular Surgery
REFERENCES
2
3
4 5
6
7 8
Gross RE, Hubbard JP: Surgical ligation of a patent ductus arteriosus. Report of first successful case. JAMA 112:729, 1939 Trusler GA, Arayangkoon P, Mustard WT: Operative closure of isolated patent ductus arteriosus in the first two years of life. Can Med Assoc J 99:879, 1968 Ellis FH, Kirklin JW, Callahan JA, Wood EH: Patent ductus arteriosus with pulmonary hypertension. J THORAC SURG 31:268, 1956 Keys A, Shapiro M1: Patency of the ductus arteriosus in adults. Am Heart J 25:158, 1943 Laustella E, Tala P, Halttunen P: Patent ductus arteriosus with pulmonary hypertension (A report of 25 operated cases.) J Cardiovasc Surg 17:245, 1968 Peiper HJ, Schramm G, Heberer G: Zur Anwendung eines totalen extrakorporalen Zirkulation fur Risikoeingroiffe beim ductus arteriosus apertus (Use of total extracorporeal circulation for surgery with particular risks in patent ductus arteriosus.) Thoraxchirurgie 18:102, 1970 Ruskin H, Samuel E: Calcification in the patent ductus arteriosus. Br J Radiol 23:710, 1950 Currarino G, Jackson 1: Calcification of the ductus arte-
9 10
11
12 13 14
15
riosus and ligamentum botalli. Radiology 94: 134-142, 1970 Pochaczevsky R, Dunst ME: Coexistent pulmonary artery and aortic arch calcification. AJR 116: 141, 1972 Morrow AG, Clark WD: Closure of the calcified patent ductus. A new operative method utilizing cardiopulmonary bypass. J THORAC CARDIOVASC SURG 51 :534, 1966 Pifarre R, Rice PL, Nemickas R: Surgical treatment of calcified patent ductus arteriosus. J THORAC CARDIOVASC SURG 65:635, 1973 Black LL, Goldman BS: Surgical treatment of the patent ductus arteriosus in the adult. Ann Surg 175:290, 1972 Furuse A, Mizuno A, Nohara F, Ito K, Saigusa M: Calcified patent ductus arteriosus. Jpn Heart J 9:316, 1968 Arai T: Surgical treatment of patent ductus arteriosus in elderly persons with huge pulmonary artery. Jpn J Thorac Surg 23:722, 1970 Goncalves-Estella A, Perez- Villoria J, Gonzalez-Reoyo F, Gimenez-Mendez JP, Castro-Cels A, Castro-Llorens M: Closure of a complicated ductus arteriosus through the transpulmonary route using hypothermia. Surgical considerations in one case. J THORAC CARDIOVASC SURG 69:698, 1975