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Surgical treatment of calcified patent ductus arteriosus
Surgical treatment of calcified patent ductus arteriosus Roque Piiarre, M.D., Phillip L. Rice, M.D., and Rimgaudas Nemickas, M.D., Maywood and Hines, Ill.
Operative management of the calcified patent ductus arteriosus may present a difficult technical problem. If the ductus is short, the tissues friable, and the orifice heavily calcified, division or closure in continuity may not be practical or possible. Utilization of total cardiopulmonary bypass to facilitate closure has been previously described.' In this paper, we shall present an alternative method which does not necessitate the institution of cardiopulmonary bypass. Case report C. S., a 52-year-old white woman, had a 12 year history of exertional dyspnea, orthopnea, and a productive cough. She had been hospitalized three times in the past 3 years for acute bronchitis and congestive heart failure. The patient had been taking diuretics, digitalis, and bronchodilators for 3 years and had remained symptomatic. On admission to Loyola University Hospital, she was in moderate respiratory distress with a blood pressure of 136/56 mm. Hg, a respiratory rate of 40 breaths per minute, a radial pulse rate of 102 beats per minute, and a temperature of 37° C. Pertinent physical findings included peripheral cyanosis, absent neck vein distention, and bilateral bronchospasm, with moist dies in the bases of the lungs. There was a marked parasternal From the Departments of Surgery and Medicine, Loyola University Medical Center, Maywood, Ill. 60153, and the Cardiopulmonary Surgical Section, Veterans Administration Hospital, Hines, Ill. 60141. Received for publication Dec. 6, 1972. Address for reprints: Roque Pifarre, M.D., Department of Surgery, Loyola University Medical Center, Maywood, III. 60153.
lift with a loud first heart sound. Along the left sternal border there was a Grade 1/6 midsystolic murmur followed by an immediate Grade 2/6 diastolic blowing murmur. At the apex a Grade 2/6 holosystolic murmur was heard. There was no peripheral edema. The electrocardiogram revealed left atrial, right atrial, and left ventricular hypertrophy as well as left anterior hemi-heart-block. Chest roentgenography suggested an enlarged right atrium and an enlarged left ventricle, with a prominent pulmonary artery and some evidence of pulmonary hypertension (Fig. I, A). Pulmonary function studies were interpreted as showing moderate-to-severe obstruction and restrictive disease. At cardiac catheterization the left ventricular angiogram showed minimal mitral insufficiency with a large left ventricle. There was no immediate opacification of the right ventricle or the pulmonary artery after injection into the left ventricle; however, after opacification of the aorta the main pulmonary artery was immediately opacified. Aortic root injection showed no aortic insufficiency. The main pulmonary artery opacified immediately after injection, and following this the left atrium and left ventricle were opacified. There was no direct opacification of the aorta after injection into the main pulmonary artery. Statistical results of catheterization are given in Table I. Conclusions from the study were patent ductus arteriosus, pulmonary hypertension, minimal mitral insufficiency, probable pulmonary insufficiency, and right ventricular dysfunction. It was recommended that the patient have operative repair of the patent ductus arteriosus. The operative technique is illustrated in Figs. 2 to 4. The chest was entered through the bed of the left fifth rib, which was resected. The distal aortic arch was dissected free, and the area of the patent ductus arteriosus was exposed. A large thrill was palpable in the patent ductus arteriosus.
635
636
The Jou rnal of
Pijarre, Rice, Nemickas
Thoraci c and Ca rdiovascular Surgery
Fig. 1. A , Preoperative radiograph of the chest shows cardiomegaly and pronounced engorgement of the pulmonary arteries. B, Chest radiograph 6 months postoperatively shows some reduction of the cardiomegaly and decreased pulmonary vasculature.
Table IA
Table IB
I
Pulmonary
A-V difference (c.c ./L./min.) Cardiac output (L ./min.) Cardiac index (L./min./ sq.M .) Systemic resistance (units/ sq.M v) Pulmonary arteriolar resistance (units/sq.M.) Heart rate (b.p.m.) Stroke volume (c.c.) Stroke index (c .c./sq.M.) Shunt (left greater than right)
25.3 8.71 1.62
4.58
Position
Aorta Left ventricle Pulmonary wedge
61 Pulmonary artery 6.7 90 34 18
96 50 2.83/1.00
Legend: A-Y. Atrioventricular.
Because the ductus was short and heavily calcified, the decision was made to open the aorta and place a patch over the orifice of the ductus. The left subclavian artery was isolated, and tapes were passed around it. A purse-string suture was placed in the distal aorta, and tapes were passed around the aorta. At this time, 5,000 U. of heparin sodium was given. An L-shaped No. 24 cannula was inserted into the subclavian artery and attached by plastic tubing to a No . 24 cannula which was inserted into the distal aorta. The aorta was
Right ventr icle Right atrium Middle of right arm Superior vena cava Inferior vena cava Left ventricular dpldt (mm. Hg/sec. )
Pressure (mm . Hg )
150/75; mean 100 150/0 to 12 a 11; v 12; mean 7 60/32; mean 38 5510 to 15 a 13; v 9; mean 4
Oxygen saturation (per cent)
86 86 74 66 54 52 49 52
1,295
clamped immediately proximal and distal to the patent ductu s arteriosus. At this time a Satinsky clamp was placed over the pulmonary artery approximately 0.5 em. from the orifice of the ductus. Great care was taken to avoid injury to the ductus during placement of this clamp. The aorta was then opened longitud inally , and the orifice of the ductus was exposed. The orifice was heavily cal-
Volume 65 Number 4
Calcified patent ductus arteriosus
637
April, 1973
Fig. 2. Method of dissection used to expose the aorta and calcified patent ductus.
Fig. 3. Drawing shows a bypass from the left subclavian artery to the distal descending thoracic aorta. The aorta is cross-clamped proximal and distal to the patent ductus. Interrupted line shows area of aortic incision. cified. Interrupted mattress sutures were passed through the aorta and subsequently through a Dacron patch. The patch was then secured and tied over the orifice of the ductus. The Satinsky clamp was removed from the pulmonary artery, and the patch was examined to be sure that it was secure. The arteriotomy was closed with a double continuous suture. The aortic clamps were re-
Fig. 4. A, Closure of the ductus with a patch of Dacron fabric. B, The closure has been completed. C, Repair of the aortotomy. moved. After flow had been re-established, the shunt was clamped and removed, and the subclavian artery was repaired. There was no thrill present in the ductus arteriosus, and the pulmonary artery pressure was reduced on palpation. The patient's recovery from anesthesia was un-
The Journal of
638
Piiarre, Rice, Nemickas
Thoracic and Cardiavascular Surgery
eventful as was her postoperative convalescence. She was discharged on the twelfth postoperative day. The patient has been followed for 24 months since the operation and has done well. She has had no episodes of acute congestive heart failure since discharge.
Comment The technique described above has since been utilized in a 49-year-old woman with a calcified patent ductus arteriosus. This patient was told of her illness 40 years prior to the operation. During this period she had regressed from an asymptomatic to a symptomatic state, manifested by arrhythmias and congestive heart failure. The operative repair was done as in the first case except that an aorto-to-aorta shunt was utilized because of difficulty in mobilizing the subclavian artery for shunt insertion. The patient had an uneventful recovery. The difficulties encountered in the repair of the calcified patent ductus arteriosus offer considerable challenge. The ductus may be
short, the tissue may be very friable, and calcium in the ductus may prevent ligation in continuity or the secure placement of vascular clamps for suture division. The institution of cardiopulmonary bypass to facilitate the repair is not without risk. The most easily accomplished and safest method of repair is utilization of the shunt procedure as described above.
Summary A technique for the repair of the calcified patent ductus arteriosus is described. This procedure employs the use of a shunt to bypass the ductus area of the aorta. The technique has been successfully employed in the repair of the calcified ductus in 2 patients. REFERENCE Morrow, A. G., and Clark, W. D.: Closure of the Calcified Patent Ductus: A New Operative Method Utilizing Cardiopulmonary Bypass, J. THORAC. CARDIOVASC. SURG. 51: 534, 1966.
Operative management of the calcified patent ductus arteriosus may present a difficult technical problem. If the ductus is short, the tissues friable, and the orifice heavily calcified, division or closure in continuity may not be practical or possible. Utilization of total cardiopulmonary bypass to facilitate closure has been previously described.' In this paper, we shall present an alternative method which does not necessitate the institution of cardiopulmonary bypass. Case report C. S., a 52-year-old white woman, had a 12 year history of exertional dyspnea, orthopnea, and a productive cough. She had been hospitalized three times in the past 3 years for acute bronchitis and congestive heart failure. The patient had been taking diuretics, digitalis, and bronchodilators for 3 years and had remained symptomatic. On admission to Loyola University Hospital, she was in moderate respiratory distress with a blood pressure of 136/56 mm. Hg, a respiratory rate of 40 breaths per minute, a radial pulse rate of 102 beats per minute, and a temperature of 37° C. Pertinent physical findings included peripheral cyanosis, absent neck vein distention, and bilateral bronchospasm, with moist dies in the bases of the lungs. There was a marked parasternal From the Departments of Surgery and Medicine, Loyola University Medical Center, Maywood, Ill. 60153, and the Cardiopulmonary Surgical Section, Veterans Administration Hospital, Hines, Ill. 60141. Received for publication Dec. 6, 1972. Address for reprints: Roque Pifarre, M.D., Department of Surgery, Loyola University Medical Center, Maywood, III. 60153.
lift with a loud first heart sound. Along the left sternal border there was a Grade 1/6 midsystolic murmur followed by an immediate Grade 2/6 diastolic blowing murmur. At the apex a Grade 2/6 holosystolic murmur was heard. There was no peripheral edema. The electrocardiogram revealed left atrial, right atrial, and left ventricular hypertrophy as well as left anterior hemi-heart-block. Chest roentgenography suggested an enlarged right atrium and an enlarged left ventricle, with a prominent pulmonary artery and some evidence of pulmonary hypertension (Fig. I, A). Pulmonary function studies were interpreted as showing moderate-to-severe obstruction and restrictive disease. At cardiac catheterization the left ventricular angiogram showed minimal mitral insufficiency with a large left ventricle. There was no immediate opacification of the right ventricle or the pulmonary artery after injection into the left ventricle; however, after opacification of the aorta the main pulmonary artery was immediately opacified. Aortic root injection showed no aortic insufficiency. The main pulmonary artery opacified immediately after injection, and following this the left atrium and left ventricle were opacified. There was no direct opacification of the aorta after injection into the main pulmonary artery. Statistical results of catheterization are given in Table I. Conclusions from the study were patent ductus arteriosus, pulmonary hypertension, minimal mitral insufficiency, probable pulmonary insufficiency, and right ventricular dysfunction. It was recommended that the patient have operative repair of the patent ductus arteriosus. The operative technique is illustrated in Figs. 2 to 4. The chest was entered through the bed of the left fifth rib, which was resected. The distal aortic arch was dissected free, and the area of the patent ductus arteriosus was exposed. A large thrill was palpable in the patent ductus arteriosus.
635
636
The Jou rnal of
Pijarre, Rice, Nemickas
Thoraci c and Ca rdiovascular Surgery
Fig. 1. A , Preoperative radiograph of the chest shows cardiomegaly and pronounced engorgement of the pulmonary arteries. B, Chest radiograph 6 months postoperatively shows some reduction of the cardiomegaly and decreased pulmonary vasculature.
Table IA
Table IB
I
Pulmonary
A-V difference (c.c ./L./min.) Cardiac output (L ./min.) Cardiac index (L./min./ sq.M .) Systemic resistance (units/ sq.M v) Pulmonary arteriolar resistance (units/sq.M.) Heart rate (b.p.m.) Stroke volume (c.c.) Stroke index (c .c./sq.M.) Shunt (left greater than right)
25.3 8.71 1.62
4.58
Position
Aorta Left ventricle Pulmonary wedge
61 Pulmonary artery 6.7 90 34 18
96 50 2.83/1.00
Legend: A-Y. Atrioventricular.
Because the ductus was short and heavily calcified, the decision was made to open the aorta and place a patch over the orifice of the ductus. The left subclavian artery was isolated, and tapes were passed around it. A purse-string suture was placed in the distal aorta, and tapes were passed around the aorta. At this time, 5,000 U. of heparin sodium was given. An L-shaped No. 24 cannula was inserted into the subclavian artery and attached by plastic tubing to a No . 24 cannula which was inserted into the distal aorta. The aorta was
Right ventr icle Right atrium Middle of right arm Superior vena cava Inferior vena cava Left ventricular dpldt (mm. Hg/sec. )
Pressure (mm . Hg )
150/75; mean 100 150/0 to 12 a 11; v 12; mean 7 60/32; mean 38 5510 to 15 a 13; v 9; mean 4
Oxygen saturation (per cent)
86 86 74 66 54 52 49 52
1,295
clamped immediately proximal and distal to the patent ductu s arteriosus. At this time a Satinsky clamp was placed over the pulmonary artery approximately 0.5 em. from the orifice of the ductus. Great care was taken to avoid injury to the ductus during placement of this clamp. The aorta was then opened longitud inally , and the orifice of the ductus was exposed. The orifice was heavily cal-
Volume 65 Number 4
Calcified patent ductus arteriosus
637
April, 1973
Fig. 2. Method of dissection used to expose the aorta and calcified patent ductus.
Fig. 3. Drawing shows a bypass from the left subclavian artery to the distal descending thoracic aorta. The aorta is cross-clamped proximal and distal to the patent ductus. Interrupted line shows area of aortic incision. cified. Interrupted mattress sutures were passed through the aorta and subsequently through a Dacron patch. The patch was then secured and tied over the orifice of the ductus. The Satinsky clamp was removed from the pulmonary artery, and the patch was examined to be sure that it was secure. The arteriotomy was closed with a double continuous suture. The aortic clamps were re-
Fig. 4. A, Closure of the ductus with a patch of Dacron fabric. B, The closure has been completed. C, Repair of the aortotomy. moved. After flow had been re-established, the shunt was clamped and removed, and the subclavian artery was repaired. There was no thrill present in the ductus arteriosus, and the pulmonary artery pressure was reduced on palpation. The patient's recovery from anesthesia was un-
The Journal of
638
Piiarre, Rice, Nemickas
Thoracic and Cardiavascular Surgery
eventful as was her postoperative convalescence. She was discharged on the twelfth postoperative day. The patient has been followed for 24 months since the operation and has done well. She has had no episodes of acute congestive heart failure since discharge.
Comment The technique described above has since been utilized in a 49-year-old woman with a calcified patent ductus arteriosus. This patient was told of her illness 40 years prior to the operation. During this period she had regressed from an asymptomatic to a symptomatic state, manifested by arrhythmias and congestive heart failure. The operative repair was done as in the first case except that an aorto-to-aorta shunt was utilized because of difficulty in mobilizing the subclavian artery for shunt insertion. The patient had an uneventful recovery. The difficulties encountered in the repair of the calcified patent ductus arteriosus offer considerable challenge. The ductus may be
short, the tissue may be very friable, and calcium in the ductus may prevent ligation in continuity or the secure placement of vascular clamps for suture division. The institution of cardiopulmonary bypass to facilitate the repair is not without risk. The most easily accomplished and safest method of repair is utilization of the shunt procedure as described above.
Summary A technique for the repair of the calcified patent ductus arteriosus is described. This procedure employs the use of a shunt to bypass the ductus area of the aorta. The technique has been successfully employed in the repair of the calcified ductus in 2 patients. REFERENCE Morrow, A. G., and Clark, W. D.: Closure of the Calcified Patent Ductus: A New Operative Method Utilizing Cardiopulmonary Bypass, J. THORAC. CARDIOVASC. SURG. 51: 534, 1966.