- Email: [email protected]
Video-Assisted Ductal Closure With New Modifications: Minimally Invasive, Maximally Effective, 1,300 Cases
Mohammad Hassan Nezafati, MD, Ghassem Soltani, MD, and Ali Vedadian, MD Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
Background. Video-assisted thoracoscopic surgery (VATS) has been shown to be a safe and effective method of closing patent ductus arteriosus (PDA). We retrospectively studied our series of patients with PDA who underwent VATS closure with new modifications. Methods. From June 1997 to December 2004, 1,300 consecutive patients diagnosed with PDA (mean age, 6 years) were referred to us, and all of them met our inclusion criteria for the VATS procedure. Recently, we made some minor alterations to our routine methodology. After complete closure of PDA by two titanium clips, the extubated patient leaves the operating room without a chest tube. Results. There were 3 cases of chylothorax, which were successfully treated by thoracotomy and ligation of the small lymphatic ducts after 1 week of close observation. The procedure was changed to thoracotomy in 7 patients.
Meanwhile, 5 additional patients had transient recurrent laryngeal nerve dysfunction. All cases were reassessed immediately after the procedure, and followed for more than 7 years by control echocardiography. No significant complication or residual shunt was recorded during the follow-up period. Mean procedure time was about 10 ⴞ 2 minutes. All patients were discharged shortly after the procedure (about 20 hours). Conclusions. Based on this experience, VATS appears to be safer and more effective as well as having other advantages such as being simple to perform, quick, and comfortable for the patients. Furthermore, the cosmetic benefits also make it appropriate as an outpatient procedure.
S
Patients and Methods
urgical interruption of patent ductus arteriosus (PDA) using a left posterolateral thoracotomy was the only available technique until 1971 when Porstmann and colleagues [1] described nonsurgical PDA closure by a catheter-delivered device. In 1979, Rashkind and colleagues [2] developed a smaller device for the transcatheter approach. In 1981, their device was introduced into clinical trials, but this technique is not performed in infants weighing less than 7 or 8 kg [3, 4]. In 1993, Laborde and colleagues [5] in Paris described videoassisted thoracoscopic surgery (VATS) for PDA closure in 39 infants and children. Video-assisted thoracoscopic surgery is a rapidly progressing new field of minimally invasive surgery, and since then, Laborde and coworkers [6] and others [7] have performed it in more than 700 cases.In published series, VATS technique has been shown to have several advantages over open thoracotomy or interventional approaches [8]. Since June 1997, the VATS technique for PDA closure has been carried out as first choice procedure for ductal closure at Mashhad University of Medical Sciences, a referral center for video-assisted PDA closure in Iran. The aim of this study was to assess the safety and efficacy of the technique. Accepted for publication April 23, 2007. Address correspondence to Dr Nezafati, Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran 91735; e-mail: [email protected]..
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2007;84:1343– 8) © 2007 by The Society of Thoracic Surgeons
From June 1997 to December 2004, 1,300 consecutive patients with PDA were recognized by color Doppler, two-dimensional echocardiography or catheterization, or both. These patients were enrolled for PDA closure by the VATS technique. The exclusion criteria for VATS procedure were: diameter of the ductus greater than 9 mm; complicated PDA such as true ductal aneurysm, endocarditis, or calcification; and pleural adhesion or a previous left-side thoracic operation. These exclusion criteria were observed in 21 cases who underwent ligation through thoracotomy: diameter of PDA greater than 10 mm in 13 cases, calcification of PDA in 5 cases, ductal aneurysm in 2 cases, and previous insertion of chest tube due to left thoracic trauma in 1 case. The protocols were evaluated by the Local Institutional Committee, and informed approval from patients or children’s parents was obtained. Technique and equipment used have been described in previous work [9], and have remained unchanged for the 7-year period with a few alterations (intraesophageal stethoscope for monitoring of ductal closure interoperatively, chest tube drainage). Specialized surgical instruments necessary for the VATS technique included an electrocautery hook, titanium clips (Ligaclip LT 400; Ethicon Endosurgery, Cincinnati, Ohio), a clip applier, lung retractor, trocar, suc0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.04.077
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tion device, and a videoscope (Karl Storz Endoskope GmbH, Tuttlingen, Germany). Management of general anesthesia included insertion of a large intravenous catheter, three-lead electrocardiographic monitoring, and pulse oximetry, preinduction. Anesthesia was induced with thiopental 5 to 7 mg/kg, atracurium 0.5 mg/kg, and fentanyl 5 g/kg. For better surgical vision, single-lung ventilation was established by selective right bronchial intubation with a Murphy-eye tracheal tube. To reduce bronchial damage, a tracheal tube of half size smaller than expected for the age was selected. Arterial oxygenation and end-tidal CO2 were monitored with a pulse oximeter (North American Dräger, Telfod, Pennsylvania) and a capnograph (Capnostat; GE Medical Systems, Milwaukee, Wisconsin). Oxygen saturation was maintained above 92% with a fraction of inspired oxygen of 100%, and in difficult cases in which oxygen saturation dropped below 90%, positive end-expiratory pressure (2.5 to 5 cm H2O) was added. Blood pressure was controlled and monitored through a 20F catheter inserted into the right radial artery. General anesthesia was maintained with halothane 0.5% v/v in O2 100% without nitrous oxide. All patients were positioned in the right lateral position as for the classic posterolateral thoracotomy approach. Three 5-mm icisions were made in the left hemithorax. The first incision was made in the third intercostals space posterior to the scapula for the videothoracocope. The second incision was made in the third intercostals space on the midaxillary line anterior to the scapula for the introduction of two right-angle hooks for lung retraction. The last incision was made in the fourth intercostal space beneath angle
Fig 1. General view of the surgical field. (DA ⫽ descending aorta; LSCA ⫽ left subclavian artery; PA ⫽ pulmonary artery; PDA ⫽ patent ductus arteriosus.)
Ann Thorac Surg 2007;84:1343– 8
Fig 2. Dissection of patent ductus arteriosus (PDA). (DA ⫽ descending aorta; LRLN ⫽ left recurrent laryngeal nerve.)
of the scapula, for insertion of the clip applier and electrocautery hook. The surgical field was viewed on a video screen (Fig 1), and after identification of the PDA, the posterior pleura on the reflection site was opened longitudinally over the aorta with the electrocautery. The area of the ductus arteriosus was exposed along with the vagus nerve, which was gently retracted with the flap medially to expose the recurrent laryngeal nerve (Fig 2). The pleural
Fig 3. Titanium clips placed on patent ductus arteriosus.
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Fig 6. Subdivision according to body weight.
Fig 4. Chest x-ray film shows the clips on patent ductus arteriosus.
incision was carried up to the base of the left subclavian artery, frequently dividing the highest intercostals vein with the electrocautery. Occasionally, clips were used for larger veins. The upper and lower angles of the PDA are dissected free from surrounding tissues, as was the aorta at its junction with the ductus, taking care to protect the vagus and recurrent laryngeal nerves, which are easily visualized. No effort was made to encircle the ductus arteriosus. The pericardium was also dissected on the pulmonary side to protect the easily identifiable recurrent laryngeal nerve from injury. It should be stressed that both sides of the ductus were dissected for appropriate placement of clip. The first titanium clip (9 mm) is placed as distal as possible from the aortic junction on the pulmonary side of the PDA and another one on the side close to the aorta (Fig 3). The operative field was checked for chylous leaks and bleeding. A small drain
Fig 5. Age distribution (n ⫽ 1,300).
was tunneled into the chest through the existing incisions, and the lung was reexpanded with hand ventilation and gentle suction on the chest tube. After closure of access ports, the pleural catheter was removed under positive pressure and previously placed suture tied. All wounds were then dressed. Immediately after extubation, an anesthesiologist directly evaluated the vocal cords. A chest radiograph and echocardiogram were assessed to exclude pneumothorax and residual shunt, respectively (Fig 4). We have recently used a small catheter as an intraesophageal stethoscope for monitoring and efficiency of ductal closure instead of transesophageal echocardiography (intraoperative). We have used a Foly catheter that has attached to its distal port a small piece of a hand glove, creating something like a diaphragm. We have connected the proximal portion of the catheter to a stethoscope tube. Using this new device was a simple and effective route to confirm the absence of ductal flow in VATS technique; moreover, it has economical advantages. This device was used in the last 500 cases. The patients were discharged after approximately 20 hours. Mean procedure time was 10 ⫾ 2 minutes (skin to skin). There was a “learning curve” phenomenon in this series, that is, the operation time gradually reduced after the first hundred cases.
Fig 7. Incidence of patent ductus arteriosus (PDA) diameter.
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Table 1. Results of Video-Assisted Thoracoscopic Surgery (VATS) Closure of Patent Ductus Arteriosus (PDA) in 1,300 Patients Outcome CARDIOVASCULAR
Mortality Thoracotomy PDA ⬎ 9 mm (immediate in OR) Inadequate visualization (immediate in OR) Tiny residual shunt (late) Missed concurrent coarctation of aorta VATS ⫹ thoracotomy Recurrent laryngeal dysfunction (transient) Recurrent laryngeal dysfunction (persistent) Extubation in operating room Hospitalization (hours) Procedure time (min) OR ⫽ operating room;
Number
Percent
NA 25 6 3
NA 1.9 0.4 0.2
3 1
0.2 0.1
12 12
0.9 0.9
1
0.1
1300 20 10 ⫾ 2
100
NA ⫽ not applicable.
Results Mean age was 6 years (range, 1 month to 35 years; Fig 5), mean weight was 11 kg (range, 6 to 65 kg; Fig 6), and 60% of patients were female. All subjects had been born at full term. No subject with less than these minimum ranges was enrolled in the study. All cases were reassessed by echocardiography immediately before discharge and followed up monthly for 3 months, at 6 months, 12 months, and then annually. Operative mortality was zero. There was no significant complication requiring thoracotomy, such as hemorrhage (which is usually caused by ductal rupture or laceration) or residual shunt. The procedure was changed to a thoracotomy in 6 adult patients due to inappropriately dilated canal (⬎9 mm) and in 1 infant when it was discovered that there was an undiagnosed aortic coarctation. Three patients who underwent successful VATS with no residual shunt at hospital discharge had newly discovered shunts at follow-up. In these patients, diameter of ductus were 9 mm (Fig 7), and we used the new clips; then they were referred for open thoracotomy by reclipping of PDAs. Thus, a total of 12 patients underwent both thoracotomy and VATS (12 of 1,300; 0.92%). Twelve patients had transient laryngeal nerve dysfunction (voice changes, hoarseness, stridor). They recovered completely in 3 to 5 weeks, but 1 patient had long-lasting dysfunction and was treated by gel injection into vocal cord (Table 1).
Comment Patent ductus arteriosus was the first congenital heart disease to be successfully ligated surgically [10] and also the first in which a transcatheter approach was utilized [11]. Several therapeutic options for PDA treatment are currently in use, including indomethacin therapy, transcatheter coil occlusion, VATS PDA closure, and open
surgical ligation through a thoracotomy. Even sternotomy is employed depending on the clinical status and especially on the size and age of the patient and the morphology of the PDA. Each technique has its own advantages and limitations [12]. The anatomical presence of PDA is usually considered to be significant and sufficient indication for closure at any time and any age, whether or not any symptom exists. In many centers, specific echocardiographicic criteria determine the approach [12] to be considered for coil occlusion or VATS, namely, the patient can not have a short, wide, or windowlike PDA. For children weighing more than 10 kg, if the PDA is less than 2.5 mm, coil occlusion is favored. Any PDA between 2.5 and 3 mm is a judgment call, based on patient size and ductal morphology. The ideal PDA for coil occlusion has length (not short and windowlike) and a ductal ampula with a narrowing at the pulmonary artery side of the PDA. If the PDA is greater than 3.0 mm, VATS is typically recommended. Larger PDAs closed with coils often necessitate the use of multiple coils, and result in a huge mass of coils with potential protrusion of coils into the aorta and left pulmonary artery with subsequent risk of aortic coarctation or left pulmonary artery stenosis. A variety of approaches—such as coils, buttons, plugs, and umbrellas— have been described for nonsurgical transcatheter closure through a relatively large diameter femoral sheath. Since the first description of transcatheter closure of a PDA by Rashkind and Cuaso [11] in 1977, many devices and techniques have been used in an attempt to avoid surgical intervention in these patients. This approach is especially feasible in patients more than 10 kg of body weight and in adults with calcified ducts who have high operative risks. In experienced hands, initial occlusion is successful in 85% to 90% of patients. At the 6-month follow-up of 205 procedures, Ali Khan and colleagues [13] reported that 22% of the patients had a small residual shunt after transcatheter PDA closure, of which 59% were in ducts greater than 6 mm. Disadvantages of this method include its cost, availability of limited sizes of occluders, rather bulky delivery apparatus making it unsuitable for most infants, potential proximal left pulmonary artery narrowing developing in small patients, occasional hemolysis after implantation, a relatively high incidence of color Doppler detected residual ductal flow in 10% to 20% of cases, device embolization, and late endarteritis [14]. Two deaths were also reported with the procedure [15]. Therefore, with these disadvantages, the use of VATS technique could be superior to intravascular coils, and latter may be employed in patients who are otherwise poor surgical candidates. Although a traditional thoracotomy is still the gold standard for PDA closure, with success rates of 77% to 100%, it requires larger incisions and is associated with late complications such as scoliosis, wing scapula, breast disfigurement, and rib function with respiratory compromise in 22% to 33% and severe scoliosis to 7.8% of cases [16, 17], recurrent laryngeal nerve dysfunction in 1.1% to 4.2%, and residual shunt in 5% to 23%. Its other relative
disadvantages include longer hospitalization, lower cost effectiveness, and more painful postoperative course. The VATS technique is a natural closure of minimally invasive surgery. It allows ductal closure with minimal chest wall trauma, with a success rate of 88% to 98%, laryngeal nerve dysfunction in 0.6% to 3.4 %, residual shunt in 0% to 5.9%, and without the other potential limitations of two alternative methods. The VATS technique is a better option than the robotically-assisted procedure for PDA closure [18]. Our experience in 1,300 cases supports the advantages of this method. The technique is feasible even for lowweight infants [24], without any need for blood transfusion, whereas transcatheter endovascular closure is usually not possible in those cases. No extensive costeffectiveness comparisons of VATS clipping versus open surgery or versus currently adopted transcatheter techniques are available in literature. Prieto and coworkers [19] stated that coil occlusion is more effective and less costly than conventional surgery. Their conclusions are principally based on the cost of postsurgical stay while considering the presence of persistent leaks clinically negligible. Regarding these issues, we estimate that thoracoscopic approach may favorably influence the costeffective therapeutic balance thanks to shorter inpatient hospital stay and less technical consumption in operating theater and anesthesia (compared with conventional surgery) and fewer residual shunts (compared with transcatheter procedure). Thus, VATS can be considered as a cost-effective method (at least in our country) as it carries approximately one fifth of the cost of the traditional thoracotomy. The only major complication in this series was transient laryngeal nerve dysfunction manifesting as dysphonia, and mainly caused by thermal and traumatic injury. This problem can be mitigated by precise and gentle dissection and avoidance of cautery near the nerve. This complication was noted in 1% of our patients, while other authors indicate 2.5% to 3% using VATS clipping [20]. The incidence of recurrent laryngeal nerve injury with standard ligation by conventional thoracotomy is reported to be 4.2% [21], while it is very high, to 22.7%, for extremely low weight babies [22]. The most significant limitation of the VATS technique is its inability to close a wide ductus (⬍9 mm) owing to the unavailability of clips greater than 9 mm. In an effort to overcome this problem, Kim and colleagues [23] used a self-made endoscopic loop for ligation in 10 patients, using only a small window, with successful ligation of the ductus in all cases and no residual shunts. A careful echocardiographic evaluation of the size and anatomy of the ductus is essential to adequately select patients for VATS. In this way, it is possible to minimize the incidence of conversion and address PDAs of larger size directly to thoracotomic closure. Video-assisted thoracoscopic surgery is a safe and effective technique in premature infants, including those with very low and extremely low birth weight [24], but these patients are at augmented risk of complicated course [7].
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It was concluded from this experience that the VATS technique for PDA closure is simple, rapid, cost effective, and more comfortable for patients. It requires shorter hospital stay and has cosmetic benefits (compared with conventional thoracotomy). There is also less residual shunts and little complications (compared with transcetheter procedure). Therefore, as an outpatient procedure, it has become our primary approach for all PDAs from neonates to adults. The authors would like to thank Prof François Laborde for his invaluable guidelines.
References 1. Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. Radiol Clin North Am 1971;203–18. 2. Rashkind WJ, Cuaso CC, Gibson R. Closure of patent ductus arteriosus in infants and small children without thoracotomy. Proceedings of the 7th Annual Meeting of the Association of European Pediatric Cardiologists, Madrid, Spain, May 8 –11, 1979. 3. Mullins CE. Patent ductus arteriosus. In: Garson A Jr, Bricker JT, Fisher DJ, eds. The science and practice of pediatric cardiology. 1st ed. Philadelphia: Lea & Febiger, 1990:1055– 69. 4. Hoskino MCK, Benson LN, Musewe N. Transcatheter occlusion of the persistently patent ductus arteriosus: forty months follow-up and prevalence of residual shunting. Circulation 1991;84:2313–7. 5. Labored F, Noirhomm P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105:278 – 80. 6. Labored F, Folliguet TA, Etienne PY, Carbognani D, Batisse A, Petrie J. Video-assisted thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases. Eur J Cardiothoracic Surg 1997;11:1052–5. 7. Villa E, Eyden FV, Le Bret E, et al. Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases. Eur J Cardiothorac Surg 2004;25:387–93. 8. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thoac Surg 1993;5:1285–9. 9. Nezafati MH, Hashemian SH, Mahmoodi E, Hamedanchi A. Video-assisted thoracoscopic surgical closure of patent ductus arteriosus: 300 cases. Asian Cardiovasc Thorac Ann 2001;9:275– 8. 10. Gross RE, Hubbard JP. Landmark article Feb 25, 1939: surgical ligation of a patent ductus arteriosus. Report of first successful case. JAMA 1984;251:1201–2. 11. Rashkind WJ, Cuaso CC. Transcatheter closure of patent ductus arteriosus. Successful use in a 3.5 kilogram infant. Pediatr Cardiol 1979;1:3–7. 12. Jacobs JP, Giroud JM, Quintessenza JA. The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional coil occlusion. Ann Thorac Surg 2003;76:1421– 8. 13. Ali Khan MA, al Yousef S, Mullins CE, Sawyer W. Experience with 205 procedures of transcatheter closure of ductus arteriosus in 182 patients, with special reference to residual shunts and long-term follow-up. J Thorac Cardiovasc Surg 1992;104:1721–7. 14. Sullivan ID. Patent arterial duct: when should it be closed? Arch Dis Child 1998;78:285–7.
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15. Tynan M. Transcatheter occlusion of persistent arterial duct. Report of the European registery. Lancet 1992;340:1062– 6. 16. Van Biezen FC, Bakx PA GM, De Villeneuve VH, Hop WCJ. Scoliosis in children after thoracotomy for aortic coarctation. J Bone Joint Surg 1993;75A:514 – 8. 17. Westfelt JN, Nordwall A. Thoracotomy and scoliosis. Spaine 1991;16:1124 –5. 18. Le Bret E, Papadatos S, Folliguet T, et al. Interruption of patent ductus arteriosus in children: robotically assisted versus videothoracoscopic surgery. J Thorac Cardiovasc Surg 2002;123:973– 6. 19. Prieto LP, DeCamillo DM, Konrad DJ, Scalet-Longworth L, Latson LA. Comparison of cost and clinical outcame between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus. Pediatrics 1998;101:1020 – 4.
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20. Bensky AS, Raines K, Hies M. Late follow-up after thoracoscopic ductal ligation. Am J Cardiol 2000;86:360 –1. 21. Fann LL, Campbell DN, Clarke DR, Washigton RL, White CV. Paralyzed left cord associated with ligation of patent ductus arteriosus. J Thorac Cardiovasc Surg 1989;98:611–3. 22. Zbar RIS, Chen AH, Behrendt DM, et al. Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus. Ann Thorac Surg 1996;61:814 – 6. 23. Kim BY, Choi HH, Park YB, Yu BS, Oh BS. Video-assisted thoracoscopic ligation of patent ductus arteriosus. Technique of sliding loop ligation. J Cardiovasc Surg (Torino) 2000;41:69 –72. 24. Hines MH, Raines KH, Payne RM, et al. Video-assisted ductal ligation in premature infants. Ann Thorac Surg 2003; 76:1417–20.
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Ann Thorac Surg 2007;84:1348
•
0003-4975/07/$32.00
Background. Video-assisted thoracoscopic surgery (VATS) has been shown to be a safe and effective method of closing patent ductus arteriosus (PDA). We retrospectively studied our series of patients with PDA who underwent VATS closure with new modifications. Methods. From June 1997 to December 2004, 1,300 consecutive patients diagnosed with PDA (mean age, 6 years) were referred to us, and all of them met our inclusion criteria for the VATS procedure. Recently, we made some minor alterations to our routine methodology. After complete closure of PDA by two titanium clips, the extubated patient leaves the operating room without a chest tube. Results. There were 3 cases of chylothorax, which were successfully treated by thoracotomy and ligation of the small lymphatic ducts after 1 week of close observation. The procedure was changed to thoracotomy in 7 patients.
Meanwhile, 5 additional patients had transient recurrent laryngeal nerve dysfunction. All cases were reassessed immediately after the procedure, and followed for more than 7 years by control echocardiography. No significant complication or residual shunt was recorded during the follow-up period. Mean procedure time was about 10 ⴞ 2 minutes. All patients were discharged shortly after the procedure (about 20 hours). Conclusions. Based on this experience, VATS appears to be safer and more effective as well as having other advantages such as being simple to perform, quick, and comfortable for the patients. Furthermore, the cosmetic benefits also make it appropriate as an outpatient procedure.
S
Patients and Methods
urgical interruption of patent ductus arteriosus (PDA) using a left posterolateral thoracotomy was the only available technique until 1971 when Porstmann and colleagues [1] described nonsurgical PDA closure by a catheter-delivered device. In 1979, Rashkind and colleagues [2] developed a smaller device for the transcatheter approach. In 1981, their device was introduced into clinical trials, but this technique is not performed in infants weighing less than 7 or 8 kg [3, 4]. In 1993, Laborde and colleagues [5] in Paris described videoassisted thoracoscopic surgery (VATS) for PDA closure in 39 infants and children. Video-assisted thoracoscopic surgery is a rapidly progressing new field of minimally invasive surgery, and since then, Laborde and coworkers [6] and others [7] have performed it in more than 700 cases.In published series, VATS technique has been shown to have several advantages over open thoracotomy or interventional approaches [8]. Since June 1997, the VATS technique for PDA closure has been carried out as first choice procedure for ductal closure at Mashhad University of Medical Sciences, a referral center for video-assisted PDA closure in Iran. The aim of this study was to assess the safety and efficacy of the technique. Accepted for publication April 23, 2007. Address correspondence to Dr Nezafati, Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran 91735; e-mail: [email protected]..
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2007;84:1343– 8) © 2007 by The Society of Thoracic Surgeons
From June 1997 to December 2004, 1,300 consecutive patients with PDA were recognized by color Doppler, two-dimensional echocardiography or catheterization, or both. These patients were enrolled for PDA closure by the VATS technique. The exclusion criteria for VATS procedure were: diameter of the ductus greater than 9 mm; complicated PDA such as true ductal aneurysm, endocarditis, or calcification; and pleural adhesion or a previous left-side thoracic operation. These exclusion criteria were observed in 21 cases who underwent ligation through thoracotomy: diameter of PDA greater than 10 mm in 13 cases, calcification of PDA in 5 cases, ductal aneurysm in 2 cases, and previous insertion of chest tube due to left thoracic trauma in 1 case. The protocols were evaluated by the Local Institutional Committee, and informed approval from patients or children’s parents was obtained. Technique and equipment used have been described in previous work [9], and have remained unchanged for the 7-year period with a few alterations (intraesophageal stethoscope for monitoring of ductal closure interoperatively, chest tube drainage). Specialized surgical instruments necessary for the VATS technique included an electrocautery hook, titanium clips (Ligaclip LT 400; Ethicon Endosurgery, Cincinnati, Ohio), a clip applier, lung retractor, trocar, suc0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.04.077
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Video-Assisted Ductal Closure With New Modifications: Minimally Invasive, Maximally Effective, 1,300 Cases
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tion device, and a videoscope (Karl Storz Endoskope GmbH, Tuttlingen, Germany). Management of general anesthesia included insertion of a large intravenous catheter, three-lead electrocardiographic monitoring, and pulse oximetry, preinduction. Anesthesia was induced with thiopental 5 to 7 mg/kg, atracurium 0.5 mg/kg, and fentanyl 5 g/kg. For better surgical vision, single-lung ventilation was established by selective right bronchial intubation with a Murphy-eye tracheal tube. To reduce bronchial damage, a tracheal tube of half size smaller than expected for the age was selected. Arterial oxygenation and end-tidal CO2 were monitored with a pulse oximeter (North American Dräger, Telfod, Pennsylvania) and a capnograph (Capnostat; GE Medical Systems, Milwaukee, Wisconsin). Oxygen saturation was maintained above 92% with a fraction of inspired oxygen of 100%, and in difficult cases in which oxygen saturation dropped below 90%, positive end-expiratory pressure (2.5 to 5 cm H2O) was added. Blood pressure was controlled and monitored through a 20F catheter inserted into the right radial artery. General anesthesia was maintained with halothane 0.5% v/v in O2 100% without nitrous oxide. All patients were positioned in the right lateral position as for the classic posterolateral thoracotomy approach. Three 5-mm icisions were made in the left hemithorax. The first incision was made in the third intercostals space posterior to the scapula for the videothoracocope. The second incision was made in the third intercostals space on the midaxillary line anterior to the scapula for the introduction of two right-angle hooks for lung retraction. The last incision was made in the fourth intercostal space beneath angle
Fig 1. General view of the surgical field. (DA ⫽ descending aorta; LSCA ⫽ left subclavian artery; PA ⫽ pulmonary artery; PDA ⫽ patent ductus arteriosus.)
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Fig 2. Dissection of patent ductus arteriosus (PDA). (DA ⫽ descending aorta; LRLN ⫽ left recurrent laryngeal nerve.)
of the scapula, for insertion of the clip applier and electrocautery hook. The surgical field was viewed on a video screen (Fig 1), and after identification of the PDA, the posterior pleura on the reflection site was opened longitudinally over the aorta with the electrocautery. The area of the ductus arteriosus was exposed along with the vagus nerve, which was gently retracted with the flap medially to expose the recurrent laryngeal nerve (Fig 2). The pleural
Fig 3. Titanium clips placed on patent ductus arteriosus.
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Fig 6. Subdivision according to body weight.
Fig 4. Chest x-ray film shows the clips on patent ductus arteriosus.
incision was carried up to the base of the left subclavian artery, frequently dividing the highest intercostals vein with the electrocautery. Occasionally, clips were used for larger veins. The upper and lower angles of the PDA are dissected free from surrounding tissues, as was the aorta at its junction with the ductus, taking care to protect the vagus and recurrent laryngeal nerves, which are easily visualized. No effort was made to encircle the ductus arteriosus. The pericardium was also dissected on the pulmonary side to protect the easily identifiable recurrent laryngeal nerve from injury. It should be stressed that both sides of the ductus were dissected for appropriate placement of clip. The first titanium clip (9 mm) is placed as distal as possible from the aortic junction on the pulmonary side of the PDA and another one on the side close to the aorta (Fig 3). The operative field was checked for chylous leaks and bleeding. A small drain
Fig 5. Age distribution (n ⫽ 1,300).
was tunneled into the chest through the existing incisions, and the lung was reexpanded with hand ventilation and gentle suction on the chest tube. After closure of access ports, the pleural catheter was removed under positive pressure and previously placed suture tied. All wounds were then dressed. Immediately after extubation, an anesthesiologist directly evaluated the vocal cords. A chest radiograph and echocardiogram were assessed to exclude pneumothorax and residual shunt, respectively (Fig 4). We have recently used a small catheter as an intraesophageal stethoscope for monitoring and efficiency of ductal closure instead of transesophageal echocardiography (intraoperative). We have used a Foly catheter that has attached to its distal port a small piece of a hand glove, creating something like a diaphragm. We have connected the proximal portion of the catheter to a stethoscope tube. Using this new device was a simple and effective route to confirm the absence of ductal flow in VATS technique; moreover, it has economical advantages. This device was used in the last 500 cases. The patients were discharged after approximately 20 hours. Mean procedure time was 10 ⫾ 2 minutes (skin to skin). There was a “learning curve” phenomenon in this series, that is, the operation time gradually reduced after the first hundred cases.
Fig 7. Incidence of patent ductus arteriosus (PDA) diameter.
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Table 1. Results of Video-Assisted Thoracoscopic Surgery (VATS) Closure of Patent Ductus Arteriosus (PDA) in 1,300 Patients Outcome CARDIOVASCULAR
Mortality Thoracotomy PDA ⬎ 9 mm (immediate in OR) Inadequate visualization (immediate in OR) Tiny residual shunt (late) Missed concurrent coarctation of aorta VATS ⫹ thoracotomy Recurrent laryngeal dysfunction (transient) Recurrent laryngeal dysfunction (persistent) Extubation in operating room Hospitalization (hours) Procedure time (min) OR ⫽ operating room;
Number
Percent
NA 25 6 3
NA 1.9 0.4 0.2
3 1
0.2 0.1
12 12
0.9 0.9
1
0.1
1300 20 10 ⫾ 2
100
NA ⫽ not applicable.
Results Mean age was 6 years (range, 1 month to 35 years; Fig 5), mean weight was 11 kg (range, 6 to 65 kg; Fig 6), and 60% of patients were female. All subjects had been born at full term. No subject with less than these minimum ranges was enrolled in the study. All cases were reassessed by echocardiography immediately before discharge and followed up monthly for 3 months, at 6 months, 12 months, and then annually. Operative mortality was zero. There was no significant complication requiring thoracotomy, such as hemorrhage (which is usually caused by ductal rupture or laceration) or residual shunt. The procedure was changed to a thoracotomy in 6 adult patients due to inappropriately dilated canal (⬎9 mm) and in 1 infant when it was discovered that there was an undiagnosed aortic coarctation. Three patients who underwent successful VATS with no residual shunt at hospital discharge had newly discovered shunts at follow-up. In these patients, diameter of ductus were 9 mm (Fig 7), and we used the new clips; then they were referred for open thoracotomy by reclipping of PDAs. Thus, a total of 12 patients underwent both thoracotomy and VATS (12 of 1,300; 0.92%). Twelve patients had transient laryngeal nerve dysfunction (voice changes, hoarseness, stridor). They recovered completely in 3 to 5 weeks, but 1 patient had long-lasting dysfunction and was treated by gel injection into vocal cord (Table 1).
Comment Patent ductus arteriosus was the first congenital heart disease to be successfully ligated surgically [10] and also the first in which a transcatheter approach was utilized [11]. Several therapeutic options for PDA treatment are currently in use, including indomethacin therapy, transcatheter coil occlusion, VATS PDA closure, and open
surgical ligation through a thoracotomy. Even sternotomy is employed depending on the clinical status and especially on the size and age of the patient and the morphology of the PDA. Each technique has its own advantages and limitations [12]. The anatomical presence of PDA is usually considered to be significant and sufficient indication for closure at any time and any age, whether or not any symptom exists. In many centers, specific echocardiographicic criteria determine the approach [12] to be considered for coil occlusion or VATS, namely, the patient can not have a short, wide, or windowlike PDA. For children weighing more than 10 kg, if the PDA is less than 2.5 mm, coil occlusion is favored. Any PDA between 2.5 and 3 mm is a judgment call, based on patient size and ductal morphology. The ideal PDA for coil occlusion has length (not short and windowlike) and a ductal ampula with a narrowing at the pulmonary artery side of the PDA. If the PDA is greater than 3.0 mm, VATS is typically recommended. Larger PDAs closed with coils often necessitate the use of multiple coils, and result in a huge mass of coils with potential protrusion of coils into the aorta and left pulmonary artery with subsequent risk of aortic coarctation or left pulmonary artery stenosis. A variety of approaches—such as coils, buttons, plugs, and umbrellas— have been described for nonsurgical transcatheter closure through a relatively large diameter femoral sheath. Since the first description of transcatheter closure of a PDA by Rashkind and Cuaso [11] in 1977, many devices and techniques have been used in an attempt to avoid surgical intervention in these patients. This approach is especially feasible in patients more than 10 kg of body weight and in adults with calcified ducts who have high operative risks. In experienced hands, initial occlusion is successful in 85% to 90% of patients. At the 6-month follow-up of 205 procedures, Ali Khan and colleagues [13] reported that 22% of the patients had a small residual shunt after transcatheter PDA closure, of which 59% were in ducts greater than 6 mm. Disadvantages of this method include its cost, availability of limited sizes of occluders, rather bulky delivery apparatus making it unsuitable for most infants, potential proximal left pulmonary artery narrowing developing in small patients, occasional hemolysis after implantation, a relatively high incidence of color Doppler detected residual ductal flow in 10% to 20% of cases, device embolization, and late endarteritis [14]. Two deaths were also reported with the procedure [15]. Therefore, with these disadvantages, the use of VATS technique could be superior to intravascular coils, and latter may be employed in patients who are otherwise poor surgical candidates. Although a traditional thoracotomy is still the gold standard for PDA closure, with success rates of 77% to 100%, it requires larger incisions and is associated with late complications such as scoliosis, wing scapula, breast disfigurement, and rib function with respiratory compromise in 22% to 33% and severe scoliosis to 7.8% of cases [16, 17], recurrent laryngeal nerve dysfunction in 1.1% to 4.2%, and residual shunt in 5% to 23%. Its other relative
disadvantages include longer hospitalization, lower cost effectiveness, and more painful postoperative course. The VATS technique is a natural closure of minimally invasive surgery. It allows ductal closure with minimal chest wall trauma, with a success rate of 88% to 98%, laryngeal nerve dysfunction in 0.6% to 3.4 %, residual shunt in 0% to 5.9%, and without the other potential limitations of two alternative methods. The VATS technique is a better option than the robotically-assisted procedure for PDA closure [18]. Our experience in 1,300 cases supports the advantages of this method. The technique is feasible even for lowweight infants [24], without any need for blood transfusion, whereas transcatheter endovascular closure is usually not possible in those cases. No extensive costeffectiveness comparisons of VATS clipping versus open surgery or versus currently adopted transcatheter techniques are available in literature. Prieto and coworkers [19] stated that coil occlusion is more effective and less costly than conventional surgery. Their conclusions are principally based on the cost of postsurgical stay while considering the presence of persistent leaks clinically negligible. Regarding these issues, we estimate that thoracoscopic approach may favorably influence the costeffective therapeutic balance thanks to shorter inpatient hospital stay and less technical consumption in operating theater and anesthesia (compared with conventional surgery) and fewer residual shunts (compared with transcatheter procedure). Thus, VATS can be considered as a cost-effective method (at least in our country) as it carries approximately one fifth of the cost of the traditional thoracotomy. The only major complication in this series was transient laryngeal nerve dysfunction manifesting as dysphonia, and mainly caused by thermal and traumatic injury. This problem can be mitigated by precise and gentle dissection and avoidance of cautery near the nerve. This complication was noted in 1% of our patients, while other authors indicate 2.5% to 3% using VATS clipping [20]. The incidence of recurrent laryngeal nerve injury with standard ligation by conventional thoracotomy is reported to be 4.2% [21], while it is very high, to 22.7%, for extremely low weight babies [22]. The most significant limitation of the VATS technique is its inability to close a wide ductus (⬍9 mm) owing to the unavailability of clips greater than 9 mm. In an effort to overcome this problem, Kim and colleagues [23] used a self-made endoscopic loop for ligation in 10 patients, using only a small window, with successful ligation of the ductus in all cases and no residual shunts. A careful echocardiographic evaluation of the size and anatomy of the ductus is essential to adequately select patients for VATS. In this way, it is possible to minimize the incidence of conversion and address PDAs of larger size directly to thoracotomic closure. Video-assisted thoracoscopic surgery is a safe and effective technique in premature infants, including those with very low and extremely low birth weight [24], but these patients are at augmented risk of complicated course [7].
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It was concluded from this experience that the VATS technique for PDA closure is simple, rapid, cost effective, and more comfortable for patients. It requires shorter hospital stay and has cosmetic benefits (compared with conventional thoracotomy). There is also less residual shunts and little complications (compared with transcetheter procedure). Therefore, as an outpatient procedure, it has become our primary approach for all PDAs from neonates to adults. The authors would like to thank Prof François Laborde for his invaluable guidelines.
References 1. Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. Radiol Clin North Am 1971;203–18. 2. Rashkind WJ, Cuaso CC, Gibson R. Closure of patent ductus arteriosus in infants and small children without thoracotomy. Proceedings of the 7th Annual Meeting of the Association of European Pediatric Cardiologists, Madrid, Spain, May 8 –11, 1979. 3. Mullins CE. Patent ductus arteriosus. In: Garson A Jr, Bricker JT, Fisher DJ, eds. The science and practice of pediatric cardiology. 1st ed. Philadelphia: Lea & Febiger, 1990:1055– 69. 4. Hoskino MCK, Benson LN, Musewe N. Transcatheter occlusion of the persistently patent ductus arteriosus: forty months follow-up and prevalence of residual shunting. Circulation 1991;84:2313–7. 5. Labored F, Noirhomm P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105:278 – 80. 6. Labored F, Folliguet TA, Etienne PY, Carbognani D, Batisse A, Petrie J. Video-assisted thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases. Eur J Cardiothoracic Surg 1997;11:1052–5. 7. Villa E, Eyden FV, Le Bret E, et al. Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases. Eur J Cardiothorac Surg 2004;25:387–93. 8. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thoac Surg 1993;5:1285–9. 9. Nezafati MH, Hashemian SH, Mahmoodi E, Hamedanchi A. Video-assisted thoracoscopic surgical closure of patent ductus arteriosus: 300 cases. Asian Cardiovasc Thorac Ann 2001;9:275– 8. 10. Gross RE, Hubbard JP. Landmark article Feb 25, 1939: surgical ligation of a patent ductus arteriosus. Report of first successful case. JAMA 1984;251:1201–2. 11. Rashkind WJ, Cuaso CC. Transcatheter closure of patent ductus arteriosus. Successful use in a 3.5 kilogram infant. Pediatr Cardiol 1979;1:3–7. 12. Jacobs JP, Giroud JM, Quintessenza JA. The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery and interventional coil occlusion. Ann Thorac Surg 2003;76:1421– 8. 13. Ali Khan MA, al Yousef S, Mullins CE, Sawyer W. Experience with 205 procedures of transcatheter closure of ductus arteriosus in 182 patients, with special reference to residual shunts and long-term follow-up. J Thorac Cardiovasc Surg 1992;104:1721–7. 14. Sullivan ID. Patent arterial duct: when should it be closed? Arch Dis Child 1998;78:285–7.
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15. Tynan M. Transcatheter occlusion of persistent arterial duct. Report of the European registery. Lancet 1992;340:1062– 6. 16. Van Biezen FC, Bakx PA GM, De Villeneuve VH, Hop WCJ. Scoliosis in children after thoracotomy for aortic coarctation. J Bone Joint Surg 1993;75A:514 – 8. 17. Westfelt JN, Nordwall A. Thoracotomy and scoliosis. Spaine 1991;16:1124 –5. 18. Le Bret E, Papadatos S, Folliguet T, et al. Interruption of patent ductus arteriosus in children: robotically assisted versus videothoracoscopic surgery. J Thorac Cardiovasc Surg 2002;123:973– 6. 19. Prieto LP, DeCamillo DM, Konrad DJ, Scalet-Longworth L, Latson LA. Comparison of cost and clinical outcame between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus. Pediatrics 1998;101:1020 – 4.
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20. Bensky AS, Raines K, Hies M. Late follow-up after thoracoscopic ductal ligation. Am J Cardiol 2000;86:360 –1. 21. Fann LL, Campbell DN, Clarke DR, Washigton RL, White CV. Paralyzed left cord associated with ligation of patent ductus arteriosus. J Thorac Cardiovasc Surg 1989;98:611–3. 22. Zbar RIS, Chen AH, Behrendt DM, et al. Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus. Ann Thorac Surg 1996;61:814 – 6. 23. Kim BY, Choi HH, Park YB, Yu BS, Oh BS. Video-assisted thoracoscopic ligation of patent ductus arteriosus. Technique of sliding loop ligation. J Cardiovasc Surg (Torino) 2000;41:69 –72. 24. Hines MH, Raines KH, Payne RM, et al. Video-assisted ductal ligation in premature infants. Ann Thorac Surg 2003; 76:1417–20.
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