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Video-assisted thoracoscopy surgery in patent ductus arteriosus

Burgos Claudio; Siccardi María Alejandra; Honorato David; Chisari Jorge.

Cardiovascular Service, Italian Hospital
Mendoza. Argentina.

Introduction
Objetives
Materials and Methods
Results
Discussion
Conclusions

Introduction:  Patent ductus arteriosus (PDA) is a frequent congenital heart-defect in newborn, infant and children. The incidence is 1 in 200 live births and is higher in pre-term infants. Surgical correction is indicated in newborn with ineffective medical treatment, infants with important left to right shunt and heart failure and asyntomatic children, because pulmonary and hemodynamic, and though rarely, bacterial endocarditis risks exist. PDA ligation through left posterolateral thoracotomy was performed first time in 1939. Porstman and col. developed catheter closure of PDA in seventies. Video-assisted thoracoscopy surgery (VATS) was performed first time by Laborde in 1993. Burke has improved this technique in closure of PDA and vascular rings since 1994, and it has been utilized in another additional procedures: venous and arterial collateral’s interruption, epicardial pacemaker and pericardial drainage placement, and thoracic conduit ligation. Successful experiences have been publicized in smaller than 1000 Gs pre-term infants and adults too.

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Objetives: PDA closure by VATS is a secure and effective technique, with surgical injury reduction in comparison with conventional surgery in our experience. This one started the last months of 1996 and is presented in this report.

Materials y Methods: Between January 1996 and March 1999, 11 children with PDA were operated by VATS in our service. They were 44% of total PDA in this period of time (n=25). The rest of patients were treated with conventional technique because they had any exclusion criteria: previous surgical ligation (n=3), ductus aneurismatic dilatation and calcification (n=1), PDA size greater than 10 mm (n=2), weight lower than 3 kg (n=2). The other 6 patients were operated by posterolateral thoracotomy before new technique implementation. We analyzed preoperative, surgical and postoperative conditions. The group received same anesthetic management, and femoral artery catheter was used to show aortic compromise during PDA clipation (very lateral clip). For endotracheal intubation a smaller size tubes for age and weight and with inflated balloon were preferred to facility left lung collapse during right lung selective intubation. In left lateral position four marks are made for thoracotomy cannulas. First aperture is made under escapula and a valvulated entry is placed to introduce the optic, connected with a camera and image circuit. This circuit have a digitizer image computer. The second incision is for instrumental ingress 3 cm upper and posterior to the first. Others 2 apertures are indicated for lung retractor and left hand instrumental. PDA is carefully dissected and clipped. Homeostasis is controlled and drainage is placed in optic thoracotomy.

Results: Between January 1996 and March 1999, we performed 11 PDA closure by VATS in our service, from 25 children with the same heart defect operated. The experience results are showed in table 1. The median of age was 3 years and 36% were under 12 months old. Female was predominance. 75% of children had good nutritional status; median of weight was 15,200 kg. 27% of patients received treatment for congestive heart failure and only a 6 months old infant had associated heart defect: small VSD. Procedure time was 40 minutes and 8 patients were extubated in operating room. The others needed mechanical ventilation for 4 hours. Two patients presented arterial hypertension in the first 48 Hs treated with fluid restriction, diuretics and vasodilators successfully. A child with Down syndrome, extubated in operating room presented upper airway obstruction episode and required mechanical respiratory assistance for 24 Hs later. All patients received normal analgesic medication and didn’t need greater doses or opiates agents. Normal activity was early recovered and important pain was not refereed. Drainage tubes were put away the second postoperative day in all cases. 4 patients had left vocal cod transient paralysis and they recovered normal function at 3 to 8 months after the procedure. Disappearance of heart murmur was confirmed intraoperative in all patients. No residual shunt was found and it was confirmed by Doppler echocardiography between 10 to 30 days after. All patients were admitted the day before and they stayed for 3 days at hospital. This series mortality was 0%.

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Discussion: PDA is a common congenital heart defect with easy surgical correction. The conventional surgery closure is an effective and standard technique. Trans catheter closure has recognized limitations: patient weight (lower than 4 kg) or ductal anatomy, and embolism, hemolysis or infection risks for the procedure. Further, 10 to 20% of residual shunt was described in other series. VATS appears secure and effective in low weight pre term infants, with low complication incidence and mortality 0%. Clips size (10 mm) should limit indications. Most common complication in several series is left vocal cord paralysis, recurrent nerve injury caused by diathermy in ductus dissection. This lesion has been described with similar incidence in open surgical ligation. Dissection with thoracoscopy instrumental designed by Redmond Burke, assimilate double utility, in our small experience, shows better results. Thoracic conduit injury is rare and we didn’t see any lesion. Selective right lung intubation avoids electronic CO2 insuflation or lung retraction, sometimes very difficult, and improves surgical field.

Conclusions: Surgical injury reduction, with greater confort, lower pain and thoracic disjunction, similar effectiveness to open PDA ligation and exclusion criteria (size greater than 10 mm or calcification) show that VATS for PDA closure is an accessible and secure option.

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Questions, contributions and commentaries to the Authors: send an e-mail message (up to 15 lines, without attachments) to surgery-pcvc@pcvc.sminter.com.ar , written either in English, Spanish, or Portuguese.


© CETIFAC
Bioengineering
UNER

Update
Dic/21/1999