Influence of ductal size on the results of transcatheter closure of patent ductus arteriosus with coils

Comparison of outcomes following thoracoscopic versus thoracotomy closure for persistent patent ductus arteriosus

BACKGROUND

Patent ductus arteriosus closure is traditionally performed by thoracotomy approach. Video-assisted thoracoscopic surgery is a less frequently utilised alternative. We sought to compare elective surgical outcomes between the two methods via a single-centre retrospective cohort analysis.

METHODS

All patients >3.2 kg undergoing surgical patent ductus arteriosus ligation at a single institution from 2000 to 2018 were retrospectively reviewed. Propensity matching for age, weight, diuretic usage, and preterm status was conducted to adjust for differences in baseline patient characteristics. Outcome measures included operative time, hospitalisation duration, post-operative complications, and re-operation.

RESULTS

A total of 173 patients were included, 127 thoracoscopy and 46 thoracotomy. In the unmatched cohorts, no significant difference in closure success was found (94% thoracoscopy versus 100% thoracotomy, p = 0.192). Although median operative time was longer for thoracoscopy (87 versus 56 minutes, p < 0.001), hospitalisation duration was shorter (1.05 versus 2.41 days, p < 0.001), as was ICU stay (0.00 versus 0.75 days, p < 0.001). There were no significant differences in re-operation or complication rates, except chest tube placement (11% thoracoscopy versus 50% thoracotomy, p < 0.001). After matching (69 thoracoscopy versus 20 thoracotomy), these differences persisted, including median operative time (81 versus 56 minutes, p = 0.007; thoracoscopy versus thoracotomy), hospitalisation duration (1.25 versus 2.27 days, p < 0.001), and chest tube placement (17% versus 60%, p < 0.001). There remained no significant difference in complications or re-operations.

CONCLUSIONS

Thoracoscopic ligation was associated with shorter ICU and hospital stays and less frequent chest tube placement, but longer operative times. Other risks, including bleeding, chylothorax, and recurrent laryngeal nerve injury, were similar.

Esophageal stethoscope: an old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for closure of a patent ductus arteriosus (PDA), but is associated with a minute rate of residual or recurrent duct patency. This study aims to analyze the efficacy of intraoperative esophageal stethoscopic monitoring in reducing the incidence of residual ductal flow during PDA clipping by VATS.

METHODS

Between June 1997 and October 2009, we retrospectively assessed 2000 consecutive patients with PDA who underwent VATS. During the procedure, heart sounds were monitored by the anesthesiologist through an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded before and after the PDA clipping and were confirmed to disappear completely. Color flow Doppler echocardiography was performed immediately before discharge, and patients were followed monthly for 3, 6, and 12 months and then annually to confirm the absence of residual or recurrent shunt.

RESULTS

Mean age was 6.0 years (range, 1 month-35 years), mean weight was 11.1 kg (range, 6-65 kg), and mean PDA diameter was 5.5 mm (range, 3-9 mm). Ninety-two percent of patients showed no ductal flow after a single clipping. In the other 8% of patients, residual flow was detected intraoperatively after a single clipping, but was eliminated by the second clipping. Twelve patients (0.6%) presented with residual ductal flow immediately after the operation (detected by color Doppler echocardiography), which was eliminated by thoracotomy before discharge. All patients left the hospital with echocardiography documenting no evidence of residual PDA. At follow-up, the incidence of residual patency was 0.2% (4 of 2000).

CONCLUSIONS

Our results demonstrate that the intraoperative esophageal stethoscope provides a remarkably effective technique for monitoring and evaluating PDA ligation by VATS, thus avoiding reintervention and the complications associated with residual ductal flow in most cases.

Transcatheter closure of patent ductus arteriosus: experience with a new device

Transcatheter closure is the preferred method of treatment of patent ductus arteriosus (PDA). Detachable coils are widely used to close small ducts, while the Amplatzer duct occluder (ADO) is generally employed for moderate or large ducts. Recently a new device, the Amplatzer duct occluder II (ADO II), a nitinol flexible mesh, with a symmetrical design to provide high conformability for treatment of all types of PDA, has received the European Community mark approval. We report on one of the first experience, four cases (1 male, 3 female, age ranging from six months to seven years old) with different type and size of PDA treated with the new device. The use of this new Amplatzer duct occluder in our experience has the advantage of ease and safety of placement, conformability, stability, low profile catheters, adaptability for long ducts as in type E.

Transcatheter closure of a large patent ductus arteriosus in a young child using the Amplatzer duct occluder

The Amplatzer duct occluder (ADO) provides a safe and effective therapy for patients with moderate- to large-sized patent ductus arteriosus (PDA), but there have been few reports of transcatheter closure of very large PDAs in young children and infants. We report a successful transcatheter closure of a very large PDA, 10.5 mm in diameter at the narrowest point, with a 14/12-mm ADO. To our knowledge, this is the largest PDA ever closed by an interventional method in such a young child.

Modified Extrapleural Ligation of Patent Ductus Arteriosus: A Convenient Surgical Approach in a Developing Country

BACKGROUND

Minimally invasive surgery for the closure of a large patent ductus arteriosus (PDA) using an extrapleural technique offers an alternative to other minimally invasive approaches such as video-assisted thoracoscopic surgery or interventional cardiologic procedures.

METHODS

Between August 1999 and December 2003, 513 patients with PDA were admitted to Unidad de Cirugia Cardiovascular de Guatemala, of whom 327 (64%) were considered surgical candidates. Of these, 218 (67%) were selected for surgical extrapleural (SEP) closure initially by weight (< 10 kg) and a ductal diameter at the pulmonary end of greater than 4 mm. Subsequently, we included also patients who weighed more than 10 kg. Median age at operation was 51 months (range 5 days to 38 years).

RESULTS

Median operating time was 32 minutes (range 23 to 52 minutes). All 218 patients had SEP closure and were extubated in the operating room. There were no hospital deaths. Two patients required a blood transfusion. Two additional patients bled postoperatively, requiring reoperation. A pneumothorax occurred in 3 patients that required a chest tube. The 6-month follow-up revealed residual ductal shunts in 2 patients that were closed percutaneously with a coil. The treatment of the remaining 295 patients included a surgical transpleural (STP) approach in 109 (37%) and transcatheter closure in 186 (63%), with a coil in 110 (37%) and an Amplatzer device in 76 (26%).

CONCLUSIONS

Minimally invasive closure of a PDA through a short, 3-cm to 5-cm skin and muscle-sparing posterior thoracotomy and an SEP approach provides a convenient and safe technique with a low incidence of complications and also a cost-saving option compared with other invasive techniques.

New developments in the transcatheter treatment of congenital heart disease

PURPOSE OF REVIEW

This review summarizes recent developments in the field of interventional paediatric cardiology. This is a rapidly evolving field with many new techniques that have been optimized or introduced during the past few years.

RECENT FINDINGS

Important new data have emerged on the device closure of atrial septal defects, ventricular septal defects and patent ductus arteriosus. The technology has been improved further and more results on complications and problems have become available. New technical developments in the treatment of stenosis of the pulmonary arteries and the aorta, such as the use of cutting balloons and (covered) stents, have resulted in new treatment options for congenital disorders that were not considered suitable for percutaneous treatment. Fascinating emerging technologies such as percutaneous aortic and pulmonary valve implantations have been introduced and the first results have been reported. Changes in imaging technology such as intracardiac echocardiography and magnetic resonance imaging affect interventional cardiology. These changes result in a new approach to congenital heart disease in which hybrid surgical and interventional procedures are used to treat complex disease.

SUMMARY

Interventional congenital cardiology is a rapidly growing field that offers new treatment options for patients with congenital heart disease.