Patent Ductus Arteriosus (PDA) may be an isolated defect or may co-exist with other congenital anomalies. The ductus may be large, moderate or small in 'size.
Indications for Surgery
Presence of a ductus arteriosus is an indication for surgery. The timing of operation is usually the first year of life. In pre-term babies, PDA closure will be requhed in the first few days after birth. When ductus is large and heart failure is a problem surgery should be uiidertaken at any time. When a large ductus has produced severe pulmonary hypertension and pulmonary vascular disease contra indication for operation is the same as in a large VSD. Operability can be decided on cardiac catheterization by balloon occlusion of the duct~ls. When the ductus is occluded left to right shunt is abolished and pulmonary artery pressure should fall and aortic pressure should go up. If it does not happen, closing the ductus is not going to be beneficial.
Technique of Closure
Ductus closure in selected cases can be achieved by cardiac catheterization and closure with coils or a device. The other technique available is thoracoscopic closure by using vascular clips.
Surgical Closure of Patent Ductus Arteriosus
The patient is positioned in right lateral position and a left ~osterolateral thoracotomy is done. In infants and children only a small lateral thoracotomy is required. The chest is opened through fourth intercostal space. A chest retractor is applied and lung retracted anteriorly. Mediastinal pleura is incised over descending aorta, arch and on to the left subclavian artery. Flaps are raised and stay sutures taken. Under controlled hypotension, the ductus is dissected and isolated. Small ductus can be ligated (Fig.). Triple ligation is done with two ligatures at aortic and p u l m o n q ends. In between a transfixion suture is applied.
The other technique is division and suture. Between two clamps, ductus is divided and aortic and pulmonary ends are sutured with 6 or 5 '0' prolene sutures. In large short ductus which is more like an aorto pulmonary window in the ductal position it is better to clamp the aorta above and below the ductus and a third clamp on the pulmonary arterial end. Ductus is divided. Aortic end is sutured with 5 '0' prolene and clamps removed. Aortic clamping time should be limited to 15 minutes and definitely not more than 20 minutes.
Indications for Surgery
Presence of a ductus arteriosus is an indication for surgery. The timing of operation is usually the first year of life. In pre-term babies, PDA closure will be requhed in the first few days after birth. When ductus is large and heart failure is a problem surgery should be uiidertaken at any time. When a large ductus has produced severe pulmonary hypertension and pulmonary vascular disease contra indication for operation is the same as in a large VSD. Operability can be decided on cardiac catheterization by balloon occlusion of the duct~ls. When the ductus is occluded left to right shunt is abolished and pulmonary artery pressure should fall and aortic pressure should go up. If it does not happen, closing the ductus is not going to be beneficial.
Technique of Closure
Ductus closure in selected cases can be achieved by cardiac catheterization and closure with coils or a device. The other technique available is thoracoscopic closure by using vascular clips.
Surgical Closure of Patent Ductus Arteriosus
The patient is positioned in right lateral position and a left ~osterolateral thoracotomy is done. In infants and children only a small lateral thoracotomy is required. The chest is opened through fourth intercostal space. A chest retractor is applied and lung retracted anteriorly. Mediastinal pleura is incised over descending aorta, arch and on to the left subclavian artery. Flaps are raised and stay sutures taken. Under controlled hypotension, the ductus is dissected and isolated. Small ductus can be ligated (Fig.). Triple ligation is done with two ligatures at aortic and p u l m o n q ends. In between a transfixion suture is applied.
The other technique is division and suture. Between two clamps, ductus is divided and aortic and pulmonary ends are sutured with 6 or 5 '0' prolene sutures. In large short ductus which is more like an aorto pulmonary window in the ductal position it is better to clamp the aorta above and below the ductus and a third clamp on the pulmonary arterial end. Ductus is divided. Aortic end is sutured with 5 '0' prolene and clamps removed. Aortic clamping time should be limited to 15 minutes and definitely not more than 20 minutes.
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| Closure,of patent ductus Arteriosus by ligation |
Results
The mortality should be 0 per cent in babies and children. At older age there is slightly increased risk for surgeiy.
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