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Evolution of strategies for management of the patent arterial duct

Published online by Cambridge University Press:  26 November 2007

Jorge M. Giroud  and
Jeffrey P. Jacobs
Jorge M. Giroud*
Affiliation:
The Congenital Heart Institute of Florida, All Children’s Hospital, Children’s Hospital of Tampa, Pediatric Cardiology Associates, University of South Florida, Saint Petersburg and Tampa, Florida, United States of America
Jeffrey P. Jacobs
Affiliation:
The Congenital Heart Institute of Florida, All Children’s Hospital, Children’s Hospital of Tampa, Cardiac Surgical Associates, University of South Florida, Saint Petersburg and Tampa, Florida, United States of America
*
Correspondence to: Jorge M. Giroud MD, Pediatric Cardiologist, The Congenital Heart Institute of Florida, Clinical Associate Professor, University of South Florida, Pediatric Cardiology Associates, 880 6th Street South, Suite 280, St Petersburg, FL 33701, USA. Tel: +727 767 4200; Fax: +727 821 2461. E-mail: jorgemgiroud@yahoo.com, http://www.CHIF.us/
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Abstract

Persistent patency of the arterial duct represents one of the most common lesions in the field of congenital cardiac disease. The strategies for management continue to evolve. In this review, we focus on management beyond the neonatal period. We review the temporal evolution of strategies for management, illustrate the currently available the techniques for permanent closure of the patent arterial duct, review the expected outcomes after closure, discuss the current controversy over the appropriate treatment of the so-called “silent” duct, and provide recommendations for the current state of management of patients with persistent patency of the arterial duct outside of the neonatal period.

At the Congenital Heart Institute of Florida, we now recommend closure of all patent arterial ducts, regardless of their size. Before selecting and performing the type of procedure, we explain the natural history of the persistently patent arterial duct to the parents or legal guardian of the child. Particular emphasis is placed on the risks of endocarditis, including the recognition that many cases of endocarditis may not be preventable.

The devastating effects of endocarditis, coupled with the perception of more anecdotal reports of endocarditis with the silent duct, as well as the low risk of interventions, has led us to recommend closure of the patent arterial duct in these situations. We now recommend intervention, after informed consent, for all patients with a patent arterial duct regardless of size, including those in which the patent duct is “silent”. We recognize, however, that this remains a controversial topic, especially given the new recommendations for endocarditis prophylaxis from American Heart Association.

Since 2003, our strategy for closure of the patent arterial duct has changed subsequent to the availability of the Amplatzer occluder. This new device has allowed significantly larger patent arterial ducts to be closed with interventional catheterization procedures that in the past would have been closed at surgery. During the interval between 2002 and 2006 inclusive, the overall surgical volume at our Institute has been stable. Over this period, the number of patients undergoing surgical ligation of the patent arterial duct has decreased, with this decline in volume most notable for the subgroup of patients weighing more than five kilograms. This decrease has been especially notable in thoracoscopic procedures and is attributable to the increased ability to close larger ducts using the Amplatzer occluder.

For infants with symptomatic pulmonary overcirculation weighing less than 5 kilograms, our preference is for the surgical approach. For patients who have ductal calcification, significant pleural scarring, or “window-like” arterial ducts, video-assisted ligation is not an option and open surgical techniques are used. When video-assisted ligation is possible, the approach is based on family and surgeon preference. When open thoracotomy is selected, we usually use a muscle-sparing left posterolateral thoracotomy.

For patients weighing more than 5 kilograms, we currently recommend percutaneous closure for all patent arterial ducts as the first intervention, reserving surgical treatment for those cases that are not amenable to the percutaneous approach. For symptomatic infants weighing greater than 5 kilogram with large ducts, we prefer to use the Amplatzer occluder. In rare instances, the size of the required ductal occluder is so large that either encroachment into the aorta or pulmonary arteries is noted, and the device is removed. The child is then referred for surgical closure. We can now often predict via echocardiography that a duct is too large for transcatheter closure, even with the Amplatzer occluder, and refer these patients directly to surgery.

For patients with an asymptomatic patent arterial duct, we prefer to wait until the weight is from 10 to 12 kilograms, or they are closer to 2 years of age. If the patent arterial duct is greater than 2.0 to 2.5 millimetres in diameter, our preference is to use the Amplatzer occluder. For smaller ducts, we typically use stainless steel coils. Using this strategy, we close all patent arterial ducts, regardless of their size.

Keywords

Ductus arteriosusminimally invasive surgeryvideo-assisted thoracoscopic surgery
Type
Original Article
Information
Cardiology in the Young , Volume 17 , Supplement S4 , September 2007 , pp. 68 - 74
Copyright
Copyright © Cambridge University Press 2007

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References

1. Galal, MO, Hussain, A, Arfi, A. Do we still need the surgeon to close the persistently patent arterial duct? Cardiol Young 2006; 16: 522–536.CrossRefGoogle ScholarPubMed
2. Fransson, SG. The Botallo Mystery (Profiles in Cardiology). Clin Cardiol 1999; 22: 434–436.Google Scholar
3. Houston, AB, Gnanapragasam, JP, Lim, MK, Doig, WB, Coleman, EN. Doppler ultrasound and the silent ductus arteriosus. Br Heart J 1991; 65: 97–99.CrossRefGoogle ScholarPubMed
4. Campbell, M. Natural history of persistent ductus arteriosus. Br Heart J 1968; 30: 4–13.CrossRefGoogle ScholarPubMed
5. Gross, RE, Hubbard, JP. Surgical ligation of a patent ductus arteriosus. JAMA 1939; 112: 729–731.CrossRefGoogle Scholar
6. Laborde, F, Noirhomme, 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: 278–280.CrossRefGoogle ScholarPubMed
7. Laborde, F, Folliquet, T, Batisse, A, Dibie, A, da-Cruz, E, Carbognani, D. Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg 1995; 110: 1681–1684.CrossRefGoogle ScholarPubMed
8. Burke, RP, Wernovsky, G, van der Velde, M, Hansen, D, Castaneda, A. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995; 109: 499–508.CrossRefGoogle ScholarPubMed
9. Burke, RP, Jacobs, JP, Cheng, W, Trento, A, Fontana, GP. Video-assisted thoracoscopic surgery for patent ductus arteriosus in low-birth-weight neonates and infants. Pediatrics 1999; 104: 227–230.CrossRefGoogle ScholarPubMed
10. Wierny, L, Plass, R, Porstmann, W. Transluminal closure of patent ductus arteriosus: long-term results of 208 cases treated without thoracotomy. Cardiovasc Intervent Radiol 1986; 9: 279–285.CrossRefGoogle ScholarPubMed
11. Rashkind, WJ, Mullins, CE, Hellenbrand, WE, Tait, MA. Nonsurgical closure of patent ductus arteriosus: clinical application of the Rashkind PDA Occluder System. Circulation 1987; 75: 583–592.CrossRefGoogle ScholarPubMed
12. Cambier, PA, Kirby, WC, Wortham, DC, Moore, JW. Percutaneous closure of the small (less than 2.5 mm) patent ductus arteriosus using coil embolization. Am J Cardiol 1992; 69: 815–816.CrossRefGoogle ScholarPubMed
13. Radtke, WA. Current therapy of the patent ductus arteriosus. Curr Opin Cardiol 1998; 13: 59–65.CrossRefGoogle ScholarPubMed
14. Jacobs, JP, Giroud, JM, Quintessenza, JA, et al. . The modern approach to patent ductus arteriosus treatment: complementary roles of video-assisted thoracoscopic surgery (VATS) and interventional cardiology coil occlusion. Ann Thorac Surg 2003; 76: 1421–1428.CrossRefGoogle ScholarPubMed
15. http://www.amplatzer.com/us/medical_professionals/ado_implant.html.Google Scholar
16. Mavroudis, C, Backer, CL, Gevitz, M. Forty six years of patent ductus arteriosus division at Children’s Memorial Hospital of Chicago. Standards for Comparison. Ann Surg 1994; 220: 402–410.Google ScholarPubMed
17. http://www.med.umich.edu/pdc/pdacoil/data.htm.Google Scholar
18. http://www.nice.org.uk/.Google Scholar
19. Lloyd, TR, 3rdBeekman, RH. Clinically silent patent ductus arteriosus. Am Heart J 1994; 127: 1664–1665.CrossRefGoogle ScholarPubMed
20. Prieto, LR, DeCamillo, DM, Konrad, DJ, Scalet-Longworth, , Latson, LA. Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus. Pediatrics 1998; 101: 1020–1024.CrossRefGoogle ScholarPubMed
21. Thilen, U, Astrom-Olsson, K. Does the risk of infective endocarditis justify routine patent ductus arteriosus closure? Eur Heart J 1997; 18: 503–506.CrossRefGoogle ScholarPubMed
22. http://www.cachnet.org/managing_recomp1.html#patent.html.Google Scholar
23. Kiwa, N, Nakazawa, M, Tateno, S, Yoshinaga, M, Terai, M. Infective endocarditis in congenital heart disease: Japanese national collaboration study. Heart 2005; 91: 795–800.Google Scholar
24. Durack, DT. Prevention of infective endocarditis. NEJM 1995; 332: 38–44.CrossRefGoogle ScholarPubMed
25. Lopez-Dupla, M, Hernandez, S, Olona, M, et al. . Clinical characteristics and outcome of infective endocarditis in individuals of the general population managed at a teaching hospital without cardiac surgery facilities. Study of 120 cases. Rev Esp Cardiol 2006; 59: 1131–1139.Google Scholar
26. Ozkokeli, M, Ates, M, Uslu, N, Akcar, M. Pulmonary and aortic valve endocarditis in an adult patient with silent patent ductus arteriosus. Jpn Heart J 2004; 45: 1057–1061.CrossRefGoogle Scholar
27. Friedland, IR, du Plessis, J, Cilliers, A. Cardiac complications in children with Staphylococcus aureus bacteremia. J Pediatr 1995; 127: 746–748.CrossRefGoogle ScholarPubMed
28. Cerruto, G, Mancuso, L. Systemic and pulmonary embolization in a patient with patent ductus arteriosus. Eur J Echocardiogr 2005; 6: 376–378.CrossRefGoogle Scholar
29. Parthenakis, FI, Kanakaraki, MK, Vardas, PE. Images in cardiology: silent patent ductus arteriosus endocarditis. Heart 2000; 84: 619.CrossRefGoogle Scholar
30. Yanyk, A, Yetkin, E, Lleri, M, Yetkin, G, Penen, K, Goskel, S. Vegetation due to Streptococcus viridans in the pulmonary artery in a child with patent ductus arteriosus. Int J Cardiol 2000; 72: 189–191.CrossRefGoogle Scholar
31. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A Guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Apr 19; [Epub ahead of print].Google Scholar