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Closure of patent ductus artreriosus in an adult
patient under cardiopulmonary bypass with total
circulatory arrest
From: Department of Cardiovascular Anesthesia, Cardiovascular Research Center, Madani Heart
Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
Eisa Bilehjani MD, Assistant Professor in Aesthesia, Fellowship in Cardiovascular
Anesthesia (Corresponding Author)
Amir Abbas Kianfar MD, Assistant Professor in Aesthesia, Fellowship in
Cardiovascular Anesthesia
Babak Nasiri MD, Assistant Professor in Cardiac Surgery
Corresponding author and reprint request to: Dr. Eisa Bilehjani, Department of Cardiovascular Anesthesia, Madani Heart Hospital, Tabriz University of Medical Sciences,Tabriz, Iran.Tel: 0098 411 3360894, Fax:0098 411 3344021, E-mail: [email protected]
Abstract
Closing patent ductus artreriosus (PDA) carries higher risk in adults than in children, because it is usually
short, large, calcified, fragile, and thin that may be associated with pulmonary artery hypertension (PAH).
In order to facilitate and reduce of risks of operation, different surgical methods recommended in adults,
usually closing PDA via median sternotomy with cardiopulmonary bypass (CPB) and hypothermic total
circulatory arrest (HTCA). We report a 19 years old woman that in addition to large, short, window-like
PDA, she had pulmonary artery hypertension and multivalvular disease. Her PDA was closed
transpulmonary with Gore-Tex patch, after primary thoracotomy, via median sternotomy and CPB/HTCA
and discharged from hospital without any problem.
Key words: Patent ductus arteriosus, Cardiopulmonary bypass, Hypothermic total circulatory arrest
Introduction
PDA is relatively the prevalent congenital heart diseases. In children its closure is performed by surgical
procedures, Percutaneus transcatheter ductal closure (PTDC) using intravenous instruments or Video
assisted thoracoscopic surgery (VATS), safely and without risk. Contrary to children, in adults PDA, in
majority, is short, large, calcified, fragile which surgical closure performed via thoracotomy, using
intravenous instruments or Video assisted thoracoscopic surgery (VATS) can be accompanied with
unpredictable morbidity or mortality. In such cases, some authors recommend using cardiopulmonary
bypass and hypothermic total circulatory arrest via median sternotomy. In this patient, at first, our team
used thoracotomy; however, regarding to our findings during operation and pulmonary artery
damage/perforation, continuity of surgery was performed via median sternotomy, using cardiopulmonary
bypass and hypothermic total circulatory arrest.
Case report
Patient was 19 years old woman, weight 42kg and height 149cm with chief complaint of dyspnea,
tachycardia, and early activity fatigue from childhood period, by previously diagnosed of large PDA was
hospitalized. In echocardiography, five months ago, following data's were as:
Large PDA (left to right shunt), severe PAH (pulmonary artery hypertension), MR2+(mitral
regurgitation), TR2+(tricuspid regurgitation), PI2+(Pulmonary insufficiency), LVEF(left ventricle
ejection fraction)=45%, QP/QS(pulmonary to systemic flow ratio) = 4.1
In clinical examination, she had hyperdynamic hemodynamic, and continuous murmur, in CXR moderate
cardiomegaly with pulmonary congestion. Cardiac catheterization performed with following findings:
Large PDA, PAP(pulmonary artery pressure) = 95/55mmHg, RVP(right ventricle pressure)=95/0-10mmHg,
LVP(left ventricle pressure)=130/0-15mmHg, AAP(ascending aorta pressure)=130/65mmHg,
DAP(descending aorta pressure)=115/65mmHg, MR2+, PI1+, LVEF=50%
The next day, the patient after pretreatment with promethazine 25 mg and morphine 5 mg (intramuscular),
admitted to operating room. After insertion of peripheral venous and artery catheters, with local
anesthesia, anesthesia induced with intravenous midazolam 10mg, fentanyl 250µg and cisatracurium
10mg. After tracheal intubations, central venous and pulmonary artery catheters, were inserted both via
right internal jugular vein. Homodynamic data's were as followings:
CVP = 8mmHg, RVP=80/0-5mmHg, PAP=80/32 mmHg, *PCWP=16mmHg, Arterial (Radial)=115/55mmHg.
Following induction of anesthesia infusion of Milrinone started in dose of 0.5µg/kg/min and has
continued until second postoperative day. Via left posterolateral thoracotomy, PDA was exposed. PDA
was large, as large as aorta, short (2-3mm) and funnel- shaped. When preparing and exposing, left
pulmonary artery was perforated, bleeding was controlled with simple packing. Operation plan changed
from thoracotomy to median sternotomy approach and using cardiopulmonary bypass/hypothermic total
circulatory arrest (CPB/HTCA). Infusion of fentanyl, midazolam and cisatracurium was started. After
applying cardiopulmonary bypass, patient was cooled to 24ºC, then total circulatory arrest, PDA closed
with Gore-Tex patch, with diameter about 15-20mm, via main pulmonary artery. After 22 minutes
HTCA, 37 minutes aorta clamping time and 99 minutes CPB by getting nasopharyngeal temperature to
35.5ºC, she weaned from CPB with sinus rhythm and infusion of dobutamine 15μg/kg/min. After
hemostasis and closing sternum and thoracotomy, the patient was transferred to ICU. During HTCA
patient's pupils became double midriasis which with rewarming pupils became reactive and normal size,
and finally miotic. For brain protection we used dexamethasone 16mg, sodium thiopental 2g, mannitol
(20%) infusion 150ml and ice-water cap before total circulatory arrest. Recovering from anesthesia
occurred with delay, started smoothly at about 14-16 hours, without any adverse reaction, and got normal
consciousness at 17-18th hour of postoperative period. After complete consciousness, at 24th hour, patient
was extubated. She transferred to ward after 72 hours ICU stay, with normal conscientious and stable
hemodynamic and discharged from hospital in the ninth day.
*PCWP: pulmonary capillary Wedge pressure
In forth postoperative day transthoracic echocardiography revealed:
LVEF= 50%, mild MR, trivial TR MR+1, No residual PDA
In second postoperative day in CXR heart size and lungs were reported normal. In pursuing by telephone
after two months the patient was good functional status and without any neurologic problem.
Discussion
Patent ductus artreriosus (PDA) is a relatively common congenital heart disease.1 Its closure in childhood
can safely be done with different techniques. These include surgical procedure via thoracotomy,
percutaneus transcatheter ductal closure (PTDC) and video-assisted thoracoscopic surgery (VATS).2,3
Relative contraindications to non-surgical methods or thoracotomy are large, short, window-shaped PDA,
pulmonary hypertension and calcified PDA.4 PDA reduce life expectancy considerably, for example if
left untreated, 90% of these patients will die by the age of sixty.5 when using PTDC in patients with large
or short PDA there is a risk of device migration with resultant pulmonary artery narrowing or embolism,
residual PDA, hemolysis and endocarditis.4,6,7 In adults PDA is usually large, short, thin, friable with
concomitant pulmonary artery hypertension therefore its closure via thoracotomy, VATC or transcatheter
approach might be impossible or unsafe.8,10 Therefore other techniques are used for closing PDA. In
adults, preferred approach is via median sternotomy, using CPB, and closure through pulmonary artery.11
In this situation hypothermic total circulatory arrest (HTCA), provides a bloodless field for the surgeon
to perform the procedure safely and effectively. Yildrim tekin et al. report PDA closure, in an adult
patient with the help of normothermic CBP. They carried out the procedure on beating heart through
pulmonary artery.8 He used finger pressure and Foley catheter for preventing of "backbleeding" from
aorta. Omari et al. also used this technique for their patient.10 Although calcification is commonly found
at the aortic side of the ductus, it is less prevalent at the pulmonary side, witch makes PDA closure easier
from pulmonary artery side.5 Although the popular technique in PDA closure in adults is low flow CPB
with systemic hypothermia, Gurcun et al. used HTCA in a patient with moderate pulmonary artery
hypertension.9 Their patient had a PDA with a diameter of about 5 mm which was repaired without using
a patch and the patient was cooled to 20ºC,CPB and circulatory arrest times were 67 and 5 minutes
respectively. We cooled our patient to 24ºC,times of CPB, aortic clamp and circulatory arrest were 99, 27
and 24 minutes respectively and PDA was closed with Gore-Tex patch with a diameter about 15-20mm.
Despite 24 minutes of HTCA our patient was extubated without any neurologic or neurobehavioral
complication. There is controversy regarding using drugs with possible neuroprotective effects, however
prior to HTCA we used dexamethasone, sodium thiopental and manitol. At the same time we used ice
water packs around the patient heed to further protect the brain. In summary in an older patient with large
and short PDA, using CPB and HTCA can be safe and appropriate technique. The usually short duration
of HTCA needed in these patients may result in fewer complication compared to other cardiac surgery.
Although with study on large numbers of these patients, may be able to reach a more definite conclusion,
however it is difficult to collect sufficient number of older patient with this anomaly.
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