Patch Closure of the Ductus Arteriosus: An Improved Method Akira Taira, M.D., a n d Hachinen Akita, M.D. ABSTRACT An improved surgical procedure for patch closure of the ductus arteriosus under cardiopulmonary bypass is presented. A patch with a Fogarty catheter inserted through its center is used. The catheter is insinuated into the aorta through a pulmonary arteriotomy under normothermic cardiopulmonary bypass. An inflated intraaortic balloon is made to plug the orifice of the ductus using gentle traction on the catheter. The catheter may be slanted in any direction that is convenient to provide satisfactory visualization of the operative field.
The routine surgical procedure for patent ductus arteriosus-division or ligation of the ductusis not always appropriate for patients with severe pulmonary hypertension or a fragile ductus wall, and diverse surgical techniques to deal with these special conditions have been reported. Patch closure of the ductus under total circulatory arrest with hypothermia induced by simple immersion or cardiopulmonary bypass is one of the preferred techniques for facilitating the repair of complicated cardiovascular lesions [3, 4, 6, 71. However, the complexity of the procedure often produces complications. Three of our patients had severe pulmonary hypertension and were treated by pulmonary arteriotomy under total circulatory arrest with perfusion hypothermia; air embolism occurred in 1 of them, a 22-year-old man [8]. A shunt can be created to bypass the ductus area of the aorta without use of extracorporeal circulation in patients with vessels of suitable size for bypass anastomoses [5]. Under hypothermia with perfusion arrest, Arai [l] has inserted a Follatex 70 balloon catheter into the From the Department of Surgery, Kagoshima University School of Medicine, Kagoshima City, Japan. Accepted for publication Sept 3, 1975. Address reprint requests to Dr. Taira, Department of Surgery, Kagoshima University School of Medicine, 1208-1 Usuki-Cho, Kagoshima City, 890 Japan.
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aorta through a pulmonary arteriotomy to obstruct the aortic orifice temporarily during patch closure of the ductus. Bhati and associates [21 used a Fogarty catheter in similar fashion but under normothermia without perfusion arrest. In our experience, the balloon catheter is a useful tool for patch closure of the ductus through a pulmonary arteriotomy. Under circulatory arrest, an inflated balloon plugs the orifice of the ductus in the aorta, thus preventing air from invading the aorta. In addition, the balloon catheter technique provides a dry operative field. In our opinion, temporarily reduced pump perfusion combined with accelerated suction at the time of catheter insertion into the ductus through a pulmonary arteriotomy is a useful auxiliary procedure. In general, neither hypothermia nor circulatory arrest is necessary. Some technical difficulties can occur when the suture is anchored to the rim of the ductus wall at the end of the procedure, especially if a running suture is used, because the Fogarty catheter itself may obstruct the view of the operative field (Fig 1).Therefore we use a patch mounted on a Fogarty catheter (Fig 2A). Following insertion of Fig 1 . Visualization of the operative field is disturbed by theFogarty catheter.
455 How to Do It: Taira and Akita: Patch Closure of Ductus Arteriosus
-
-_ -- ---- -- -_-_-- ----
\
A
Fig 2. ( A ) Patch mounted on Fogarty catheter. A pursestring suture is placed around the catheter. ( B ) The cathC7ter may be moved in any direction convenient for the operation. Dotted lines and arrows indicate possible directions the catheter may slant.
the catheter tip into the aorta through the ductus, the balloon is inflated in the aorta; the catheter is then pulled u p gently and may be slanted in any direction convenient for the operative procedure (Fig 28). With the visual field unobstructed by the catheter, the patch procedure becomes simpler and safer. After completion of the procedure, the catheter is withdrawn and the pursestring suture is tied.
References 1. Arai T: Surgical treatment of patent ductus arteriosus in elderly persons with huge pulmonary artery. Jap J Thorac Surg 23:722, 1970 2. Bhati BS, Nandakumaran CP, Shatapathy P, et al: Closure of patent ductus arteriosus during open-
B heart surgery. J Thorac Cardiovasc Surg 63:820, 1972 3. Kirklin JW, Devloo RA: Hypothermic perfusion and circulatory arrest for surgical correction of tetralogy of Fallot with previous constructed Pott’s anastomosis. Dis Chest 39:87, 1961 4. Lillehei CW, Todd DB, Levy MJ, et al: Partial cardiopulmonary bypass hypothermia, and total circulatory arrest: a life saving technique for ruptured mycotic aortic aneurysms, ruptured left ventricle, and other complicated cardiac pathology. J Thorac Cardiovasc Surg 58:530, 1969 5. Pifarrk R, Rice PL, Nemickas R: Surgical treatment of calcified patent ductus arteriosus. J Thorac Cardiovasc Surg 65:635, 1973 6. Schwenter EP, Bahnson HT: Total circulatory arrest for treatment of advanced arteriovenous fistula. Ann Surg 175:70, 1971 7. Sealy WC, Brown IW Jr, Young WG Jr: A report on the use of both extracorporeal circulation and hypothermia for open heart surgery. Ann Surg 147:603, 1958 8 . Taira A, Amako H, Ohtsubo M, et al: Perfusion hypothermia with total circulatory arrest as a definitive surgery for large aorto-pulmonary shunt. Acta Med Kaaoshima Suppl 15:133, 1973
The routine surgical procedure for patent ductus arteriosus-division or ligation of the ductusis not always appropriate for patients with severe pulmonary hypertension or a fragile ductus wall, and diverse surgical techniques to deal with these special conditions have been reported. Patch closure of the ductus under total circulatory arrest with hypothermia induced by simple immersion or cardiopulmonary bypass is one of the preferred techniques for facilitating the repair of complicated cardiovascular lesions [3, 4, 6, 71. However, the complexity of the procedure often produces complications. Three of our patients had severe pulmonary hypertension and were treated by pulmonary arteriotomy under total circulatory arrest with perfusion hypothermia; air embolism occurred in 1 of them, a 22-year-old man [8]. A shunt can be created to bypass the ductus area of the aorta without use of extracorporeal circulation in patients with vessels of suitable size for bypass anastomoses [5]. Under hypothermia with perfusion arrest, Arai [l] has inserted a Follatex 70 balloon catheter into the From the Department of Surgery, Kagoshima University School of Medicine, Kagoshima City, Japan. Accepted for publication Sept 3, 1975. Address reprint requests to Dr. Taira, Department of Surgery, Kagoshima University School of Medicine, 1208-1 Usuki-Cho, Kagoshima City, 890 Japan.
454
aorta through a pulmonary arteriotomy to obstruct the aortic orifice temporarily during patch closure of the ductus. Bhati and associates [21 used a Fogarty catheter in similar fashion but under normothermia without perfusion arrest. In our experience, the balloon catheter is a useful tool for patch closure of the ductus through a pulmonary arteriotomy. Under circulatory arrest, an inflated balloon plugs the orifice of the ductus in the aorta, thus preventing air from invading the aorta. In addition, the balloon catheter technique provides a dry operative field. In our opinion, temporarily reduced pump perfusion combined with accelerated suction at the time of catheter insertion into the ductus through a pulmonary arteriotomy is a useful auxiliary procedure. In general, neither hypothermia nor circulatory arrest is necessary. Some technical difficulties can occur when the suture is anchored to the rim of the ductus wall at the end of the procedure, especially if a running suture is used, because the Fogarty catheter itself may obstruct the view of the operative field (Fig 1).Therefore we use a patch mounted on a Fogarty catheter (Fig 2A). Following insertion of Fig 1 . Visualization of the operative field is disturbed by theFogarty catheter.
455 How to Do It: Taira and Akita: Patch Closure of Ductus Arteriosus
-
-_ -- ---- -- -_-_-- ----
\
A
Fig 2. ( A ) Patch mounted on Fogarty catheter. A pursestring suture is placed around the catheter. ( B ) The cathC7ter may be moved in any direction convenient for the operation. Dotted lines and arrows indicate possible directions the catheter may slant.
the catheter tip into the aorta through the ductus, the balloon is inflated in the aorta; the catheter is then pulled u p gently and may be slanted in any direction convenient for the operative procedure (Fig 28). With the visual field unobstructed by the catheter, the patch procedure becomes simpler and safer. After completion of the procedure, the catheter is withdrawn and the pursestring suture is tied.
References 1. Arai T: Surgical treatment of patent ductus arteriosus in elderly persons with huge pulmonary artery. Jap J Thorac Surg 23:722, 1970 2. Bhati BS, Nandakumaran CP, Shatapathy P, et al: Closure of patent ductus arteriosus during open-
B heart surgery. J Thorac Cardiovasc Surg 63:820, 1972 3. Kirklin JW, Devloo RA: Hypothermic perfusion and circulatory arrest for surgical correction of tetralogy of Fallot with previous constructed Pott’s anastomosis. Dis Chest 39:87, 1961 4. Lillehei CW, Todd DB, Levy MJ, et al: Partial cardiopulmonary bypass hypothermia, and total circulatory arrest: a life saving technique for ruptured mycotic aortic aneurysms, ruptured left ventricle, and other complicated cardiac pathology. J Thorac Cardiovasc Surg 58:530, 1969 5. Pifarrk R, Rice PL, Nemickas R: Surgical treatment of calcified patent ductus arteriosus. J Thorac Cardiovasc Surg 65:635, 1973 6. Schwenter EP, Bahnson HT: Total circulatory arrest for treatment of advanced arteriovenous fistula. Ann Surg 175:70, 1971 7. Sealy WC, Brown IW Jr, Young WG Jr: A report on the use of both extracorporeal circulation and hypothermia for open heart surgery. Ann Surg 147:603, 1958 8 . Taira A, Amako H, Ohtsubo M, et al: Perfusion hypothermia with total circulatory arrest as a definitive surgery for large aorto-pulmonary shunt. Acta Med Kaaoshima Suppl 15:133, 1973
