Congenital Heart Disease Adv. Cardiol., vol. 26, pp. 125-126 (Karger, Basel 1979)
Surgical Treatment of PDA in Premature Infants PAUL
A. EBERT
The incidence of patent ductus in normal births ranges somewhere between 5 and 10 per 1000. If one seperates the infants under 1,750 g, the incidence of patent ductus may be as high as 25-40% depending on the series reviewed. Of these infants who are less than 1,750 g, if no significant heart failure is present, or if it can be managed medically, then the survival of these infants is approximately 92%. However, when severe congestive heart failure is present, survival of infants less than 1,750 g may be in the range of 65%. Obviously, the patent ductus arteriosus plays an important role in these figures even though other congenital anomalies that are causes of mortality are not included in these statistics. The advent of indomethecin as an attempt to medically close the ductus has simplified the procedure and has been very successful in most people's experience. Surgical ligation of the ductus, in our experience, has had an overall success rate of approximately 70%. Of premature infants who underwent surgical ligation, approximately 70% left the hospital alive. This includes the worst forms of respiratory distress syndrome, and other complications such as intracranial hemorrhage, necrotizing enterocolitis, etc. It is obvious that successful surgical treatment can be accomplished and in many instances the ductus can be ligated with the surgical team going to the intensive care nursery, or the baby transported to the operating suite. Prompt attention to good management, temperature regulation, and anesthetic administration are extremely critical in these very small, premature infants. A single ligature passed about the ductus of 2 or 3--0 suture is usually adequate for ligation and no attempt should be considered to any more formal division or suture ligation, etc. The total operative time in these infants should be around 30-40 min., as maintenance of temperature is one of the most difficult problems of the premature infant.
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Department of Surgery, University of California, San Francisco, Calif.
EBERT
126
P. A. EBERT, MD, Professor and Chairman, Department of Surgery, University of California, 551 Pamassus Avenue, San Francisco, CA 94122 (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 6:15:21 AM
In evaluating treatment failures for premature infants, it is obvious that delay in recognition is the number one difficulty. In many of the premature infants with pulmonary distress, the ductus is not recognized to be of significant size and the baby has reduced systemic circulation with the large shunt present. This increases the likelihood of intestinal ischemia, intracranial hemorrhage and other problems of low peripheral perfusion. Once recognized, prompt treatment should be exercised. Indomethecin has a time period of approximately 24 h before major effectiveness; then, if improvement is not prompt, surgical intervention should be undertaken. If the baby is in extreme difficulty and cannot be stabilized with intense neonatal care, then prompt surgical ligation should be undertaken. Although the operative stress of surgery may seem greater than administration of indomethecin, the time factor in the more critically ill babies is more important than the surgical insult. The advantage of promptly decreasing the pulmonary shunt and increasing systemic perfusion may obviate the complications in the intestinal tract. In many instances, the severity of respiratory distress syndrome is amplified by the presence of a ductus and it can never be certain until the ductus is ligated how much influence is present. We have had numerous examples of babies with severe respiratory distress who had almost instantaneous resolution of their pulmonary difficulties following ligation of the patent ductus.
Surgical Treatment of PDA in Premature Infants PAUL
A. EBERT
The incidence of patent ductus in normal births ranges somewhere between 5 and 10 per 1000. If one seperates the infants under 1,750 g, the incidence of patent ductus may be as high as 25-40% depending on the series reviewed. Of these infants who are less than 1,750 g, if no significant heart failure is present, or if it can be managed medically, then the survival of these infants is approximately 92%. However, when severe congestive heart failure is present, survival of infants less than 1,750 g may be in the range of 65%. Obviously, the patent ductus arteriosus plays an important role in these figures even though other congenital anomalies that are causes of mortality are not included in these statistics. The advent of indomethecin as an attempt to medically close the ductus has simplified the procedure and has been very successful in most people's experience. Surgical ligation of the ductus, in our experience, has had an overall success rate of approximately 70%. Of premature infants who underwent surgical ligation, approximately 70% left the hospital alive. This includes the worst forms of respiratory distress syndrome, and other complications such as intracranial hemorrhage, necrotizing enterocolitis, etc. It is obvious that successful surgical treatment can be accomplished and in many instances the ductus can be ligated with the surgical team going to the intensive care nursery, or the baby transported to the operating suite. Prompt attention to good management, temperature regulation, and anesthetic administration are extremely critical in these very small, premature infants. A single ligature passed about the ductus of 2 or 3--0 suture is usually adequate for ligation and no attempt should be considered to any more formal division or suture ligation, etc. The total operative time in these infants should be around 30-40 min., as maintenance of temperature is one of the most difficult problems of the premature infant.
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 6:15:21 AM
Department of Surgery, University of California, San Francisco, Calif.
EBERT
126
P. A. EBERT, MD, Professor and Chairman, Department of Surgery, University of California, 551 Pamassus Avenue, San Francisco, CA 94122 (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/19/2019 6:15:21 AM
In evaluating treatment failures for premature infants, it is obvious that delay in recognition is the number one difficulty. In many of the premature infants with pulmonary distress, the ductus is not recognized to be of significant size and the baby has reduced systemic circulation with the large shunt present. This increases the likelihood of intestinal ischemia, intracranial hemorrhage and other problems of low peripheral perfusion. Once recognized, prompt treatment should be exercised. Indomethecin has a time period of approximately 24 h before major effectiveness; then, if improvement is not prompt, surgical intervention should be undertaken. If the baby is in extreme difficulty and cannot be stabilized with intense neonatal care, then prompt surgical ligation should be undertaken. Although the operative stress of surgery may seem greater than administration of indomethecin, the time factor in the more critically ill babies is more important than the surgical insult. The advantage of promptly decreasing the pulmonary shunt and increasing systemic perfusion may obviate the complications in the intestinal tract. In many instances, the severity of respiratory distress syndrome is amplified by the presence of a ductus and it can never be certain until the ductus is ligated how much influence is present. We have had numerous examples of babies with severe respiratory distress who had almost instantaneous resolution of their pulmonary difficulties following ligation of the patent ductus.
