Frequency of occurrence of residual ductal flow after surgical ligation by color-flow mapping

doi:10.1016/0002-9149(91)90911-4

The American Journal of Cardiology

Volume 67, Issue 7, 15 March 1991, Pages 653-654

https://doi.org/10.1016/0002-9149(91)90911-4 Get rights and content

Abstract

Whereas closure of patent ductus arteriosus (PDA) with large left-to-right shunts may be required for symptomatic relief, the reason for recommending closure of small ducts is to prevent infectious arteritis, otherwise reported with an incidence of 0.45% per year.¹ Ductal division usually offers complete closure, whereas ligation has been reported to be associated with recurrences, either due to recanalization or to incomplete closure.^2–6 The true incidence of residual ductal shunting after PDA ligation has not been clearly defined, because follow-up generally has been based on auscultatory findings that have proved unreliable in identifying residual ductal shunting.⁷ Because incomplete PDA ligation may necessitate reoperation or life-long infection prophylaxis, it is important to identify patients with small residual ductal flow. Color-flow mapping is a very sensitive method for the identification of PDA flow.^7–9 Consequently, color Doppler studies were performed in 31 patients who had undergone surgical PDA ligation to evaluate the incidence of residual ductal flow.

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Cited by (104)

Surgical management of patent ductus arteriosus in the very preterm infant and postligation cardiac compromise
2018, Hemodynamics and Cardiology: Neonatology Questions and Controversies
As neonatal intensive care has evolved over the past decades, the clinical decision to treat preterm infants with persistent patent ductus arteriosus (PDA) with surgical ligation has become increasingly fraught with uncertainty. The high efficacy of early pharmacotherapy and advances in non-invasive ventilation have contributed to a progressive and sustained reduction in referrals for surgical ligation among very preterm infants. In addition, observational associations of ligation with adverse neonatal and neurodevelopmental outcomes have prompted concern for harm and rendered the ligation decision more challenging for clinicians, though these findings may be due to residual bias rather than a true causal detrimental effect of surgery. Ligation may still be indicated for some infants, though there is a need for comprehensive methods of evaluation to reliably identify high volume shunts whose surgical interruption may result in measureable benefit. A randomized clinical trial of surgical ligation vs. conservative management among preterm infants with persistent PDA after unsuccessful pharmacotherapy is necessary to appropriately assess the efficacy of surgical intervention. A trans-catheter approach to ductal closure in the very immature infant is an exciting therapeutic alternative that is still in its infancy. For infants who do undergo surgery, postoperative hemodynamic instability may be related to increased left ventricular afterload and potentially ameliorated by treatment with milrinone. This chapter will review the evidence regarding the benefits and risks of PDA ligation in preterm infants and propose a pathophysiology-based management paradigm to guide perioperative care.
Outcomes following neonatal patent ductus arteriosus ligation done by pediatric surgeons: A retrospective cohort analysis
2013, Journal of Pediatric Surgery
Citation Excerpt :
As in this study most PDAs subjected to ligation are reported as moderately large to large causing significant cardiopulmonary dysfunction [3,9]. The reported incidence of residual PDA following suture ligation is 3%–26% [23–25]. In our study this occurred in 1 patient (1%) following clip application.
Patent Ductus Arteriosus (PDA) ligation in premature infants is an urgent procedure performed by some but not all pediatric surgeons. Proficiency in PDA ligation is not a requirement of Canadian pediatric surgery training. Our purpose was to determine the outcomes of neonatal PDA ligation done by pediatric surgeons.
We performed a retrospective review of premature infants who underwent PDA ligation by pediatric surgeons in 3 Canadian centers from 2005 to 2009. Outcomes were compared to published controls.
The review identified 98 patients with a mean corrected GA and weight at repair of 29 weeks and 1122 g, respectively. There were no intraoperative deaths. The 30-day and inhospital mortality rates were 1% and 5%. Mortality and morbidity were comparable to the published outcomes.
This study documents that a significant number of preterm infant PDA ligations are safely done by pediatric surgeons. To meet the Canadian needs for this service by pediatric surgeons, proficiency in PDA ligation should be considered important in pediatric surgery training programs.
Esophageal stethoscope: An old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure
2010, Journal of Pediatric Surgery
Citation Excerpt :
Furthermore, high-flow velocity as seen with residual patency is associated with an increased risk of endocarditis. Several studies have documented residual and recurrent flow after VATS clipping ranging from 1.4% to 10% during the follow-up period [8,12-15], whereas, residual flow after open PDA closure has been seen in 0% to 23% of patients [16,17]. Closure of PDA in the cardiac catheterization laboratory has been increasingly used, but some restrictions on body weight and ductus morphology limit the indication.
Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for closure of a patent ductus arteriosus (PDA), but is associated with a minute rate of residual or recurrent duct patency. This study aims to analyze the efficacy of intraoperative esophageal stethoscopic monitoring in reducing the incidence of residual ductal flow during PDA clipping by VATS.
Between June 1997 and October 2009, we retrospectively assessed 2000 consecutive patients with PDA who underwent VATS. During the procedure, heart sounds were monitored by the anesthesiologist through an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded before and after the PDA clipping and were confirmed to disappear completely. Color flow Doppler echocardiography was performed immediately before discharge, and patients were followed monthly for 3, 6, and 12 months and then annually to confirm the absence of residual or recurrent shunt.
Mean age was 6.0 years (range, 1 month-35 years), mean weight was 11.1 kg (range, 6-65 kg), and mean PDA diameter was 5.5 mm (range, 3-9 mm). Ninety-two percent of patients showed no ductal flow after a single clipping. In the other 8% of patients, residual flow was detected intraoperatively after a single clipping, but was eliminated by the second clipping. Twelve patients (0.6%) presented with residual ductal flow immediately after the operation (detected by color Doppler echocardiography), which was eliminated by thoracotomy before discharge. All patients left the hospital with echocardiography documenting no evidence of residual PDA. At follow-up, the incidence of residual patency was 0.2% (4 of 2000).
Our results demonstrate that the intraoperative esophageal stethoscope provides a remarkably effective technique for monitoring and evaluating PDA ligation by VATS, thus avoiding reintervention and the complications associated with residual ductal flow in most cases.
The arterial duct: Its persistence and its patency
2010, Paediatric Cardiology
The Arterial Duct: Its Persistence and Its Patency
2009, Paediatric Cardiology
Patency or recanalization of the arterial duct after surgical double ligation and transfixion
2007, Cardiology in the Young

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¹: Dr. Sørensen's address: Department of Paediatric Cardiology, The Hospital for Sick Children, Great Ormond Street, London WC1N 3JH, United Kingdom.

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Brief reportFrequency of occurrence of residual ductal flow after surgical ligation by color-flow mapping

Abstract

J Thorac Cardiovasc Surg

Int J Cardiol

Am J Cardiol

Natural history of persistent ductus arteriosus

Br Heart J

Surgical aspects of patent ductus arteriosus

Arch Dis Child

Brief report
Frequency of occurrence of residual ductal flow after surgical ligation by color-flow mapping