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: isa_bilehjani@yahoo.com

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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