Interruption of the aortic arch. Surgical considerations.

During a 10 year period, January, 1965, through January, 1975, 5 patients with interruption of the aortic arch (IAA) underwent operation at the Texas Heart Institute. The mortality rate was 60 per cent; 2 patients survived the operation. One 11-day-old infant with IAA, type A, a ventricular septal defect (VSD), and a patent ductus arteriosus (PDA) underwent successful two-stage treatment. A left subclavian-ductus anastomosis, closure of the PDA, and banding of the pulmonary artery were done initially. The VSD was closed later. The second survivor, a 3-year-old girl, had IAA, type B, with a PDA and VSD. Total correction was done with the aid of cardiopulmonary bypass and hypothermia. Considerations include palliative and staged procedures versus total correction with either conventional cardiopulmonary bypass or deep hypothermia and circulatory arrest. Survival rate is improved if associated lesions are totally repaired or palliated at the time of reconstruction of IAA.     

体外循环心脏停跳和不停跳下动脉导管闭合术

目的　提高体外循环心脏停跳和不停跳下动脉导管未闭 ( patentductusarteriosus ,PDA)的外科治疗水平。方法　 2 7例PDA患者 ,导管直径 0 .4～ 2 .8cm。均在体外循环下经肺动脉切口行PDA内口缝闭术。 9例采用深低温低流量 ,10例采用低温 ,8例采用浅低温心脏不停跳。对合并心内畸形同期矫正。结果　 1例术后出现低心排血量综合征 ,经药物治疗纠正。 1例术后出现声音嘶哑 ,4周后恢复。全组病例术后心脏杂音消失 ,无导管再通或残余分流 ,无死亡 ,均康复出院。结论　对PDA合并重度肺动脉高压和PDA合并其他心内畸形需同期矫正等复杂病例 ,在体外循环心脏停跳和不停跳下 ,尤其是心脏不停跳下经肺动脉切口缝闭PDA内口可取得满意的疗效     

应用Amplatzer封堵器治疗动脉导管未闭

目的　评价 Amplatzer封堵器在动脉导管未闭 (PDA)介入治疗中的安全性和疗效。　方法　自 2 0 0 0年9月开始应用 Amplatzer封堵器治疗 30例 PDA患者 ,在术后 2 4小时、1个月、3个月行超声心动图检查 ,观察封堵效果及有无并发症。　结果　 PDA最窄处直径为 2 .5～ 12 .0 mm,平均 5 .3mm;1例伴有重度肺动脉高压的粗大 PDA采用 Amplatzer房间隔缺损封堵器治疗 ,余 2 9例用 Am platzer PDA封堵器。2 9例术后 2 4小时、1例 48小时时彩色多普勒超声心动图检查均未见残余分流 ,1例术后早期发生机械性溶血。随访中 ,未出现封堵器移位、残余分流和再通。结论　应用 Amplatzer封堵器治疗 PDA是一种安全有效的非外科手术方法 ,适应证广、技术成功率高、近期疗效满意 ,远期效果尚需进一步观察     

Combined Aortic Valve Replacement and Closure of Patent Ductus Arteriosus in the Elderly

Two cases of patent ductus arteriosus (PDA) and aortic stenosis are presented. Both were diagnosed at routine cardiac catheterization and significant aortic gradient was concomitantly encountered. The first patient had subacute bacterial endocarditis due to B. cereus infection. Eventually it was proven to be localized on the PDA on the pulmonary artery side. Both patients underwent closure of PDA through endopulmonary closure and aortic valve replacement. Postoperative courses were uneventful. These cases demonstrated the technically easy closure of the PDA in the elderly. The literature has documented only six cases including our two cases. (J Card Surg 1994;9:85–88)     

Delayed embolization of ductal occluder device into the aorta with near-complete obstruction of the aorta and critical cardiac decompensation

Delayed embolization of ductal occluder device into the aorta after transcatheter closure of a patent ductus arteriosus (PDA) with almost complete obstruction of the aorta is extremely rare. Our patient had delayed migration of a ductal occluder device into the descending thoracic aorta (DTA) 6 months after its deployment. Because of critical biventricular dysfunction, urgent surgical removal of the device from the descending aorta was done via left posterolateral thoracotomy without using cardiopulmonary bypass. PDA was not closed because of doubt about the reversibility of pulmonary artery hypertension and severe right ventricular dysfunction so that it can act as an outlet to the decompensated right ventricle. The patient made an uneventful recovery. The patient was started on pulmonary vasodilators and is planned for right heart catheterization study after 2 months to check for the operability of PDA.     

Nonoperative closure of left-to-right shunts.

Efforts to close left-to-right shunts at Ochsner Medical Institutions have been directed toward atrial septal defects (ASD) and patent ductus arteriosus (PDA). PDA's were constructed in dogs by interposing a segment of jugular vein between the aorta and main pulmonary artery. Five dogs in which the PDA was closed by a plug device inserted through the femoral vessels were put to death at 6 to 12 months. Histologic sections showed good fibrous ingrowth with endothelial covering on the aorta and pulmonary artery sides. There were no migrations redidual shunts. At cardiac catherterization, 18 patients had ASD's sized and located as to position in the septum. The sized ranged from 13 to greater than 30 mm. in diameter. The ASD sizes in patients who underwent standard operative closure were compared to the measurements at catheterization, and the variation was insignificant. In 5 patients, centrally positioned secundum ASD's were closed with double umbrella devices, 25 to 35 mm. in diameter. Anatomic contraindications for umbrella closure include ASD's greater than 30mm. in diameter, anomalous pulmonary venous connection, common atrium, inferiorly or superioly located secrumdum ASD, and sinus venosus ASD. Follow-up studies from 6 to 12 months on 5 patients with umbrella closure have revealed no hemolysis, arrhythmias, thromboembolism, migration, or other untoward effects.     

Surgical rescue of embolized amplatzer devices

Abstract Background and Aim: Transcatheter closure of atrial septal defect (ASD) and patent ductus arteriosus (PDA) with Amplatzer septal/duct occluder (ASO/ADO) is an established, safe, and efficient procedure with high success. However, device embolization remains a major complication requiring immediate intervention (either percutaneous or surgical) for retrieval and correction of the heart defect. The aim of this study is to share the experience of managing embolized ASO/ADO. Methods: Of the 284 cases of device closure performed from October 2002 to December 2010, four patients (1.4%) had device embolization requiring immediate surgical retrieval. Two adult female patients with secundum ASD had ASO device implanted. One embolized to the right ventricle and the other into the ascending aorta. An eight‐month‐old boy and a four‐year‐old girl with hypertensive PDA had device closure. Device embolization occurred into the descending aorta and right pulmonary artery, respectively. Results: All four devices were retrieved and the defects closed successfully with a low morbidity and no mortality. Conclusion: Careful consideration should be given to surgical or transcatheter closure of a heart defect. Life‐threatening complications although rare can occur. Our experience strongly suggests that these devices should only be inserted in facilities where cardiac surgical support is immediately available. (J Card Surg 2011;26:254‐258)     

覆膜支架在成人动脉导管未闭合并肺动脉高压的临床应用

目的 总结覆膜支架治疗成人动脉导管未闭合并肺动脉高压的体会.方法 2005年9月至2007年3月,4例成人动脉导管未闭合并肺动脉高压病例应用覆膜支架封堵,均为女性,年龄18～42岁,平均(31.5±5.4)岁.动脉导管平均直径(28.3±0.8)mm,肺动脉收缩压平均(66.0±8.3)mmHg.术后随访3～18个月,平均(10.5±1.5)个月.结果 术后造影示3例动脉导管完全封闭,1例残余少量左向右分流.术后2周超声心动及大血管CT示残余分流消失,肺动脉收缩压平均(40.5±7.5)mmHg.4例术后平稳,临床症状缓解.结论 覆膜支架治疗成人动脉导管未闭合并肺动脉高压近期效果良好,是一种可选择的治疗方法.     

A case report of Rastelli operation in 2-month-old infant with truncus arteriosus (type II)

A two-month-old girl with heart failure from truncus arteriosus (Collett & Edwards Type II) underwent a total correction by the Rastelli procedure using 12-mm-diameter Hancock valved conduit. The orifice of pulmonary arteries was closed from inside without detachment of the pulmonary artery from truncus. The distal anastomosis of the conduit was made to left pulmonary artery. Primary sternal closure was difficult and delayed closure was performed using splint with a resin plate. The skin was primarily closed using bilateral advancement myocutaneous flaps. Complete closure of the sternum was made on the 11th postoperative day. A rotation flap of the right abdominal rectal muscle was used to cover the partially necrotic skin over the sternum. The patient had persistent respiratory and cardiac problems, but was discharged 14 months after surgery.     

Left ventricular approach for muscular ventricular septal defects in infant]

Two infants less than 4 months of age underwent repair of apical muscular VSD with left ventriculotomy. First case was 3 months old boy who had already undergone enlargement of the hypoplastic aortic arch with subclavian flap aortoplasty and pulmonary artery banding because of the associated aortic coarctation. Second case was 4 months old Down syndrome girl who associated with ASD and PDA. Both infants were diagnosed the apical muscular VSD with echocardiography and left ventriculography. We performed short longitudinal left ventriculotomy which was parallel to the left anterior descending coronary artery between the diagonal branch and left circumflex artery. VSD was closed with Gore-Tex patch using 6-0 prolene buttress stitches. Post operative echocardiography showed good LV contractile function (Ejection Fraction = 71%, 80%), and no residual interventricular shunt. Left ventriculotomy for the apical VSD closure allowed good exposure and did not reduce the LV function even in infants. Therefore, we concluded that left ventriculotomy was an useful procedure for the apical muscular VSD in infants.     

A case report of aneurysm of the ductus arteriosus combined with mitral regurgitation

A case with the giant aneurysm of the ductus arteriosus combined with severe mitral regurgitation is reported. 58-year-old male underwent MVR and patch closure of the ductal orifice for staged operation. The first operation was MVR and patch closure of the PDA orifice of the pulmonary artery end using retrograde cerebral perfusion (RCP) with deep hypothermic circulatory arrest (DHC). The second operation was performed on 3 months after the first operation using left thoracotomy approach, and patch closure of the ductal orifice via the aorta using RCP with DHC was performed. Upon following-up examination, the patient is now doing well 20 months after the initial surgery.     

Closure of patent ductus arteriosus under extracorporeal circulation through pulmonary arteriotomy]

Twenty-nine patients underwent closure of patent ductus arteriosus (PDA) via pulmonary arteriotomy under low-flow extracorporeal circulation combined with profound hypothermia. No complications from air embolism or hemorrhage were encountered during the operation. The early and late results were satisfactory. This technique was used as a safe method for PDA complicated by severe pulmonary hypertension, infective endocarditis, recurrence of ductal patency and for PDA in adults or coexistence of intracardiac anomaly.     

Surgical treatment of patient ductus arteriosus associated with pulmonary hypertension under cardiopulmonary bypass

From July 1985 through December 1987, 30 patients with PDA and pulmonary hypertension were treated surgically under cardiopulmonary bypass. 17 cases underwent closure of PDA through transpulmonary arterial incision and 13 cases by ligation of PDA. The operative mortality was 3.3% and there was no late death. Follow-up study from 6 months to 3 years after operation showed satisfactory results.     

An operative case of partial anomalous pulmonary venous connection with patent ductus arteriosus and atrial septal defect

The patient was a 28-year-old female who had underwent the operation of the closure of ASD on 7 years old. She administered due to palpitation. Cardiac catheterization revealed PDA, residual ASD, and PAPVC that blood flow from right superior pulmonary vein returned to the high level of SVC (juxsta-inominate vein). Successful repair was performed by intraluminal direct closure for PDA and placing a long patch for ASD and PAPVC.     

Total cavopulmonary connection for grown diminutive pulmonary artery after staged Blalock-Taussig shunt

We report a two-year-old girl with asplenia, {A, L, L} DORV, pulmonary atresia, common AV valve, PDA, and TAPVC, who successfully underwent total cavo pulmonary connection (TCPC). Deep cyanosis was pointed out since birth. Cardiac catheterization performed on the sixth day after birth revealed a diminutive pulmonary artery tree of which PA index was 41 mm²/m². Left modified Blalock-Taussig shunt was created at 27 days of age. The PA index increased to 282 mm²/mm², but disparity in diameter between the left and the right pulmonary artery was yielded by PDA subsidence. Therefore additional contralateral B-T shunt was made at one year of age. Follow-up cardiac catheterization at 28 months of age showed well developed pulmonary artery; PA index of 460 mm²/m², right pulmonary resistance (Rp) of 3.49 units, left Rp of 2.33 units, and estimated total Rp was 1.39. According to study, bidirectional Glenn procedure or TCPC was indicated. Considering neccesity of urgent repair of common pulmonary vein obstruction, regurgitation of the common atrio-ventricular valve and pulmonary artery stenosis, TCPC was performed with concomitant repair of the associated lesions. Severe butterfly-figure stenosis of the central PA was augmented by anastomosing both the left SVC and the left-sided atrium. In conclusion, diminutive pulmonary artery could be adequately grown by phase-in Blalock-Taussig shunts. Pulmonary blood flow scintigraphy was thought to be useful for estimation of pulmonary resistance in such cases with different pulmonary resistance between right and left PA.     

Unrecognized anomalous origin of the left coronary artery from the pulmonary artery as a cause of ventricular fibrillation after patent ductus arteriosus ligation in an infant

We present a case of an infant who developed ventricular fibrillation after patent ductus arteriosus (PDA) ligation. The infant had unrecognized anomalous origin of the left coronary artery from the pulmonary artery before PDA ligation. Acute reduction in systemic pulmonary artery pressures after PDA ligation resulted in an abrupt reduction in left main coronary artery blood flow. After prompt resuscitation, cardiac catheterization confirmed the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery. The infant subsequently underwent coronary artery translocation and recovered uneventfully.     

Failures and complications of transcatheter coil occlusion of patent ductus arteriosus

An analysis of fails and complications of transcatheter coil occlusion of patent ductus arteriosus (PDA) was made. An attempt to close PDA with Gianturco coils was undertaken in 132 patients. Fails were noted in 4 (3.1%) children, 3 of them failed to hold the coil in PDA due to its greater width, and in 1 patient the catheter could not be delivered through a narrow duct. Complications were noted in 9 patients (7%): migration of the coils into the pulmonary artery branches took place in 8 patients, and in 1 patient there appeared haemolysis due to a large residual shunt. Snare-assisted removal of the migrating coils was carried out in 7 children, in 1 girl the coil could not be extracted from the peripheral branch of the left pulmonary artery. In 7 patients reocclusion of PDA was made, in 1 case no reembolization was performed. Haemolysis was liquidated by an additional implantation of the coils in repeated procedure. Risk of fail and complications was associated with great minimal diameter of patent ductus arteriosus.     

Surgical Closure of the Patent Ductus Arteriosus with an Intravascular Prosthesis: Clinical Experience

The authors developed a new prosthesis for patent ductus arteriosus (PDA) closure, using a delivery device inserted through the main pulmonary artery (MPA) avoiding ductal dissection and use of cardiopulmonary bypass. The prosthesis was inserted in 19 consecutive patients between 1985 and 1992. They have been followed for a mean of 4.8 years (minimum 30 days, maximum 7.5 years). There were 14 women (72%) and the average age was 11 years (16 months to 38 years). All patients presented with pulmonary hypertension (4 severe, 5 moderate, and 10 mild). Simultaneous surgical procedures for congenital heart disease were performed in two cases. One patient had a diffuse calcified PDA. The average diameter of the inserted prosthesis was 7.5 mm (3.5 to 12.5 mm). Neither hemorrhage nor prosthesis dislocation/embolization occurred during the implantation or in the postoperative period. In a newborn (30 days) with severe cardiomegaly and thin MPA, we decided to ligate the ductus. Chronic cor pulmonale contributed to death in one patient 3.7 years after operation. The remaining patients recovered well, without clinical evidence of residual shunt. Therefore, we recommend the use of this new prosthesis for PDA closure in cases of large ductus or ductus complicated with calcification, pulmonary hypertension, and when associated open heart surgery is required. (J Card Surg 1994;9:343–347)     

Pulmonary hypertension accompanying ventricular septal defect and patent ductus arteriosus. Management in infancy and early childhood.

Forty-one infants and children with the combination of patent ductus arteriosus (PDA) and ventricular septal defect (VSD) were encountered over 20 years. Twenty-four presented in infancy with congestive cardiac failure. Pulmonary hypertension was present in 32, the cause in 19 being increased pulmonary blood flow. Increased pulmonary vascular resistance (PVR) was detected in 13 (indicated by a pulmonary to systemic resistance ratio (Rp : RS) greater than 0.24:1 and PVR greater than 4 units). Thus 22% had a pulmonary artery systolic pressure less than 30 mmHg and 68% had a pulmonary vascular resistance below four units, indicating an unusually mild form of the combined condition in these patients. Surgical management is discussed, and in particular the question of simultaneous closure of the defects during infancy. Cardiac failure, resistant to drug treatment, and increased PVR are indications of operation. The PDA should be closed and only if there is no substantial fall in pulmonary artery pressure is the VSD repaired.     

Embolization of an Amplatzer atrial septal closure device to the pulmonary artery

A 44-year-old woman with a history of transient ischemic attack underwent closure of atrial septal defect with a 26 mm Amplatzer device. The device was released without residual shunt or impingement on intracardiac structures. Within seconds, the transesophageal echocardiography showed the initial dislodgement of the device from the atrial septum and its consequent slipping back into the right atrium close to the tricuspid valve. Soon after the device disappeared from the right atrium and it could be founded into the right ventricle under the tricuspid valve. The patient was transferred in the operating room for an emergency operation. The device could not be found in the right ventricle because its downstream migration. The Amplatzer septal occluder was identified by palpation into the pulmonary artery trunk: it was retrieved from the right ventricle through the pulmonary valve and the atrial septal defect was closed by running suture.