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Ann Thorac Surg 1995;59:668-670
© 1995 The Society of Thoracic Surgeons

Safety of Patent Ductus Arteriosus Closure in Premature Infants Without Tube Thoracostomy

Departments of Thoracic-Cardiovascular Surgery and Pediatrics, Loyola University Medical Center, Maywood, Illinois

Accepted for publication November 16, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
During a 30-month period, 34 premature infants underwent surgical closure of a patent ductus arteriosus. The mean gestational age at birth was 25 ± 0.3 weeks and the mean age at the time of operation was 3 ± 0.3 weeks (mean weight, 829 ± 54 g). Indomethacin therapy had failed in 32 patients, and 2 had contraindications to its use. The initial 8 patients had parascapular incision and ligation of the patent ductus arteriosus; the last 26 patients had a short transaxillary incision and clipping. The average duration of the operation from the time of incision to skin closure was 36 ± 2 minutes (range, 15 to 65 minutes). One patient (3%) needed chest tube insertion intraoperatively because of visceral pleura disruption. Two patients (5.8%) had a ``small pneumothorax'' (<10% of the lung field) that resolved within 24 hours. There was no morbidity or mortality directly related to the operative procedure, although 3 patients (8.8%) ultimately died from problems related to their severe prematurity. We conclude that surgical closure of patent ductus arteriosus without chest tube drainage can be accomplished safely in premature infants. Postoperative nursing care is simplified and the cost is reduced because the need for the chest tube and drainage system is eliminated and the number of chest radiograms needed postoperatively is reduced.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Since the initial successful surgical closure of a patent ductus arteriosus by Gross and Hubbard in 1938 [1], its division and ligation has become a standard operation that is associated with negligible morbidity and mortality [2]. Even in the severely premature infant, this operation is now performed with few complications, and no mortality attributable to the surgical procedure has been reported for recent large series [3, 4].

Because of the given safety of patent ductus arteriosus closure, surgeons have now focused on muscle-sparing and short incisions to facilitate better chest growth and a better cosmetic result. There is also a major push for developing the most cost-effective approach to patent ductus arteriosus closure.

In the past 10 years, we have successfully performed patent ductus arteriosus division and ligation without chest tube drainage in older infants and children. Satisfied with the safety of this approach, in 1991 we started applying it to premature infants considered medically more fragile. We reviewed our experience to determine whether this latter approach is sensible or not.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Over a 30-month period ending in June 1994, 34 premature infants underwent surgical closure of a patent ductus arteriosus at our institution. Their clinical profile, the surgical technique used, and the results were retrospectively analyzed. The diagnosis was established on the basis of clinical examination and echocardiographic findings. Infants who required concomitant procedures or who were not premature at birth were excluded from this study.

Clinical Profile
There were 16 female and 18 male infants. The mean gestational age at birth was 25 ± 0.3 weeks (range, 22 to 32 weeks) and the mean age at the time of operation was 3 ± 0.3 weeks (range, 1 to 7 weeks). The mean weight at the time of operation was 829 ± 54 g (range, 510 to 2,300 g). The indications for surgical closure consisted of a patent ductus arteriosus in a premature infant who either remained ventilator dependent, or remained in congestive heart failure despite medical management and showed a left-to-right shunt on echocardiograms. All patients had either failed attempts at medical closure with indomethacin (n = 32) or had contraindications to its use (n = 2). Ninety-seven percent of the indomethacin patients (31 of 32) received about two rounds of treatment (six total doses).

Surgical Technique
Our surgical technique for patent ductus arteriosus closure in older infants and children has evolved over the years. We initially used the classic parascapular posterolateral incision, dividing the latissimus dorsi muscle and retracting the serratus anterior muscle anteriorly to enter the chest through the fourth intercostal space. Later we used a shorter, straight lateral incision, splitting the latissimus dorsi muscle along its fibers. More recently, we have adopted an approach in which a very short transaxillary incision is made between the pectoralis major and latissimus dorsi muscles, entering the chest through the third intercostal space [5].

In this series, all operations were performed in the operating room. The first 8 patients had a short, straight lateral thoracotomy incision. Because of the difficulty in raising skin flaps in premature infants to split the latissimus dorsi muscle along its fibers, this muscle was simply divided. The fourth intercostal space was entered. The patent ductus arteriosus was ligated with a single 2-0 silk braided tie. In the last 26 patients, the transaxillary approach (Fig 1) was used. The third intercostal space was entered. The Weck hemoclip (Edward Weck, Durham, NC) was used to close the ductus arteriosus, and this required minimal dissection above and below the duct to allow for clip application. The average length of the incision was 2 cm.

View larger version (180K): [in this window] [in a new window]   Fig 1. . Transaxillary incision (arrows) on a 900-g infant. The incision is 1.5 cm long and is located between the pectoralis major and latissimus dorsi muscles.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The mean duration of the operation from the time of incision to the completion of skin closure was 36 ± 2 minutes (range, 15 to 65 minutes). Blood loss was minimal, and there were no intraoperative complications. The immediate postoperative chest radiogram demonstrated a ``small pneumothorax'' (<10% of the lung field on a standard anteroposterior view) in 2 of the 34 infants (5.8%), but proved to be of no clinical consequence in either and was shown to resolve completely in both infants within 24 hours on the basis of chest radiogram findings. A single patient underwent intraoperative chest tube placement because of disruption of the visceral pleura and a persistent air leak. The immediate postoperative chest radiogram in this infant demonstrated a considerable persistent pneumothorax, and a second chest tube was placed which led to resolution of the pneumothorax. Both chest tubes were removed without incident on the third postoperative day. In the remaining 31 infants (91%), the postoperative chest radiogram demonstrated no pneumothorax. There was no morbidity or mortality related directly to the operative procedure, though 3 infants (8.8%) subsequently suffered significant pneumonia during their prolonged hospitalization and 3 infants (8.8%) ultimately died from other problems associated with their severe prematurity.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In premature infants, tissues are quite friable and can tear easily. Subcutaneous tissues are practically nonexistent. Often it is difficult to create a subcutaneous tunnel during chest tube placement in any effort to minimize an external air leak from around the tube or after chest tube removal. Additionally, pleural drainage is often negligible, so the usefulness of chest tube drainage in these infants is questionable.

Some surgeons have performed extrapleural dissection in an effort to circumvent the need for tube thoracostomy. However, the pleura is so thin that, in the few cases in which we attempted this, we found it to be easily torn. We have found that a transpleural approach with care to avoid disrupting the visceral pleura is a key element in avoiding the need for postoperative chest tube drainage.

Not routinely using tube thoracostomy eliminates the potential complications of the chest tube itself, such as bleeding, nerve damage, lung laceration, or erosion into vital structures [6]. Additionally, because ventilator-dependent premature infants are turned frequently and even placed prone to promote better pulmonary drainage and function, the nursing care is simpler and more efficient when chest tube drainage is not used.

Another advantage of not routinely using tube thoracostomy is the elimination of the cost of the chest tube, drainage apparatus, and the chest radiogram that is often obtained after removal of the chest tube. Although the savings may represent a relatively small fraction of the overall expense in the care of a premature infant requiring a lengthy hospitalization, such a cost reduction would be substantial as it accumulates over a large number of patients.

The cost-effectiveness of patent ductus arteriosus closure without tube thoracostomy will probably be easier to quantitate in older infants and children. We are currently applying such an approach as an outpatient procedure utilizing the short transaxillary incision and clip closure of the patent ductus arteriosus. Although this will constitute a separate report, it is anticipated that this approach will compare favorably with alternative procedures such as percutaneous endovascular occlusion [7] and thoracoscopic closure of the patent ductus arteriosus [8].

The simplicity and safety of the transaxillary approach without chest tube drainage may prompt earlier use of this technique in premature infants. Although we report here on the use of this technique after two attempts at ``nonsurgical'' closure with indomethacin therapy, we are currently reevaluating such strategy. Earlier use of this technique may facilitate ventilator weaning and the initiation of oral intake. It is appealing to speculate that such an approach may further reduce cost.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr DeLeon, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Gross RE, Hubbard JP. Surgical ligation of a patent ductus arteriosus. JAMA 1939;112:729–31.
2. Wright JS, Newman DL. Ligation of the patent ductus: technical considerations at different ages. J Thorac Cardiovasc Surg 1978;75:695–8.[Abstract]
3. Trus T, Winthrop AL, Pipe S, et al. Optimal management of patent ductus arteriosus in the neonate weighing less than 800 grams. J Pediatr Surg 1993;28:1132–9.
4. Canarelli JP, Poulain H, Clamadieu C, et al. Ligation of the patent ductus arteriosus in premature infants-indications and procedures. Eur J Pediatr Surg 1993;3:3–5.[Medline]
5. Browne D. Patent ductus arteriosus. Proc R Soc Med 1952;45:719–22.[Medline]
6. Iberti TJ, Stern PM. Chest tube thoracostomy. Crit Care Clin 1992;8:879–95.[Medline]
7. Gray DT, Eyler DL, Walker AM, et al. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. The Patent Ductus Arteriosus Closure Comparative Study Group. N Engl J Med 1993;329:1517–23.[Abstract/Free Full Text]
8. Forster R. Thorascopic clipping of patent ductus arteriosus in premature infants. Ann Thorac Surg 1993;56:1418–20.[Abstract]

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