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PubMed1983

Repair of aortopulmonary window at left thoracotomy for patent ductus arteriosus.

The inability to differentiate accurately between patent ductus arteriosus and aortopulmonary window may occasionally result in finding an aortopulmonary window while prepared to close a patent ductus arteriosus at left thoracotomy. Anatomic and technical factors now allow aortopulmonary window closure from the left chest using surgical clips in certain selected cases. The successful repair of such a case is presented.

Aorta↗
PubMed2005

Prenatal constriction of the fetal ductus arteriosus--related to maternal pain medication?

Physiological fetal circulation requires patency of the ductus arteriosus. As gestation proceeds, the sensitivity of the ductus to dilating prostaglandins diminishes. The sensitivity to constricting agents like PGE-synthetase inhibitors, present in many analgetics, however, increases. Fetuses affected by an antenatal constriction of the ductus arteriosus (DC) may present with different signs of cardiac failure including dilated right ventricle, tricuspid regurgitation and abnormal venous Doppler. We report on four cases with prenatal DC, presenting at 34, 35, 36 and 37 weeks of gestation. They were referred to fetal echocardiography because of abnormal routine echo scans with unexplained signs of right heart decompensation. Three patients were medicated during pregnancy with either aspirin (low dose), metamizole or ibuprofen. One patient did not take any drugs, especially no pain medication drug in pregnancy. Immediate delivery was performed in all cases. The neonates were in a good condition; echocardiography showed different degrees of right heart hypertrophy which disappeared in all infants by the age of 3 months except in case 2. Unexplained fetal right heart decompensation requires detailed echocardiographic evaluation of the ductus arteriosus and a sophisticated medical history with regard to analgesics. In contrast to ibuprofen and high-dose aspirin, metamizole and low-dose aspirin have not yet been reported as possible agents constricting the fetal arterial duct. In any suspected context, early delivery as in our cases may save babies life. Any application of non-steroidal anti-inflammatory drugs in pregnancy requires close fetal follow-up due to their potentially life-threatening effect.

Analgesics, Non-Narcotic↗
PubMed2001

Simultaneous double or triple coil technique for closure of moderate sized (> or = 3.0 mm) patent ductus arteriosus.

One important complication of coil occlusion of patent ductus arteriosus using the conventional Gianturco coil is migration of coils into peripheral vessels. Especially in patients having relatively larger size ductus, the risk for such complication could be increased. In this regard, a detachable coil may have some technical benefits in performing coil occlusion and reducing the incidence of complications such as migration of coil. Based on our clinical experiences, we describe the clinical efficacy of a simultaneous double or triple coil occlusion technique using the Cook detachable coil system to close the ductus arteriosus, especially in patients whose ductus diameter more than 3.0 mm.

Adolescent↗
PubMed1989

Ligating the ductus arteriosus before birth remodels the pulmonary vasculature of the lamb.

The clinical syndrome of persistent pulmonary hypertension of the newborn includes a developmentally abnormal pulmonary microvasculature which contains excessive amounts of muscle and which cannot adapt to air breathing in the perinatal period. Surgical ligation of the ductus arteriosus of the fetal lamb has produced a physiologic model of pulmonary hypertension of the newborn. The aim of the present investigation is to determine whether surgical ligation of the ductus arteriosus in fetal sheep produces anatomic changes in the pulmonary blood vessels. The pulmonary vasculature of seven neonatal lambs that underwent surgical ligation of the ductus arteriosus from 6 to 17 d before birth was compared to that of five control lambs with a patent ductus arteriosus without fetal surgery and three control lambs with a patent ductus arteriosus that underwent sham surgery. Quantitative microscopic analysis of the barium gelatin-filled peripheral pulmonary vascular bed revealed an increase in the proportion of partially and fully muscularized pulmonary arteries at the level of the terminal bronchiole and within the acinus (p less than 0.0001). This finding demonstrates that medial muscle develops in areas of the distal pulmonary vascular bed where it is normally absent. Periadventitial fibrosis surrounding intraacinar pulmonary arteries was also present. No change in the number of small intraacinar arteries was detected. This structural remodeling of the peripheral pulmonary vascular bed was initiated in utero by ductus arteriosus occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1979

Dilatation of the ductus arteriosus by prostaglandin E1 in aortic arch abnormalities.

Infants with aortic arch interruption of juxtaductal coarctation of the aorta may depend on patency of the ductus arteriosus to provide adequate lower body perfusion. In many such infants the ductus arteriosus constricts after birth, resulting in severe heart failure, poor systemic perfusion and acidemia. We infused prostaglandin E1 (PGE1) at a rate of 0.05--0.1 microgram/kg/min into seven infants with aortic arch interruption and eight infants with coarctation. In one infant in each group the ductus arteriosus was already closed and did not reopen. In one infant with coarctation an adequate trial was not accomplished, and in another adequate pressure measurements were not obtained. Of the remaining 11, the ductus arteriosus was effectively dilated by PGE1 in 10 infants. This was evidenced by an increase in descending aortic blood pressures and a reduction in the pressure difference between the main pulmonary artery and descending aorta in six infants with aortic arch interruption and between ascending and descending aorta in four infants with coarctation. Lower body perfusion improved and left ventricular failure was improved. The infant who did not respond was 5 months old. There were no complications.

Aorta, Thoracic↗
PubMed2000

Video assisted thoracoscopic ligation of patent ductus arteriosus. Technique of sliding loop ligation.

Variant video-assisted thoracoscopic surgical technique for closure of patent ductus arteriosus has been introduced. Although the endoscopic clipping device may be a preferred method for interruption of the patent ductus arteriosus, there is always the risk of inadequate clip placement and limitation of application in width of ductus arteriosus. In an effort to overcome this problem we have used a self-made endoscopic loop ligation in 10 patients and herein report the method. Only a small window and one port of access are necessary to dissect the patent ductus arteriosus from the surrounding tissues and to apply the extracorporeally created sliding loop. Successful ligation without shunt is obtained in all cases. The technique is simple and safe even in the presence of a wide ductus.

Child↗
PubMed1995

Fetal cardiac function and ductus arteriosus during indomethacin and sulindac therapy for threatened preterm labor: a randomized study.

OBJECTIVE: The purpose of this randomized study was to evaluate the effects of indomethacin (10 patients) and sulindac (10 patients) given for 4-days on the fetal cardiac function and ductus arteriosus in pregnancies complicated by threatened premature labor between 28 and 32 gestational weeks. STUDY DESIGN: By use of pulsed color Doppler techniques the pulsatility index in fetal ductus arteriosus was calculated. Peak systolic velocities in the fetal ascending aorta and pulmonary trunk were also measured. By M-mode echocardiography both ventricular inner end-diastolic and end-systolic diameters were measured and ventricular fractional shortenings were calculated. Tricuspid valve regurgitation was evaluated by pulsed and color Doppler techniques. The ultrasonic examinations were made before and 4, 24, 48, and 72 hours after the start and 24 hours after the end of medication. RESULTS: Indomethacin significantly decreased the mean pulsatility index in fetal ductus arteriosus 4 hours after the beginning of medication. This decrease became greater later during medication, and it was associated with a significant increase in both ventricular inner end-diastolic diameters and with a significant decrease in right ventricular fractional shortening. The mean pulsatility index in the fetal ductus arteriosus increased to control values at 24 hours after the end of medication. Sulindac significantly decreased the mean pulsatility index in fetal ductus arteriosus only 24 hours after the beginning of medication. All other mean pulsatility index values did not differ from control values. Other cardiac parameters remained unchanged during sulindac treatment. CONCLUSION: Indomethacin has a significant reversible constrictive effect on the fetal ductus arteriosus that is associated with secondary changes, especially in the right ventricle. Sulindac seems to have only a mild and transient constrictive effect on the fetal ductus arteriosus.

Ductus Arteriosus↗
PubMed2004

Initial results and medium-term follow-up of stent implantation of patent ductus arteriosus in duct-dependent pulmonary circulation.

OBJECTIVES: This study was designed to assess the safety, efficacy, medium-term outcome, and complications of patent ductus arteriosus (PDA) stenting in duct-dependent pulmonary circulation. BACKGROUND: Patent ductus arteriosus stenting has been proposed as an alternative to surgical shunt on account of postoperative morbidity and complications of surgical shunting. METHODS: Between April 2000 and February 2003, 69 patients with duct-dependent pulmonary circulation underwent cardiac catheterization with the intent of PDA stenting as first palliative procedure. Patients with critical pulmonary stenosis and pulmonary atresia with intact ventricular septum post-radiofrequency valvotomy who had PDA stenting were excluded. Thirteen more patients were excluded because of branch pulmonary artery (PA) stenosis. The follow-up was by clinical examination, echocardiography, and repeat cardiac catheterization at six to nine months following the procedure. RESULTS: Patent ductus arteriosus stenting was successful in 51 patients (91.1%) and failed in 5 patients (8.9%). The mean narrowest PDA diameter was 1.9 +/- 0.6 mm. The mean procedure and fluoroscopy time were 95.7 min and 29.4 min, respectively. In one patient the stent dislodged and migrated to the left femoral artery and another patient developed transient intravascular hemolysis. There was no procedure-related mortality. Three patients (5.9%) died one day to two months after the procedure. At follow-up (3.2 months to 2.4 years), 8 patients developed significant stent stenosis requiring reintervention. Seven patients developed worsening of preexisting branch PA stenosis. The freedom from reintervention was 89% and 55% at 6 months and 1 year, respectively. CONCLUSIONS: Patent ductus arteriosus stenting is an attractive alternative to surgical shunt in a majority of patients with duct-dependent circulation. An absolute contraindication to this technique is the presence of branch pulmonary stenosis.

Child, Preschool↗
PubMed1997

Absent pulmonary valve syndrome with intact ventricular septum: role of ductus arteriosus revisited.

We report two patients (four and twelve days old respectively) with heart failure due to absent pulmonary valve and patent ductus arteriosus. The ductus arteriosus in both patients had unusual course arising early from the aortic arch and maintaining an acute angle with the aortic arch. The etiology of absent pulmonary valve syndrome is still not clear. We speculate on the role of arterial duct in the development of absent pulmonary valve syndrome.

Ductus Arteriosus, Patent↗
PubMed1995

Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases.

Video-assisted thoracoscopic surgical interruption for patient ductus arteriosus is a well-standardized procedure already described. We present our entire series of such cases, from the first case (performed on Sept. 5, 1991) to March 1, 1995. Two hundred thirty patients in a variety of age groups underwent video-assisted interruption: younger than 6 months (70 patients, 30%), 6 to 48 months (123 patients, 54%), and older than 48 months (37 patients, 16%). The mean weight was 12.6 kg (range 1.2 to 65 kg). Thirty-nine patients had symptomatic pulmonary hypertension. Associated intracardiac anomalies included atrial septal defect (three), ventricular septal defect (five), and anomalous pulmonary venous return (one). All patients underwent video-assisted interruption of the patient ductus arteriosus with two titanium clips. Closure was evaluated by postoperative echocardiography before extubation. Five patients had a persistent patent ductus after video-assisted interruption, all early in our experience and related to insufficient dissection resulting in inadequate clip placement. Four patients had successful immediate clip repositioning (three by video-assisted interruption and one by thoracotomy). Subsequent echocardiography revealed persistent closure in these patients. A persistent patent ductus arteriosus with minimal flow was discovered in one patient without symptoms after discharge. Recurrent laryngeal nerve dysfunction was noted in six patients (2.6%, five transient and one persistent). There were no deaths, hemorrhages, transfusions required, or chylothoraces in this series. Mean operative time was 20 +/- 15 minutes, and hospital stay averaged 48 hours for patients younger than 6 months and 72 hours for patients older than 6 months. This is a safe, rapid, cost-effective technique that results in excellent results and a shortened hospital stay. Video-assisted interruption represents the technique of choice for closure of a patient ductus arteriosus.

Child, Preschool↗
PubMed1997

alpha-Toxin-permeabilised rabbit fetal ductus arteriosus is more sensitive to Ca2+ than aorta or main pulmonary artery.

OBJECTIVES: The Ca2+ sensitivity of contractile protein-generated tension production was measured in the smooth muscle of the rabbit ductus arteriosus and compared with two neighbouring fetal blood vessels (main pulmonary artery and aorta). The effect of prostaglandin E2 (PGE2), 3-isobutyl-1-methylxanthine (IBMX, a phosphodiesterase inhibitor), cyclic adenosine 3'5'-monophosphate (CAMP) and forskolin (an activator of adenylate cyclase) on Ca(2+)-activated force generated by preparations from ductus arteriosus was also examined. METHODS: Strips of smooth muscle from the three vessels were permeabilised using crude alpha-toxin from Staphylococcus aureus. The relationship between [Ca2+] and force production was then measured in the three tissues and the effect of PGE2, cAMP, IBMX and forskolin was examined on submaximal Ca(2+)-activated force (0.3 microM Ca2+) in preparations from rabbit ductus arteriosus. RESULTS: Permeabilised smooth muscle from fetal rabbit ductus arteriosus was significantly more sensitive to Ca2+ (EC50, 0.20 microM) than its two neighbouring blood vessels aorta (EC50, 0.52 microM) and main pulmonary artery (EC50, 0.72 microM). Submaximal Ca(2+)-activated force (0.3 microM Ca2+) was depressed by PGE2 (1 nM) in the presence of IBMX (10 microM), by cAMP (10 and 100 microM) and by forskolin alone (0.1 microM and 1 microM). CONCLUSION: PGE2-mediated depression of Ca(2+)-activated force in the smooth muscle of the ductus arteriosus may play a role in the maintenance of a patent ductus arteriosus in the fetus. The intrinsically high Ca2+ sensitivity of smooth muscle contractile proteins may aid the sustained vasoconstriction of the ductus when the PGE2 levels fall after birth.

1-Methyl-3-isobutylxanthine↗
PubMed1989

The effect of adenosine triphosphate on the functional status of the ductus arteriosus.

We investigated whether a low-dose infusion of ATP-MgCl2 could affect the functional status of the ductus arteriosus during hypoxia-induced pulmonary vasoconstriction. Three-day-old piglets were made hypoxic by ventilation with a mixture containing 10% oxygen, 4% CO2, and balance nitrogen. Serial infusions of ATP-MgCl2 at 0.1, 0.5, and 1.0 mg/kg/min were compared with preinfusion hypoxia baselines. The functional status of the ductus arteriosus was determined by change in transit time of a bolus of iced saline between thermistor probes in the pulmonary artery and aorta. The method was validated using a Blalock-Taussing shunt (subclavian to pulmonary artery) in 3-week-old piglets instrumented in a similar manner. In these three-day-old piglets, hypoxia alone produced a significant elevation in pulmonary artery pressure and reduction in PO2. All dose rates of ATP-MgCl2 produced a significant decrease in mean pulmonary artery pressure. Systemic pressure was significantly decreased only during the 1.0-mg/kg/min infusion. Transit times of a bolus of iced saline during the validation were definitive for characterizing a situation of "shunt open" or "shunt closed." Infusion of ATP-MgCl2 produced no change in the status of the ductus arteriosus in 45 (94%) of the determinations. In only three cases was the effect of ATP-MgCl2 sufficient to result in a functional change in the status of the ductus arteriosus. Pre- and postductal pulmonary artery PO2 were not altered during ATP-MgCl2 infusion, thus corroborating the transit time determinations. From these results, we conclude that an infusion of ATP-MgCl2 does not alter the functional status of the ductus arteriosus.

Adenosine Triphosphate↗
PubMed1989

Lobar emphysema associated with patient ductus arteriosus and pulmonary obstructive vascular disease.

Three cases of respiratory distress with patent ductus arteriosus are presented. The left-to-right shunt across the ductus arteriosus produced dilated pulmonary arteries and secondary bronchial compression, leading to lobar emphysema. The increase of blood flow across the ductus arteriosus causes structural changes of the wall of the preacinar and intra-acinar arteries. All three patients died, most probably from the association of parenchymatous pulmonary disease and pulmonary obstructive vascular disease.

Bronchi↗
PubMed1984

Cytochrome P 450-linked monooxygenase: involvement in the lamb ductus arteriosus.

CO and metyrapone were tested on isolated ductus arteriosus preparations from mature fetal lambs equilibrated at low (4-12 Torr) and high (511-712 Torr) O2 partial pressure (PO2). CO completely reversed the contractile tension of the ductus at either PO2 value and was equally effective in the absence and presence of indomethacin. CO relaxation still occurred when the tissue was exposed to a gas mixture having a CO-to-O2 ratio of 0.27. The inhibitory effect of CO on the O2-contracted ductus was variably reversed by light. Metyrapone was also a relaxant agent, and its action was greater at low than at high PO2. Unlike the lamb ductus, the O2-constricted guinea pig ductus did not respond to CO (maximum CO-to-O2 ratio around 1), whereas it was relaxed by metyrapone. These findings implicate a cytochrome P450-catalyzed enzymic process in the maintenance of muscle tone of the lamb ductus arteriosus and in the contractile response of the vessel to O2.

Animals↗
PubMed1998

Thoracoscopic interruption of patent ductus arteriosus compromises cardiopulmonary function in newborn pigs.

UNLABELLED: Interruption of patent ductus arteriosus (PDA) using video-assisted thoracoscopic surgery (VATS) has recently been introduced into clinical practice. To study cardiovascular and pulmonary function during VATS, we treated 16 newborn pigs (weight 1421+/-44 g) with PDA with conventional surgical interruption (CSI; n = 7) or interruption via VATS (n = 9). Measurements of hemodynamics and gas exchange were performed before, during, and after surgery. Systemic perfusion was calculated using Fick's equation. Stress hormones (ACTH, epinephrine, and norepinephrine) were determined before and after surgery. The duration of the surgical procedure was 41+/-8 min for CSI and 49+/-9 min for VATS (mean+/-SEM). With VATS, PaO2 decreased during and after surgery (P < 0.05), whereas alveolar-arterial PO2 difference (PA-aO2) and PaCO2 were increased (P < 0.05). Compared with CSI after surgery, PaO2 with VATS was decreased (130+/-10 vs 171+/-12 mm Hg; P < 0.05). Systemic perfusion was lower during VATS (76.7% of baseline) than during CSI (107% of baseline; P < 0.05). Heart rate, mean arterial pressure, and right ventricular end-diastolic pressure remained unchanged with both treatments. Stress hormones were comparable between groups. We conclude that systemic perfusion and oxygenation were impaired during VATS compared with CSI. Therefore, VATS may be contraindicated in pediatric patients with minor cardiopulmonary reserve. IMPLICATIONS: We studied the cardiopulmonary effects of endoscopic interruption of the patent ductus arteriosus in an animal model of newborn pigs. Gas exchange and systemic perfusion were impaired compared with conventional interruption of the patent ductus arteriosus after thoracotomy.

Animals↗
PubMed1984

Patency of the ductus arteriosus in normal neonates: two-dimensional echocardiography versus Doppler assessment.

Two-dimensional echocardiography using a high resolution, 7.5 ,Jsz transduce was compared with Doppler echocardiography for the assessment of patency of the ductus arteriosus in normal newborn infants. Twenty-eight neonates were studied between 1 and 10 hours (mean 5.5) after birth and both examinations were possible in 27 (96%). Doppler echocardiography under two-dimensional direction indicated ductal patency in all 27 neonates. Doppler sampling in the pulmonary end of the ductus rather than the main pulmonary artery was more sensitive for detecting patency. When two-dimensional echocardiography only was used to predict patency, there was 85% sensitivity. Two-dimensional echocardiography showed no evidence of ductus arteriosus narrowing ion four neonates studied shortly after birth. In 18, the pulmonary portion of the ductus arteriosus appeared narrowed and in 8 of these, the narrowing extended toward the mid-portion of the ductus. In five others, there was only mid-ductus arteriosus narrowing. It is concluded that high resolution two-dimensional echocardiography can be used to assess ductus arteriosus morphology, but is limited in predicting ductal patency near the time of normal physiologic closure. Combined two-dimensional and Doppler echocardiography is a highly sensitive technique for detection of ductal patency when sampling is performed in the pulmonary end of the ductus arteriosus.

Ductus Arteriosus↗
PubMed1990

Indomethacin for patent ductus arteriosus closure. Application of serum concentrations and pharmacodynamics to improve response.

Indomethacin dosing for patent ductus arteriosus closure has been standardized despite wide interpatient variability in indomethacin pharmacokinetics. We compared a novel indomethacin dosing approach using individual pharmacokinetic and pharmacodynamic information (group A) with a control group from our institution (group B) and a level 3 university-based intensive care nursery (group C) who were dosed using current dosing guidelines. Permanent patent ductus arteriosus closure was achieved in 27 of 28 (96.4%) group A patients, 10 of 16 (62.5%) group B patients, and 7 of 13 (52.8%) group C patients. Success rates were significantly higher in group A than Groups B and C (P less than .02). Renal toxicity was the only toxicity reported in any group. The major manifestations of renal toxicity, ie, urine output below 1 mL/kg/h or increased serum creatinine by greater than or equal to 0.5 mg/dL, occurred in none of the group A patients but in seven (43.8%) group B and eight (61.5%) group C patients. Renal toxicity was significantly greater in groups B and C than group A (P less than .02). A pharmacodynamic concentration versus response curve was developed and proved predictive of patent ductus arteriosus closure rates in previous studies where indomethacin concentration versus response data were available. Serum concentration monitoring is a valuable adjunct to indomethacin therapy for patent ductus arteriosus closure, especially when a pharmacodynamic approach is used.

Algorithms↗