Within recent years, video-assisted thoracic surgery

Transcription

1 Video-Assisted Thoracoscopic Ligation of Patent Ductus Arteriosus: Safe and Outpatient Michael H. Hines, MD, Andrew S. Bensky, MD, John W. Hammon, Jr, MD, and D. Glenn Pennington, MD Departments of Cardiothoracic Surgery and Pediatric Cardiology, Wake Forest University Baptist Medical Center and Brenner Children s Hospital, Winston-Salem, North Carolina Background. Minimally invasive techniques for interruption of patent ductus arteriosus have been reported, but are in use at only a few centers. We examined our series of patients who underwent thoracoscopic patent ductus arteriosus ligation. Methods. We reviewed 59 consecutive patients, age 6 days to 50 years, weighing 640 g to 62 kg, who underwent video-assisted placement of a stainless steel clip across the patent ductus arteriosus. Results. Thirty-eight nonneonates and 21 neonates (18 were < 1,500 g) underwent video-assisted thoracic surgery for patent ductus arteriosus closure with intraoperative echocardiographic confirmation in nonneonates. There were no residual shunts, transfusions, chylothoraces, or significant pneumothoraces. Four were converted to thoracotomy, 3 for anatomic variances, and 1 for coagulopathy. Thirty-six of 38 nonneonate patients stayed less than 24 hours; 18 were discharged the evening of the operation. Two were admitted, one after thoracotomy, and one for a small mucosal intubation injury. No others required a chest tube. There were two recurrent nerve injuries. All neonates survived, and were extubated. Conclusions. Video-assisted thoracoscopic ductus closure is a safe, reliable technique and can be performed as an outpatient procedure in nonneonate patients. (Ann Thorac Surg 1998;66:853 9) 1998 by The Society of Thoracic Surgeons Within recent years, video-assisted thoracic surgery (VATS) has been shown in adults to have several advantages over open thoracotomy [1], and for many surgeons it has become the preferred approach for specific disorders [2]. Thoracoscopic interruption of a patent ductus arteriosus (PDA) with very low morbidity has also been reported within the last few years by one US center [3, 4], and by groups in France [5, 6] and Taiwan [7]. Despite these successful reports, however, use of the technique has not become widespread. We began using a thoracoscopic approach for PDA ligation in July 1995, and now review our experience. Material and Methods Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6 8, Address reprint requests to Dr Hines, Department of Cardiothoracic Surgery, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC ( mhines@wfubmc.edu). Fifty-nine patients, age 6 days to 50 years and weighing from 570 g to 61.8 kg, diagnosed by transthoracic echocardiography (TTE) with a PDA were referred for VATS closure. Patent ductus arteriosus size was graded subjectively by the cardiologist on the following scale: small, small to moderate, moderate, moderate to large, and large. At our center, initially only patients weighing more than 3.5 kg who were referred for ductal ligation were considered for VATS approach. After the experience of the first 15 procedures, however, all patients were considered, including premature infants. Any infant less than 1,500 g, who was significantly unstable, or required high-frequency oscillatory ventilation and who was felt to be at risk for instability during transport to the operating room, was excluded and underwent an open procedure in the neonatal intensive care unit (8 infants during this period). All thoracoscopic procedures were performed in the operating room. The patients were administered general endotracheal anesthesia using a single-lumen tube, with the exception of one 50-year-old woman who had a double-lumen tube placed. In patients larger than 3 kg, transesophageal echocardiography (TEE) was performed to confirm the presence of a PDA using a commercially available pediatric biplane or adult omniplane echocardiography probe (Hewlett Packard, Andover, MA). Patients were stabilized in a standard left thoracotomy position and widely prepared and draped. Using specially modified arthroscopy ports and trocars (Dyonics, Birmingham, AL), four thoracostomy ports were used, ranging from 3 to 5 mm diameter, depending on the site, the size of instrument used, and the size of the patient. The videoscope port (3 mm for the 2.7-mm scope in patients less than 3 kg, and a 4-mm port for the 4-mm scope for larger patients) was placed just below the tip of the scapula, usually in the fourth interspace. The lung retractor port (either 4 or 5 mm depending on retractor chosen) was placed in the fourth or fifth interspace between the mid and posterior axillary line. A 5-mm port was placed behind the scapular edge about halfway between the videoscope port and the midline of the back. A fourth grasper port, 3 mm in 1998 by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)

2 854 HINES ET AL Ann Thorac Surg THORACOSCOPIC PATENT DUCTUS LIGATION 1998;66:853 9 size, was placed over the third rib in the mid-axillary line in all patients except 4 of the most recent premature infants in whom only three ports were used. Ventilation was held for insertion of the first port to allow the lung to drop away from the chest wall and prevent injury to the parenchyma. Subsequent ports were placed similarly or at times using direct visual guidance with the videoscope. If present, adhesions were lysed with the electrocautery under videoscopic guidance. With anesthesia personnel using gentle hand ventilation for the duration of the procedure, the videoscope, (Dyonics) was inserted followed by the lung retractor (Pilling-Weck Inc, Research Triangle Park, NC) or cottontipped applicator in patients less than 3 to 4 kg in whom the expandable lung retractor did not have sufficient room to open. The upper lobe and superior segment of the lower lobe were gently retracted inferiorly and medially, exposing the aortic arch. The pleural reflection was grasped and opened longitudinally over the aorta with the electrocautery, creating a flap parallel to the aorta. With anteromedial retraction of this flap, the area of the ductus arteriosus was exposed along with the vagus nerve, which was gently retracted with the flap medially to expose the recurrent laryngeal nerve. The pleural incision was carried up to the base of the left subclavian artery, frequently dividing the highest intercostal vein with the electrocautery. Occasionally clips were used for larger veins. The ductus arteriosus was identified and with careful blunt dissection a plane was created above and below it. No effort was made to encircle the ductus arteriosus. The 5-mm port was replaced with a small self-retaining nasal speculum to gently spread the tissue and allow insertion of the flat clip applier that would not pass through the round port. The appropriate size clip was selected and inserted, taking care to completely cross the ductus arteriosus, with the inferior edge of the applier superior to the recurrent nerve. The applier was guided away from the aortic arch so as not to injure it with the tips of the clip or applier. A medium, medium-large, or large stainless steel Weck clip (Pilling-Weck Inc) was applied using concurrent echocardiographic imaging to confirm positioning and successful closure. The superior edges of the pleural flap were carefully inspected for bleeding or lymphatic leak and cauterized. No attempt was made to close the pleural incision. The lung retractor, grasper, and three nonscope ports were removed and carefully inspected from within for evidence of bleeding. A small-bore chest tube was inserted in the retractor port, and using the scope, guided anterolaterally along the lateral chest wall, outside of the fissure. The scope and fourth port were slowly removed and that site inspected for bleeding. All four sites were infiltrated with 0.25% bupivicaine, and closed with minimal absorbable subcutaneous sutures. Many of the smaller thoracoscopy sites required no sutures, especially in the smaller patients. The posterior port site was closed with absorbable suture. The lung was reexpanded with hand ventilation, and gentle suction on the chest tube. The tube was then removed under positive pressure, and a previously placed absorbable suture tied. All wounds were then dressed with Steristrips (3M, Medical- Surgical Division, St. Paul, MN). Neonates were returned directly to the neonatal intensive care unit, a chest x-ray film was obtained, and the infants were extubated at a time dictated by their clinical condition. All nonneonate patients were awakened from anesthesia and extubated in the operating room, and then taken to the recovery room. Patients were given ibuprofen, 10 mg/kg orally, every 8 hours for pain, and advanced to a regular diet over the next several hours. Initially, chest x-ray films were obtained on arrival in the recovery room for the nonneonates, and repeated the next morning before discharge. After the first 15 patients, immediate postoperative x-ray films were obtained only if clinically indicated by decreased breath sounds, a drop in pulse oximetry, or excessive subcutaneous air. Routine x-ray films were obtained later on the day of the operation to rule out pneumothorax or effusion before discharge that afternoon or evening. Neonates were followed up directly or indirectly until discharge to home, from our tertiary center or from the referring nursery. Same-day surgical patients were seen back at 2 to 3 weeks after the operation, their wounds were checked, and a follow-up chest x-ray film was obtained. Results Twenty-one neonates and 38 nonneonates underwent VATS PDA closure. There were 38 female and 21 male patients overall, with a definite female predominance in the nonneonate group (29 female and 9 male patients), as classically described in the literature [8], but an almost equal distribution in the neonate group (9 female, 12 male patients). Ductal size varied greatly and was distributed as follows: 5 small, 4 small to moderate, 3 moderate, 4 moderate to large, and 5 large. One term infant had a significant patent foramen ovale, another had critical pulmonic stenosis, but none of the other neonates had any associated cardiac defects. The indication for closure was mild congestive heart failure with failure to wean ventilatory support or oxygen requirements. Twenty of 21 neonates had failed at least two courses of indomethacin therapy before referral for operation. One was referred after failure of a single course because of a large PDA and a history of gastrointestinal hemorrhage and necrotizing enterocolitis. Eighteen neonates were premature, 23 to 31 weeks gestation (mean, 26 weeks), and weighed 570 to 1,500 g (mean, 949 g) and ranged in age from 6 to 43 days (mean, 22 days) at the time of the procedure. Seventeen of 18 premature neonates (94%) had successful VATS closure of the ductus arteriosus. The other infant was converted to an open muscle-sparing minithoracotomy because of poor visualization through the scope, secondary to the child s known coagulopathy, and an inability to keep the tip of the scope clear of drops of blood. The PDA in 1 of 3 term neonates was closed successfully with VATS techniques. The other 2 were success-

3 Ann Thorac Surg HINES ET AL 1998;66:853 9 THORACOSCOPIC PATENT DUCTUS LIGATION 855 fully exposed through the scope but were electively converted to open procedures. The first was a 38-week, 4.1-kg infant with a small aortic arch and a large ductus arteriosus. There was some concern in the operating room about the presence of a double arch, and the procedure was converted to an open minithoracotomy to extend the dissection and better define the anatomy before ductal ligation. The arch was found to be somewhat small, and the ductus arteriosus very large, but no double arch or ring was identified and the ductus arteriosus was successfully interrupted. The second child was a term 2.9-kg infant who was cyanotic at birth and found to have critical pulmonic stenosis. She was maintained on prostaglandin infusion until she underwent balloon valvotomy. The ductus arteriosus failed to close after discontinuation of the prostaglandin, as well as after two courses of indomethacin therapy. Because of the large left-to-right shunt across the ductus arteriosus, we were unable to evaluate the effectiveness of the balloon valvotomy or to rule out significant residual obstruction with echocardiography. The child was taken to the operating room with plans to encircle and temporarily snare the PDA and reevaluate the pulmonary outflow tract gradient with TEE before permanent surgical closure of the ductus arteriosus. Because of the large size of the ductus arteriosus, we were unable to accomplish this through the thoracoscope, and converted electively to an open muscle-sparing minithoracotomy. The ductus arteriosus was snared, there was no significant residual gradient by TEE, and the ductus arteriosus was interrupted. Mean operating room and procedure times for the neonates undergoing successful VATS ligation (excluding the 3 converted to open procedures) were 107 and 44 minutes. There was no difference in times for neonates when comparing procedures done early or late in the series; however, premature infants were only included in the last 15 months, after the experience with 18 nonneonate patients. In the group of 21 neonates, all survived and were eventually extubated and discharged, except for 3 premature infants who, though extubated, currently continue to progress in the nursery. There were no recurrent nerve injuries, phrenic nerve injuries, postoperative effusions, chylothoraces, or pneumothoraces related to the procedure. One infant had an episode of endotracheal tube plugging, and sustained a pneumothorax after vigorous suctioning and hand ventilation late on postoperative day 1 requiring tube thoracostomy. This was thought to be unrelated to the surgical procedure as there was no pneumothorax present on two previous postoperative films. There were no postoperative wound infections or significant fevers. One infant was found to have free intraperitoneal air on the postoperative x-ray film, and underwent exploratory laparotomy. A perforation of the small bowel was discovered, but was believed to be several days old from the amount of fibrinous peritonitis. The infant remained hemodynamically stable despite the perforated bowel and stress of two procedures and recovered to be extubated and discharged. Although most of the premature infants received blood transfusions during their hospital stay, there was no significant intraoperative bleeding, and none of the infants required blood transfusion because of intraoperative or postoperative blood loss. A few of the infants with previous thrombocytopenia received preoperative platelets for low platelet counts the night before the operation. The 38 nonneonate patients were distributed into four general groups: There were 21 children between 1 and 24 months of age (3.8 to 16.4 kg), including 4 former premature infants with known asymptomatic PDAs. There were 11 children between 2 and 5 years of age (9.6 to 18.2 kg), including 1 former premature infant. Five adolescents, ages 10 to 17 years (35.6 to 61.8 kg), and one 50-year-old adult (58.7 kg) also underwent the procedure. Ductal sizes by echocardiography were as follows: 14 small, 10 small to moderate, 7 moderate, 2 moderate to large, and 5 large. Associated cardiovascular lesions were noted in 9 of 38 nonneonate patients including 4 patent foramina, 3 small ventricular septal defects, 1 bicuspid aortic valve, and 1 child with a previous atrial septal defect and anomalous systemic venous drainage. In addition, one 12-year-old girl had a structurally normal heart other than the PDA, but had Ehlers-Danlos syndrome. The indication for closure in most patients was for endocarditis prophylaxis as most were asymptomatic. Three children with large ductus arteriosus had moderate evidence of failure to thrive, but only one required medical treatment for congestive heart failure. Thirty-seven of 38 nonneonate patients (97.4%) had successful closure of the ductus arteriosus with the VATS technique. The only technical failure was in a 10-year-old boy, who had a history of secundum atrial septal defect repair many years earlier with a known persistent left superior vena cava draining into the coronary sinus. At the time of thoracoscopy it was found that he had an interrupted inferior vena cava, with left-sided hemiazygous continuation completely covering the distal arch and descending aorta. An attempt was made to partially mobilize the vein, but we could not see the ductus arteriosus sufficiently through the scope to safely complete the procedure. He underwent an elective musclesparing minithoracotomy, and with proper retraction of the vein, the ductus arteriosus was interrupted. Mean operating room and procedure times for 36 patients were 140 and 73 minutes, excluding two outliers: the 10-year-old with the hemiazygous continuation (285 and 228 minutes) and the 50-year-old with a previous thoracotomy and adhesions (223 and 134 minutes). There was a noticeable decrease in times during the 27-month period because of some learning curve processes for the surgeon and staff. Mean operating room and procedure times both decreased from the first dozen (155 and 88 minutes) to the middle dozen (144 and 72 minutes), and to the final dozen (121 and 57 minutes) nonneonate patients. All 38 patients had complete closure of the ductus arteriosus documented with intraoperative echocardiography (TEE in 37 and transthoracic echocardiography in the 2.3-kg formerly premature neonate). There were no

4 856 HINES ET AL Ann Thorac Surg THORACOSCOPIC PATENT DUCTUS LIGATION 1998;66:853 9 residual shunts, and no evidence of left pulmonary artery stenosis. Thirty-six had complete closure with one clip, and 2 patients required a second clip for small posterior residual shunt. Both incomplete ligations were suspected surgically at the time of clipping and were confirmed immediately with TEE. There were no residual or recurrent murmurs appreciated at discharge or at 2- to 3-week postoperative follow-up. All 38 patients were awakened and extubated in the operating room, and were taken briefly to the recovery room. Thirty-seven of 38 were taken to the Day Hospital, a 24-hour observation bed, and 1 was admitted after conversion to thoracotomy. The initial 12 patients were kept overnight as a routine, and they were discharged from observation the next morning after a normal chest x-ray film. The subsequent 25 patients were evaluated the afternoon of the operation; the evaluation included chest radiography. One patient was admitted with subcutaneous emphysema (see subsequently). Eighteen were discharged on the day of the operation. Six were observed overnight, but not admitted to the hospital: one because he was a 2.3-kg, 2-month-old formerly premature infant, but he had an uncomplicated course and went home the next morning; a 14-month-old because of a history of severe asthma, but she also did well, requiring no special therapy other than her usual bronchodilators; and 4 children, ages 5, 12, 15, and 17 years, were kept to treat postoperative nausea or vomiting. Symptoms resolved in all 4 and they went home the next morning. There were two hospital admissions in the group of 38. The first was the 10-year-old boy previously discussed, whose procedure was converted to thoracotomy. He went from the recovery room to the pediatric floor and was discharged on the second postoperative morning. The second admission was a 50-year-old woman who had previously been in a motor vehicle accident and suffered a thoracic spine burst fracture, requiring a left thoracoabdominal approach for fixation. An aortogram was obtained at the time to rule out aortic transection, and a small PDA was discovered. After she spent several years recovering from her back operation, the PDA was reinvestigated and she was referred for VATS closure. A double-lumen endotracheal tube was used because of her size and because of the history of thoracic operation and the likelihood of adhesions and the possibility of needing more extensive dissection. She had moderate adhesions taken down with the electrocautery, and then had an uneventful interruption of a small ductus arteriosus. She was awakened and extubated and taken to the recovery room and then to the Day Hospital observation bed. Progressive subcutaneous emphysema soon developed, but she had no pneumothorax on chest x-ray film. A chest tube was placed, but there was no air leak, and the subcutaneous air gradually worsened through the night. She was admitted to the hospital and underwent flexible bronchoscopy under topical anesthesia and intravenous sedation. This demonstrated a small mucosal disruption on the medial wall of the left mainstem bronchus just beyond the carina. It was thought to be secondary to the double-lumen tube placement, but did not appear to be large or full thickness. The remainder of the tracheobronchial tree was inspected and no other injury identified. She remained stable and afebrile and the injury was managed expectantly. The mediastinal air eventually ruptured into the left pleural space where the chest tube was present and the subcutaneous emphysema resolved rapidly. The chest tube was later removed and the patient was discharged on the seventh postoperative day. There were two recurrent nerve injuries (3.4%), suspected because of hoarseness and documented with flexible laryngoscopy. The first, in a 3-year-old child, completely resolved by 9 months. The second, in a 12-year-old girl with Ehlers-Danlos syndrome, is currently 12 months after the operation without recovery of cord function. There were no phrenic nerve injuries. There were no chylothoraces, significant pneumothoraces, or chest tubes required other than in the child whose procedure was converted to thoracotomy, and the woman with the left mainstem injury as just described. A few patients had minimal subcutaneous emphysema that required no treatment. There were no wound infections. There was no significant postoperative bleeding, and no patient required transfusion. Comment Video-assisted thoracic surgery in adults has been documented to offer many advantages over open thoracotomy, including decreases in pain, improved shoulder strength, and improved early pulmonary function [1]. Video-assisted thoracic surgical techniques offer other advantages to pediatric patients, including decreased incidence of scoliosis after thoracotomy, reported at 22% to 33%, with one report of 7.8% severe scoliosis [9 11]. Other reported late complications include winged scapulas, chest wall deformities, breast disfigurement, and rib fusion with respiratory compromise in patients who underwent thoracotomy as infants for repair of tracheoesophageal fistula [11]. Many surgeons are now performing open ligation or division of the ductus arteriosus through limited and often muscle-sparing incisions, which will clearly be associated with less chest wall deformity than the standard muscle-splitting thoracotomy. However, the minithoracotomy incision still requires division of the intercostal muscles, spreading of the ribs, and possible stretching of the paraspinus muscles. Long-term follow-up of the minithoracotomy and VATS procedures will be needed to compare results of scoliosis, scar, and chest wall deformity. Video-assisted thoracic surgery techniques have been applied to several conditions in children with congenital heart disease, predominantly the interruption of a PDA [3]. Despite the reports from one center in the United States [3, 4], as well as centers in France [5, 6] and Taiwan [7], describing successful VATS PDA ligation with low morbidity and no operative mortality, many surgeons remain hesitant to use the technique. Most criticisms of the technique consist of a concern about sudden exsanguinating hem-

5 Ann Thorac Surg HINES ET AL 1998;66:853 9 THORACOSCOPIC PATENT DUCTUS LIGATION 857 orrhage from a ruptured ductus arteriosus and the lack of immediate control available with an open technique. We achieved successful VATS closure in 55 of 59 patients attempted (93%). We maintained a liberal indication for attempting the VATS approach as we were always prepared to proceed with a thoracotomy. Several patients with a history of surgery, large ductus arteriosus, or very small size would otherwise not have benefited from the minimally invasive technique. We consider the 4 patients who had elective conversion to an open procedure technical failures, but not complications. They suffered no additional morbidity from the aborted VATS attempt, and then received the gold standard open procedure. The true complications consisted of 2 recurrent nerve injuries, one of which has resolved, and 1 patient with a left mainstem bronchus injury caused by traumatic intubation with a double-lumen tube. These data from our series, along with the previously published data, support the fact that with careful technique characteristic of pediatric cardiac surgery, VATS approach can be done very safely, with low morbidity, and in essentially patients of all sizes. Our experience also shows that, in most nonneonate patients, it can be safely accomplished as an outpatient procedure. Since the first description of transcatheter closure of a PDA by Rashkind and Cuaso in 1977 [12], many devices and techniques have been used in attempt to avoid surgical intervention in these patients. Even with the advancement of technology and available devices, complete obliteration of the shunt is still not immediately achieved in all patients. Residual shunts are reported in 17% to 38% of patients at 1 year [13 15], with 8% still remaining at 4 years [14]. The most recently published series using Gianturco coils had initial successful closure in 19 of 22 patients (91%); however 5 of 19 (26%) were reopened in the first year, for a total failure rate of 8 of 22, or 36% [16]. Other complications have been reported, including femoral artery injuries and arteriovenous fistulas, the need for transfusion, mild left pulmonary artery stenosis from protrusion of multiple coils, hemolysis, and coil embolization requiring surgical retrieval including one lodged in the tricuspid valve [13 15]. Two deaths were also associated with the procedure [13]. In addition the technique is often limited by size, both by femoral arteries too small for the delivery systems, and by ductus arteriosus too large to coil. Perhaps most importantly, transcatheter occlusion involves intravascular occlusion with a foreign body to treat a lesion that is frequently being closed primarily to prevent endocarditis, whereas surgical approaches provide extraluminal interruption. Because many centers also perform this procedure under general anesthesia, coil occlusion may not be able to compete with an outpatient VATS approach, which achieves 100% immediate shunt obliteration, a very low complication rate, and reports of very low rates of late residual flow. The use of intravascular coils may become limited to patients who are otherwise poor surgical candidates. With refinement of the technique in nonneonates and with more experience and confidence, we now have eliminated unnecessary blood work, removed any intensive care unit stay, established early extubation, eliminated the use of chest tubes, and reduced the length of stay to an outpatient procedure for most patients. All these are advances over the original reports, although the force behind the progress was the success of the early series. The only unanswered question at this point is regarding the incidence of recurrent shunt with clip interruption as was seen with early simple silk ligation. Although we have had no recurrence of murmurs clinically, we are currently investigating this issue with extended (beyond 12 months) echocardiographic follow-up. The transition into VATS techniques for experienced pediatric cardiac surgeons may require some experience in the animal laboratory to become familiar and facile with the instrumentation. For more recently trained surgeons with laparoscopic training during residency, the transition is very natural. It can quickly become integrated into pediatric cardiac surgical training programs as well. Video-assisted thoracoscopic ligation has become our primary approach for all PDAs. Continued and increased use of the technique will allow the collection of more information and improvements in instrumentation and techniques, and likely lead to increased investigations into other potential applications of minimally invasive surgery in congenital heart disease. References 1. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56: Mack MJ, Scruggs GR, Kelly KM, Shennib H, Landreneau RJ. Video-assisted thoracic surgery: has technology found its place? Ann Thorac Surg 1997;64: Burke RP, Wernovsky G, van der Velde M, Hansen D, Castañeda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109: Burke RP, van der Velde M, Hansen D, Jonas RA. Patent ductus arteriosus: interruption by video-assisted thoracoscopic surgery (VATS) in 100 consecutive patients [Abstract]. Circulation 1995;92;8(Suppl 1): Laborde F, Noirhomme P, Karam J, et al. A new videoassisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105: Laborde F, Folliguet T, Batisse A, et al. Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg 1995;110: Chu JJ, Chang CH, Lin PJ, et al. Video-assisted thoracoscopic operation for interruption of patent ductus arteriosus in adults. Ann Thorac Surg 1997;63: Keys A, Shapiro MJ. Patency of the ductus arteriosus in adults. Am Heart J 1943;25: Van Biezen FC, Bakx PAGM, De Villeneuve VH, Hop WCJ. Scoliosis in children after thoracotomy for aortic coarctation. J Bone Joint Surg 1993;75-A;4: Westfelt JN, Nordwall A. Thoracotomy and scoliosis. Spine 1991;16:

6 858 HINES ET AL Ann Thorac Surg THORACOSCOPIC PATENT DUCTUS LIGATION 1998;66: Jaureguizar E, Vazquez J, Murcia J, Diez Pardo JA. Morbid musculoskeletal sequelae of thoracotomy for tracheoesophageal fistula. J Pediatr Surg 1985;20: Rashkind WJ, Cuaso CC. Transcatheter closure of patent ductus arteriosus. Successful use in a 3.5 kilogram infant. Pediatr Cardiol 1979;1: Tynan M. Transcatheter occlusion of persistent arterial duct. Report of the European Registry. Lancet 1992;340: Hosking MCK, Benson LN, Musewe N, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus. Forty-month follow-up and prevalence of residual shunting. Circulation 1991;84: Hijazi ZM, Geggel RL. Results of anterograde transcatheter closure of patent ductus arteriosus using single or multiple Gianturco coils. Am J Cardiol 1994;74: Daniels CJ, Cassidy SC, Teske DW, Wheller JJ, Allen HD. Reopening after successful coil occlusion for patent ductus arteriosus. J Am Coll Cardiol 1998;31: DISCUSSION DR ROSS M. UNGERLEIDER (Durham, NC): I really enjoyed listening to this, because there has been a real transformation in the adaptability of surgeons to endoscopic techniques. And those of you who trained in using endoscopes have found that these are very safe and very effective. I think you presented your material in a very thoughtful way, with very appropriate comments, and I think you are to be congratulated on a truly outstanding clinical series. I think it is very timely, because we see this happening in a lot of different avenues of surgery. Those of us who did not train endoscopically have to be very careful when we evaluate these kinds of results, so as not to stand in the way of real progress. Let me share with you a moment of analysis (and I do appreciate the opportunity to look at the paper in advance), and then ask you three questions to expound on your experience. As I look at the title of your paper, you are proffering this as a technique that is safe and outpatient. If I look at the groups of patients who present to us for PDA ligation, there really are four groups. There are premature infants, of which you had 18, and 17 successful closures. But they are not going to be outpatients and they are still going to be hospitalized for other reasons. In fact, I would wonder if the advantages, if there are some, of closing the ductus with this technique, which requires taking the infant out of the intensive care unit and to the operating room, are outweighed by the advantages of doing ductal ligations in the intensive care unit for this population of patients who are going to stay in the intensive care unit anyhow. The second group of patients who come to ductal ligation are neonates. It is very uncommon to see a ductus arteriosus be clinically significant in a neonate. And in fact, you had 3, and in only 1 of those patients was the ductus arteriosus able to be closed using video-assisted techniques, and that is because oftentimes when we see a very symptomatic ductus in a neonate it has some unusual components to the anatomy, such as a possible coarctation or a very small aorta, which might make ligation hazardous or difficult with any techniques. Then you have infants. And in your 21 infants I think this is a very attractive technique. Finally, there are children and adults. You reported 17 of these and you had 16 successes, again attractive, but there are other options. As I think about all of this, and the kinds of patients that we see for ductus ligation, I would ask you these 3 questions. Number one, who really should be the group of patients that this technique should be offered to? Should it really be, as you say on your last slide, all patients with patent ductus arteriosus? Or, perhaps, is there a group, and you could expound on this, that would be best served and might be able to benefit the most from this technique without it having to be offered to all? And in light of that, number two, what are the contraindications? Maybe I have mentioned a couple, but perhaps there are others that in your experience you would like to share with us that might lead one who is embarking on these techniques to be a little more circumspect and not use the thoracoscopic approach unwisely. And then finally, and I think this is going to be most important, what are the really objective benefits of this technique? It seems nice, it works, but do the kids, the older kids, for example, of which you had 16, do they really go back to school more quickly than patients who have had thoracotomies? Is there anything objective that can be measured? Perhaps through the process of doing this, you could show that this is more beneficial than thoracotomy, or is it just another technique that surgeons, who have been trained to do it, can use in their armamentarium? Those are my questions. I think it is a wonderful series, and you are to be congratulated on a fine presentation. DR HINES: Thank you, Dr Ungerleider. I think the fact that Dr Pennington let me pursue this tells you he is more laid back than many bosses, so I appreciate that. I think if I can get all the questions in order the premature infants, that is a group that I am not sure about. We are doing them, and it works. The benefit is really going to be downstream, long term, and I would like to come back to that. In the neonates, I do agree that a lot of them are not going to be able to be done, but I am not sure you lose anything by the attempt. That is why when Redmond started doing this, we did not consider having to convert to an open procedure a complication but rather a technical failure, because what you fall back to is the standard thoracotomy, and so you have not really lost anything. The 50-year-old woman we operated on had a previous operation and had Harrington rods placed through a thoracotomy, and I almost did not do her through the scope because I was worried about adhesions. She did not have any calcifications in her ductus on x-ray films, so I decided to take a peek. We did and we took the adhesions down easily, and we were able to complete it. And I think that approach is worthwhile in the neonates, even in the term infants, as you might be able to successfully close some of them. You certainly do not lose anything. When we convert to an open procedure, I basically connect the two posterior ports and do it through a minimal, muscle-sparing hole, basically through the auscultatory triangle. As to contraindications, I think I would be very worried about doing it through the scope if it was an older patient who had calcification in the ductus. I think if we had patients who were older, and who were at very high risk, it may be appropriate to put a coil in them, but you would have to look at it on a patient-to-patient basis. As far as documenting the benefit, it is amazing to me that these children, at 3 and 4 hours, are sitting up, running around, and playing in the hall. As a matter of fact, the reason I started sending them home was they were up on the floor and would not go to sleep; they had just gotten out of general anesthesia, they were keeping the nursing staff busy, keeping the parents up, and running up and down the hall all night. I had started keeping them overnight just because that is the way we had