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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 129-133

Management of patients with patent ductus arteriosus: Challenges and outcome in low-resource settings


1 Department of Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Date of Submission11-Jul-2020
Date of Decision01-Aug-2020
Date of Acceptance10-Dec-2020
Date of Web Publication29-Oct-2021

Correspondence Address:
Dr. Ismail Inuwa Mohammed
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Nigeria
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DOI: 10.4103/smj.smj_66_20

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  Abstract 


Background: Patent ductus arteriosus (PDA) is quite a common acyanotic congenital heart disease (CHD). Its ligation in Sub-Saharan Africa is challenging due to lack of adequate cardiothoracic surgeons. We, therefore, present our experience and our challenges in our center with limited resources. Objectives: To determine the challenges and outcome of surgical ligation of PDA in our center. Methods: This was a retrospective review of all PDA ligations done from January 2012 to December 2017. Data were extracted from the operation theater register and patients files. Information such as age, sex, symptoms at presentation, intraoperative findings, and outcome of surgery were analyzed. Discordances between echocardiography and intraoperative finding of PDA were noticed in only two cases, and these were excluded from the study because PDA was not seen intraoperatively and they were referred for further evaluation. Statistical Package for the Social Sciences version 16 was used for data entry and analysis. Results: Twenty-five patients had PDA ligation during the study period; the subjects comprised 17 females and 8 males with a male-to-female ratio of 1:2. Two adult cases were recorded. Three cases had other associated CHD. All surgeries were carried out successfully and only a single case of complication was reported (4%, chylothorax). Conclusion: PDA ligation is relatively safe if properly done with successful outcome.

Keywords: Complications, ductal ligation, left lateral thoracotomy, outcome, patent ductus arteriosus, Sub-Saharan Africa


How to cite this article:
Mohammed II, Ahmad JI, Nurein TO, Ishaq NA, Aliyu I. Management of patients with patent ductus arteriosus: Challenges and outcome in low-resource settings. Sahel Med J 2021;24:129-33

How to cite this URL:
Mohammed II, Ahmad JI, Nurein TO, Ishaq NA, Aliyu I. Management of patients with patent ductus arteriosus: Challenges and outcome in low-resource settings. Sahel Med J [serial online] 2021 [cited 2021 Dec 8];24:129-33. Available from: https://www.smjonline.org/text.asp?2021/24/3/129/329522




  Introduction Top


Patent ductus arteriosus (PDA) is persistence of the patency of the ductus arteriosus, which is a fetal structure connecting the left pulmonary artery and the proximal part of the descending aorta that persists beyond 3 weeks after delivery.[1] It is one of the most common causes of congenital heart disease (CHD). It accounts for 5%–10% of all cases of CHD, with an incidence of 8/1000 live birth in premature babies and 1/2000 live birth in term babies.[1],[2],[3],[4],[5]

Clinical presentation can range from asymptomatic to features of heart failure depending on the size of the PDA, and treatment also ranges from medical therapy in preterm babies with indomethacin to catheter-based minimally invasive procedure, which is now the gold standard in well-established centers. However, surgical PDA ligation is an option if other modalities of treatment fail. However, the story is different in most Sub-Saharan African countries with limited cardiothoracic facilities. In our center, surgical PDA ligation remains the main stay of treatment; therefore, we present our challenges and outcome over a 6-year period.


  Methods Top


This was a retrospective study spanning over 6 years from January 2012 to December 2017. Operating theater register and patients files were used and all PDA ligations carried out during the study period under review were retrieved; however, those with incomplete records were excluded. The data extracted included age, sex, presenting complains, echocardiographic findings [Figure 1], chest X-rays, indication for surgery, intraoperative findings, and outcome of the surgeries and were all analyzed. All patients less than the age of 15 years were referred by the pediatric cardiologist, while those above this age were referred by the adult cardiologist; this was based on the hospital policy of 14 years as the cutoff age for pediatric patients. Discordances between echocardiography and intraoperative finding of PDA were noticed in only two cases and these were excluded from the study because PDA was not seen intraoperatively and they were referred back to the pediatric cardiologist for further evaluation. This study also included the six cases previously reported.[6] All patients were placed on medical therapy before the surgery (frusemide and spironolactone) except in asymptomatic cases. Ethical approval for this study was obtained from the Research and Ethics Committee of Aminu Kano Teaching Hospital, Kano (NHREC/28/01/2020/AKTH/EC/2885).
Figure 1: Echocardiographic picture of a patent ductus arteriosus case showing continuous retrograde flow using Doppler color flow

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Surgical procedure

All had surgical intervention by open left posterior lateral thoracotomy and double ligation of the PDA using nonabsorbable suture with nylon 1 or 2/0 and silk suture 1. All the patients had chest tube inserted after the procedure for between 1 and 21 days. Surgeries were done under general anesthesia with endotracheal tube in situ. They were placed on right lateral decubitus position; the chest was opened through left posterior lateral thoracotomy skin incision via the 4th intercostal space. The left lung was retracted downward and anteriorly. The superior intercostal vein was ligated and divided. The parietal pleura was opened over the proximal descending aorta. PDA was identified using blunt dissection. Two sutures were applied under the PDA with nylon 1 and silk 1 [Figure 2]. Double ligation was done in all cases, and none were transected.
Figure 2: The intraoperative picture showing the patent ductus arteriosus isolated and double sutures encircling it

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Data analysis

The obtained data were analyzed using Statistical Package for the Social Sciences (SPSS Inc., Chicago, Illinois, United State of America) version 16. Qualitative variables were summarized as frequencies and percentages, whereas quantitative variable such as age was summarized as means and standard deviations. The Fisher's exact test of significance was used to compare qualitative variables, with P < 0.05 being set as statistically significant.


  Results Top


Age and sex characteristics of the cases

During the study period, 25 cases of PDA were ligated via thoracotomy and double sutural ligation. There were 8 (32%) males and 17 (68%) females, with a male-to-female ratio of 1:2.1. Twenty-three (92%) cases were children; two (8%) cases were adult PDA consisting of one female and one male and their ages were 22 and 28 years, respectively. Their weight ranged between 4.0 kg and 50 kg with a median of 12 kg. The subjects were aged between 2 and 336 months, with a median of 33 months. There were 15 (60%) premature births and 10 (40%) term births.

The interval between diagnosis and surgery ranged from 2 months to 168 months with a mean of 34 months. However, most diagnoses were done within the 1st year of life; furthermore, majority of the subjects had surgery between 13 and 60 months of life, but 48% of the subjects had surgery for the PDA within 12 months of establishing the diagnosis. The age at surgical intervention ranged from 4 months to 336 months with a mean of 64.3 ± 80.8 months; however, only 4% of them had surgery >120 months after establishing the diagnosis [Table 1].
Table 1: Age distribution of the subjects at diagnosis, at the time of surgery, and time interval between diagnosis and surgery

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Clinical presentations

Four (16%) cases were asymptomatic and were diagnosed during evaluation for other reasons including medical checkup. Four (16%) cases presented with congestive cardiac failure. Fifteen (60%) patients presented with easy fatigability and recurrent chest infections; two (8%) cases were erroneously treated for recurrent asthmatic attack before the diagnosis was in our hospital by auscultations and confirmation by echocardiography.

None of the cases had maternal history of illness during pregnancy and no evidence of pulmonary hypertension was documented by echocardiography in any of the cases.

Surgical findings and outcome

Two (8%) cases had PDA with atrial septal defect (ASD) and 1 (4%) case had PDA with ASD and ventricular septal defect (VSD); 22 (88%) cases were isolated PDA. The measured diameter of the PDA ranged from 0.5 to 1.6 cm, with a mean of 1.0 ± 0.3 cm. Seventeen (68%) of the PDAs were between 0.5 and 1.0 cm in diameter, whereas 8 (32%) of them were >1.0 cm in diameter.

One (4%) case had pericardial adhesion and ligation was done transpericardium. Four (16%) cases had residual PDA after double ligation, which was discovered during follow-up at the 3rd and 6th months postoperatively and these were confirmed by echocardiography. One (4%) case developed chylothorax postoperatively due to extensive dissection and this was managed with chest tube drainage only. For the patient that had transpericardial approach, the postoperative chest X-ray showed widening of the mediastinum, whereas others had normal X-rays (96%). However, no mortality was recorded in this study.

Most subjects that had residual PDA shunts were between the 0.5 and 1.0 cm group; however, this observation was not statistically significant [Table 2].
Table 2: Comparing the size of the patent ductus arteriosus and occurrence of residual shunt

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The duration of hospital stay ranged from 6 days to 16 days with a mean of 8 ± 2.1 days. Majority of the subjects (52%) were discharged within 1 week after surgery [Table 3].
Table 3: Duration of hospital stay

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  Discussion Top


Despite the advances in the diagnosis of CHD with echocardiography, some cases are still missed in early childhood; this explains the two cases that were diagnosed at adulthood in our study. This may be due to lack of echo machines in most health-care facilities in rural areas where they came from. Furthermore, not much has been achieved in the area of surgical intervention; surgical management of heart diseases including PDA ligation in Sub-Saharan Africa is challenging due to dearth of cardiothoracic surgeons, absence of cardiopulmonary bypass (CPB) machines in most health facilities, and catheter-based device closure.[7],[8] These factors have fueled health tourism often witnessed in many developing countries;[9] however, a great number of these patients also die at home when waiting to access funds for surgery.[10],[11]

Although the incidence of PDA in Sub-Saharan Africa is not completely known, previous studies in our center reported PDA as accounting for 10.9% of all cases of CHD.[12],[13],[14] Similarly, as previously reported, PDA ligation accounted for 6.7% of major cardiothoracic surgeries done in our unit.[6] The male:female ratio in this study was 1:2, reflecting females preponderance; this observation was similarly reported by Costa et al.[15] and Onakpoye et al.[16] Closure of PDAs which are not part of duct-dependent lesion is recommended latest at the 3rd month of life.[16],[17],[18] Otherwise, this may predispose to recurrent chest infection, heart failure, and failure to thrive, which were observed in our cases, though majority of our cases (64%) were diagnosed within the 1st year of life; most of our cases (52%) had surgery after between 1 and 5 years. Lack of funds and late establishment of the cardiothoracic unit might have accounted for these delays; furthermore, cases with other associated congenital defects such as ASD and VSD had only the PDA repaired because of lack of facilities for open heart surgery such as the CPB machine or device closure in our center. Closure of the PDA significantly reduced their morbidity despite the other unattended cardiac defects. These observations were also reported by Onakpoye et al.[16] Only 3 (12%) patients had an early ligation of their PDA at 2, 11, and 12 months, respectively, due to congestive cardiac failure and failure to thrive; this was attributable to the large size of the PDA, which measured 1.6, 1.5, and 1.3 cm, respectively, resulting in failed medical therapy. This is a common observation in most children with acyanotic CHD with large left-to-right shunt lesion.[14]

Surgical correction of PDA by lateral thoracotomy was introduced in 1938 by Gross as documented by Actis Dato;[18] however, catheter-based closure remains the method of choice for treating PDA; this is associated with minimal morbidity, shorter hospital stay, and almost 95%–100% complete closure rate.[15] However, in resource-constrained settings such as in most Sub-Saharan African countries, open surgery with PDA ligation remains the main stay of surgery. The lateral thoracotomy approach may involve single ligation, double ligation (which we practice), or triple ligation as reported by Onakpoye et al.[16] and also ligation with PDA duct resection.[15] These approaches have been associated with varied reported successes.

Minimally invasive catheter-based procedures and thoracoscopic method to close or ligate the PDA using clips are not available in our center; therefore, we offered open surgical treatment via left posterior lateral thoracotomy with double ligation of the PDA without resecting the PDA duct; this approach minimizes the risk of bleeding, which is commoner if the duct is divided after ligation. Minimal complications were recorded in our study; only a single case (4%) of postoperative chylothorax was reported; this was lower than the 8% reported by Costa et al.[15] and 12% reported by Onakpoye et al.[16] The two adults though had no diagnostic pulmonary vascular catherization for pulmonary pressure, but echocardiography did not report any evidence of pulmonary hypertension. The postoperative courses of our patients were smooth except for the case of chylothorax who spent longer hospital stay (3 weeks). Sixteen percent of our patients had residual PDA flow at discharge, and at 3rd and 6th months of follow-up visit, this is a recognized fallout of PDA ligation (unlike in cases of PDA ligation and transaction). This was comparable to the 13% reported by Costa et al.[16] Similarly, majority of our patients were discharged within 1 week after surgery; this was also reported by Onakpoye et al.[15] PDA ligation is a safe procedure which does not require CPB machine, though complication have been observed in 2% of cases, which have been reported by some authors;[15],[19],[20],[21] no death was recorded in our study. This may be attributed to our less aggressive dissections, nonresection of the ligated ductus, which is often practiced in our centers.

Limitations of the study

The small sample size in this study was a limitation; however, our sample size was comparable to that of the surgical group in da Costa et al.'s study[15] and even larger than that of Onakpoye et al.[16] Furthermore, investigative cardiac catherization was not done (due to lack of facility), especially in the two adults to exclude pulmonary hypertension; however, moderate precision has been established between cardiac catherization and echocardiography findings in diagnosing pulmonary hypertension.[21] Therefore, its absence in their echocardiography may not completely exclude its existence; however, the patients made remarkable improvement postoperation and have remained stable afterward.


  Conclusion Top


The surgical outcome in our patients was remarkable; despite the good result in our study, there is a need for improvement in our early diagnosis of PDA and treatment. The use of minimally invasive procedures needs to be introduced to reduce postoperative morbidity and hospital stay. Management of lately diagnosed PDA is still a challenge in this subregion because of the need to effectively measure pulmonary pressure using cardiac catherization.

What is known about this topic:

  • In the surgical management of PDA, catheter-based intervention is the procedure of choice; however, in failed procedure or where facility such as catheterization laboratory is not available, open surgery is favored
  • Open surgery may involve resection and ligation of the PDA duct as practiced in other centers; however, there is a significant risk of bleeding, infection, and chylothorax.


What this study adds:

  • Double sutural ligation without PDA duct resection also has successful outcome, with minimal complications.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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  [Table 1], [Table 2], [Table 3]



 

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