Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases.
OBJECTIVE
To overcome drawbacks of thoracotomy and percutaneous techniques, we have performed video-assisted thoracoscopic surgery (VATS) since 1991 to treat patent ductus arteriosus (PDA). This retrospective study aims to analyse morbidity and outcome in order to add data in the evaluation of minimally invasive operations.


METHODS
From September 1991 to March 2003, 703 patients underwent PDA clipping by VATS. The indications for operation were clinically significant patency or failure to close in older children. Diameter >8 mm, previous thoracotomy, calcifications, infection, or aneurysm were contraindications to VATS. In right decubitus, only two thoracostomy incisions (for 5-mm trocars) and a smaller one (for direct hook insertion) were required. In the post-operative stay two echocardiographic controls were scheduled, the first before extubation and the second before discharge. Referring cardiologists assured follow-up.


RESULTS
Mean age was 3.0+/-3.8 years (5 days-33 years), mean weight 10.7+/-8.0 kg (1.2-65 kg), and 3.1% of our activity were low birth-weight infants (LBWIs) weighting < or =2.5 kg. Operative and 30-day mortality was nil. Median operative time was 20 min and median stay 2 days. Unfavourable events globally occurred in 6.8% of cases (13.6% of the LBWIs, RR 4.0, CL 95% 1.5-10.4). Recurrent laryngeal nerve injury was noted in 3% (13.6% of the LBWI, RR 5.1, CL 95% 1.6-15), but only 0.4% had long lasting dysfunction. Incidence of chylothorax was 0.6%, thoracotomy 1%, transfusion for bleeding 0.1%, pneumothorax 1.3%. LBWIs were at increased risk for the latter two events. Residual patency was detected immediately in 1.4% (all non-LBWI) and underwent additional surgery. Incidence of residual patency at follow-up was 0.6% (0% LBWI, 0.6% in 2.5-25 kg group, 5.0% in >25 kg group, P=0.001).


CONCLUSIONS
This study records a long experience of PDA treatment in a wide range of body size and age. VATS clipping is safe, but LBWIs are at augmented risk of complication. It may be carried out with a high degree of efficacy in all the ductus diameters <9 mm. VATS clipping requires minimal operating time and avoids morbidity related to chest wall trauma, percutaneous vascular access, and intravascular foreign bodies.
Villa
Emmanuel
E
Département de Pathologie Cardiaque, L'Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France.
Vanden Eynden
Frédéric
F
Le Bret
Emmanuel
E
Folliguet
Thierry
T
Laborde
François
F
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D004374:Ductus Arteriosus, Patent / Q000601:surgery*; D015150:Echocardiography, Doppler; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D016896:Treatment Outcome