Interactive Cardiovascular and Thoracic Surgery 2:398-399(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Patent ductus arteriosus and left coronary ostium stenosis: an hybrid approach
Salvatore Agatia,
Carmelo Mignosaa,*,
Innocenzo Biancab and
Dario Salvoc
a Cardiac Surgery Unit, ‘San Vincenzo’ Hospital, Contrada Sirina, 98039 ME Taormina, Italy
b Pediatric Cardiology Unit, ‘San Vincenzo’ Hospital, Contrada Sirina, 98039 ME Taormina, Italy
c Pediatric Cardiac Anesthesiology Service, ‘San Vincenzo’ Hospital, Contrada Sirina, 98039 ME Taormina, Italy
* Corresponding author. Tel./fax: +39-0942-579249
carmignosa{at}tiscali.it
Received April 1, 2003;
received in revised form May 26, 2003;
accepted May 26, 2003
 |
Abstract
|
|---|
Nowadays combination of surgical procedures and interventional cardiology has been increasingly reported in literature for the treatment of coronary artery diseases. To confirm the applicability of such an approach we present a case where several approaches could be considered. A 56-year-old lady with incidental finding of patent ductus arteriosus (PDA) and concomitant left main coronary artery ostium stenosis was scheduled to have PDA trancatheter closure and surgical angioplasty of the coronary ostium. This ‘hybrid’ approach to such an unusual clinical presentation was successful and at 1 year follow-up the patient is symptoms free and no residual shunts have been detected.
Key Words: Ductus arteriosus; Coronary ostium stenosis
|
1. Introduction
|
|---|
Grown-up congenital heart is a field in constant evolution, with a quest for optimal management of adult patients with congenital cardiac disease. Patent ductus arteriosus (PDA) is a clear example of a congenital cardiac lesion compatible with survival to adult age. Authors report a case of a 56-year-old lady with incidental finding of PDA associated with left main coronary artery ostium stenosis. The management of this rare combination offers several options: either by interventional cardiology or surgical due to its anatomic features, the authors adopted an ‘hybrid’ combined approach: PDA percutaneous closure and surgical angioplasty of the coronary artery ostium.
|
2. Methods
|
|---|
A 56-year-old hyperlipidemic lady with an history of hypertension was referred to our Cardiology Department for evaluation because of recent fatigue occurrence and dyspnea on mild exercise. Clinical evaluation demonstrated the presence of continuous murmur (3–4/6 Levine, centrum cordis). Echo confirmed the clinical suspicion of PDA with significant left to right shunt. Extreme diffuse calcification of the PDA was detected in chest X-ray. The patient underwent cardiac catheterization for percutaneous closure. Angiography showed a ‘tubular type’ PDA—type C according to the Krichenko's classification [1]—and concomitant presence of a severe isolated left main coronary artery ostium stenosis.
|
3. Results
|
|---|
We proceeded with a successful PDA percutaneous closure utilizing an Amplatzer Ductal Occluder (AGA, Medical Corporation, Golden Valley, MN). Forty-eight hours later she underwent surgery for ostium stenosis. Normothermic cardiopulmonary bypass was established with double venous cannulation. Myocardial protection was achieved by anterograde hyperkaliemic blood cardioplegia. When cardiac arrest was obtained the ascending aorta was opened transversely. The incision was prolonged towards the left coronary ostium, which had pinhole appearance. The ostium was opened together with the whole main stem. The incision stopped at the origin of the left anterior descending. An ‘onlay’ autologous saphenous vein patch was utilized for extensive angioplasty. It was implanted with running 7/0 Prolene suture (Ethicon, Somerville, NJ). The procedure was then completed in the usual fashion. The patient had an uneventful recovery and on the fifth post-operative day was discharged home. At 1 year follow-up she remains symptom free, with absence of ischemic electrocardiogram changes. Echo showed neither residual shunt nor leakage at ductal level and normal myocardial function.
|
4. Discussion
|
|---|
PDA is the second most common congenital cardiac disease with incidence of one on 2000 live births in term infants. Its occurrence in adult age is rare. In a recent report by Ananthasubramanian and Karthik [2] on 30 190 bidimensional echoes performed over a population more than 50 years of age they detected, incidentally, a PDA in only 15 cases (0.04%). Since the first description of successful PDA surgical ligation by Gross and Hubard [9] its treatment has progressively moved towards transcatheter closure. Although at the present time percutaneous closure is the technique of choice for its treatment, surgery is still indicated for low-weight preterm babies, when an associated cardiac lesion is present, or when percutaneous technique fails. Isolated coronary ostium stenosis is another rare condition. Topaz and coworkers [3] reported an incidence of 0.07% (16 patients) among 21 545 coronary angiographies. Twelve out of 16 patients had an isolated ostium stenosis of the left main. It occurred more frequently in women as reported by Thompson [4]; and atherosclerosis is the most frequent etiology. Surgical treatment is the indication of choice. Two options are currently proposed: CABG or direct surgical approach (angioplasty). The latter is preferred when the ostial lesion is isolated. This surgical technique firstly proposed by Effler and coworkers [5] was abandoned due to post-operative high mortality rate. Hitchcock and coworkers [6] reported a series of nine consecutive patients with neither hospital mortality nor perioperative myocardial infarction utilizing a trans-aortic posterior approach. Dion and colleagues [7,8] in two different works confirmed the feasibility and reproducibility of the ostial angioplasty with low hospital mortality rate. They emphasized the rationale of such an approach based on the prizometer principle and proposed as technique of choice the anterior trans-aortic approach. Association of PDA with isolated left coronary artery ostial stenosis has never been reported in the literature. This prompted us to establish a decision-making pathway personalized to this particular case. In our unit PDAs are electively closed percutaneously. When an associated cardiac lesion is present patients undergo surgery for complete repair. Diffuse PDA calcification is a specific indication for its percutaneous closure considering that in the presence of these conditions surgical closure carries an incremental risk. Having this in mind, in accord with our cardiologist, we decided to propose the patient for a combined hybrid approach: percutaneous closure and subsequent direct surgical ostial angioplasty. According to our previous experience we believe that surgical ostial angioplasty with an anterior trans-aortic approach in presence of isolated left coronary artery ostium stenosis is the treatment of choice even when another cardiac lesion is associated. Infact we performed this technique in two other patients with isolated ostial lesion: a 56-year-old male symptomatic for angina and a 57-year-old male with associated aortic valve stenosis. In the latter case the ostial lesion was an incidental finding. He received a concomitant mechanical aortic valve replacement. In neither case was there hospital mortality nor perioperative myocardial infarction. At 3 years follow-up both patients are event-free for angina and recovered to a normal active life.
The case we report demonstrates that nowadays in clinical practice we may face rare cases characterized by combination of different cardiac lesions for whom treatment is not standardized. The opportunity to propose an hybrid approach tailored to the specific case enables to minimize risks and optimize results.
|
Acknowledgements
|
|---|
We would like to express our gratitude to Prof. Giacomo Pongiglione—‘Giovannina Gaslini’ Institute, Genova, Italy—for his assistance, cooperation and support.
doi:10.1016/S1569-9293(03)00114-2
|
References
|
|---|
- Krichenko A, Benson LN, Burrows P, Möes CAF, McLaughlin P, Freedom RM. Angiographic classification of isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol. 1989;63:877–880[CrossRef][Medline]
- Ananthasubramaniam K, Karthik MD. Patent ductus arteriosus in elderly patients: clinical and echocardiographic features—a case-based review. J Am Soc Echocardiogr. 2001;14(4):321–324 [Report][CrossRef][Medline]
- Topaz O, Warner M, Lanter P, Soffer A. Isolated significant left main coronary artery stenosis: angiographic, hemodynamic, and clinical findings in 16 patients. Am Heart J. 1991;122:1308–1314[CrossRef][Medline]
- Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol. 1986;7:997–1003[Abstract]
- Effler DB, Sones FM, Favaloro R, Groves LK. Coronary endarterectomy with patch graft reconstruction: clinical experience with 34 cases. Ann Surg. 1965;162:590–601[Medline]
- Hitchcock JF, Robles de Medina EO, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease. J Thorac Cardiovasc Surg. 1983;85:880–884[Abstract]
- Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg. 1990;99:241–250[Abstract]
- Dion R, Elias B, El Khoury, Noirhomme P, Verhlest R, Hanet C. Surgical angioplasty of the left main coronary artery. Eur J Cardiothorac Surg. 1997;11:857–864[Abstract]
- Gross RE, Hubbard JP. Surgical ligation of patent ductus arteriosus. Report of first successful case. J Am Med Assoc. 1939;112:729[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction