E Elmistekawy, A Syed, H Fawzy, M Marzook, H Darwish
congenital heart disease, pda, premature
E Elmistekawy, A Syed, H Fawzy, M Marzook, H Darwish. Ductal Closure In An Extremely Low Birth Weight Premature Infant. The Internet Journal of Thoracic and Cardiovascular Surgery. 2005 Volume 8 Number 1.
Surgical closure of patent ductus arteriousus (PDA) is indicated in premature infants with very low birth weight specially who have a contraindication to or have been failed a trial of indomethacin therapy. We report surgical ligation of patent ductus arteriousus in an extremely very low birth weight infant (480 gm).In our opinion weight of the infant is not a contraindication for the safety of the procedure.
Premature and small for gestational age neonates are affected by congenital heart disease more than normal babies and are most likely to develop symptomatic patent ductus arteriousus (PDA) (1). In most of these infants indomethacin is usually effective in mediating ductus closure (2) .However in some cases in which indomethacin is not effective or contraindicated surgical PDA closure is warranted (3). Literature review revealed that this case is the smallest reported baby who underwent successful surgical closure of PDA.
A baby girl was born at 25 weeks gestational age to a 25 year's old (Gravida 3 Para 2) mother. Her birth weight was 480 gm .The baby was resuscitated and mechanically ventilated at birth. Echocardiograpic examination detected large PDA 3 mm in diameter with a significant left to right shunt associated with patent foramen ovale and small muscular VSD. She had interventricular hemorrhage grade II and developed pulmonary hemorrhage. As indomethacin was contraindicated and PDA was thought to the predominant cause of heart failure in her case. Surgical closure of PDA was decided after discussion the situation with the parents.
Surgical closure of PDA was performed on bedside in Neonatal Intensive Care Unit(NICU) in order to prevent hypothermia, interruption of care and to avoid accidental vascular access removal or extubation .Through small posterolateral thoracotomy , ductal closure was accomplished using a medium size vascular clip(LIGACLIP EXTRA .Ethicon Endovascular .INC. USA).The tiny infant tolerated the surgery well .Repeat echocardiography showed closed PDA with no shunt and good flow to descending aorta and left pulmonary artery .She was ventilated for 85 days postoperatively .She received total parentral nutrition initially , gradually shifting to entral feeding and finally oral feeding. She was discharged home thriving with body weight of 1870 gm. Two months after discharge she came to the follow up in good general condition with body weight of 3400 gm.
Despite indomethacin therapy, some premature infants require surgical closure of PDA. Indomethacin is not without complications especially in the very low birth weight (VLBW) infants .It can cause chronic lung disease, necrotizing entercolitis and intraventricular hemorrhage (4).
Surgical closure in very low birth weight infants is safe with almost no morbidly or mortality related to the surgical procedure (5).It is proposed that surgical therapy should be regarded as first line therapy for VLBW premature infants who are at higher risk of medical treatment failure(6) .
Surgical closure of PDA can be contemplated in infants with very low birth weight. In our opinion weight of the infant is not a contraindication for the safety of the procedure.
Elsayed M. Elmistekawy MD Cardiac Surgery Section, Cardiac Services Department North West Armed Forces Hospital, P O Box: 100, Tabuk, Saudi Arabia Tel: 0966- 44411088 – Ext: 85423 Fax: 0966-44411056 Email: firstname.lastname@example.org