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CASE REPORT
Ahead of print publication  

Patent ductus arteriosus in a Nigerian adult: A case report and overview of treatment modalities


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

Date of Submission11-Jun-2020
Date of Decision25-Aug-2020
Date of Acceptance21-Sep-2020

Correspondence Address:
Ismail Mohammed Inuwa,
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_332_20

  Abstract 


A 22-year-old university student presented to our hospital with a 7-year history of recurrent palpitation and easy fatigability, with occasional dry cough and no history of fever or weight loss. Examination revealed the presence of machinery murmur, and echocardiography revealed isolated patent ductus arteriosus (PDA). She had left thoracotomy and double ligation of the uncalcified PDA. Chest drain was inserted and she did well postoperatively, and she was discharged home on the 5th postoperative day. Postoperative echocardiography revealed no residual PDA.

Keywords: Adult, clinical manifestations, patent ductus arteriosus, surgical ligation



How to cite this URL:
Inuwa IM, Ahmad JI, Nurein TO, Ishaq NA, Miko Abdullahi MM, Aliyu I. Patent ductus arteriosus in a Nigerian adult: A case report and overview of treatment modalities. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=319175




  Introduction Top


Patent ductus arteriosus (PDA) in adults (ductus botalli)[1] is not a common encounter even in under-developed countries where cardiac surgeries are not routine. Its diagnosis is often missed due to insufficient pediatric cardiologist and limited facilities for echocardiography. Management of adult PDA is challenging due to its tendency to calcify and the associated risk of pulmonary hypertension. In such circumstances, it will require the use of cardiopulmonary bypass (CPB) machine to ensure safe surgery. CPB machine is not readily available in limited resource centers like ours. Therefore, the management of such cases could be a daunting task. We therefore present a case of adult PDA managed in our center without a CPB machine or a minimal access procedure such as catheter-based devices closure procedures.


  Case Report Top


A 22-year-old female university student presented to our surgical outpatient department (SOPD) with a 7-year history of recurrent palpitation and easy fatigability with occasional dry cough. There was no associated fever, weight loss, or body swelling. She had a history of recurrent chest infection during early childhood, for which she was treated as pneumonia in peripheral hospitals until 7 years ago when this current symptom reappeared and she was ask to do echocardiography. There was no family history of similar illness; the pregnancy and labor were uneventful. Cardiovascular examination revealed cardiomegaly with apex displaced to the sixth left intercostal space (ICS) lateral to the midclavicular line; she had 1st, 2nd, and 3rd heart sounds with a loud pulmonary component of the second heart sound; there was a continuous murmur at the second left ICS radiating posteriorly. The electrocardiogram showed sinus tachycardia, left atrial enlargement, and left ventricular hypertrophy. Echocardiography revealed PDA of 13 mm and left ventricular hypertrophy with preserved systolic function, and there was no evidence of pulmonary hypertension. She was counseled and prepared PDA ligation. She had PDA double ligation with nonabsorbable suture prolene 2/0 [Figure 1] under general anesthesia with endotracheal tube in situ. The patient was in the right lateral decubitus position, and the chest was approached via posterolateral thoracotomy through the fourth ICS. Chest tube drain size of 32G was inserted after the procedure and the patient did well after the procedure; however, the chest tube was removed on the 3rd postoperative day. Postoperative echocardiography revealed no residual PDA. The patient was discharged home on the 5th postoperative day in a good state, to be seen in SOPD a week later for removal of stiches.
Figure 1: A ligated patent ductus arteriosus

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  Discussion Top


PDA is one of the acyanotic congenital heart diseases; it occurs as a result of persistent of the communication between the left pulmonary artery and the proximal part of the descending aorta after birth which should have closed within 3 weeks of life.[2] It is more common in premature infants; the male-to-female ratio is 1:2.[3] PDA is the fifth most common congenital cardiac defect seen,[4] and it is often associated with other congenital defects such as ventricular septal defect (VSD), atrial septal defect (ASD), tetralogy of Fallot, and transposition of great arteries (TGA). Sometimes, its presence may be necessary for the survival of a child with complex congenital cardiac disease such as TGA in the absence of ASD or VSD – this is a shunt-dependent lesion. PDA represents 5%–10% of congenital heart diseases, with an incidence of 8:1000 live births.[5] It has variable presentation ranging from an asymptomatic state to gross congestive cardiac failure; this depends on the size of the PDA, the flow rate, and the presence of other associated anomalies.[6] The natural history of PDA is spontaneous closure, progression with development of bacterial endocarditis, congestive cardiac failure, and development of pulmonary vascular obstructive disease at a later stage.[7] Morbidity and mortality rates are directly proportional to the size of PDA.[7]

It is estimated that if left untreated by the age of 20 years, there is a 20% risk of mortality; by 40 years, this rises to 40% risk of mortality; and by 60 years, it further increases to 60% risk of mortality.[8] Large PDA if left untreated may lead to the development of pulmonary hypertension. Only about 0.6% undergoes spontaneous closure.[9] Occasionally, older children can present as late as was observed in this index patient who presented at the age of 15 years and diagnosis was established 7 years later. The definitive treatment of PDA is surgical closure, but initial medical treatment is effective, and sometimes, even spontaneous closure can be achieved.[9] Medical treatment with the use of indomethacin facilitates closure at 0.2 mg/kg start and 0.1 mg/kg 12 hourly for 2 days. Further, ibuprofen is found to be effective for ductal closure.[10] Antiheart failure regimen in cases of congestive heart failure using furosemide, spironolactone, and lisinopril may be useful. Prophylaxis against infective endocarditis using antibiotics is necessary.[11] It should be noted that if PDA exists with ductal-dependent lesion, maintaining its patency is essential; this is achieved using prostaglandin at 0.05–0.1 mcg/kg/min intravenously.[12]

After stabilizing the patient, the common indication for PDA ligation includes failure of indomethacin treatment, especially in premature infants after 3 weeks, persistent of PDA beyond 3 weeks of life, and contraindication to medical treatment, such as the presence of thrombocytopenia and renal insufficiency. However, if patient develops pulmonary hypertension, surgery is contraindicated. The gold standard in the treatment of PDA, especially adult PDA which is usually small or medium in size, is catheter-based procedure (transcatheter closure).[12] In small PDA, coil can be used, while in moderate-to-large PDA, Amplatzer device can be used. In our center, we do not have these devices. Other options are thoracoscopic ligation of the PDA using video-assisted thoracoscopic surgery (VATS), coil embolization during cardiac catheterization, and finally open thoracotomy and PDA ligation or division. In our center, we are yet to start ligation via VATS due to lack of equipment; therefore, in this index patient, the management approach was by the left posterolateral thoracotomy and PDA double ligation with nonabsorbable suture-prolene 2/0 and vicryl 2/0. In this case, the PDA was not calcified, probably, because the patient was less than the fourth decade of life; furthermore, there was no evidence of pulmonary hypertension. The best timing for surgery is between 1 and 2 years, or at any age at diagnosis, so long as there is no contraindication for surgery. In infant with congestive heart failure which fails to respond to medical treatment or recurrent pneumonia, surgery is needed.[12] Prognosis is excellent in uncomplicated cases of isolated PDA. Severity of symptoms and associated cardiac anomalies will worsen the outcome. Spontaneous closure of a PDA in term babies older than the age of 2 years is rare, but it occurs in75% of premature babies.[5]


  Conclusion Top


Management of adults with PDA in low resource center like ours is quite challenging; high index of suspicion and proper evaluation of patient including echocardiography will make the diagnosis easier; the gold standard of treatment is the catheter-based procedures; however, if not available, open surgery by thoracotomy and double ligation of the PDA are adequate and the outcome is excellent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW. Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease. Neth Heart J 2008;16:255-9.  Back to cited text no. 1
    
2.
van de Sandt FM, Boekholdt SM, Bouma BJ, Groenink M, Backx AP, Koolbergen DR, et al. Patent ductus arteriosus in adults-Indications and possibilities for closure. Neth Heart J 2011;19:297-300.  Back to cited text no. 2
    
3.
Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation 2006;114:1873-82.  Back to cited text no. 3
    
4.
Patent Ductus Arteriosus (PDA) in Adults; Symptoms and Treatment Cleveland Clinic. Available from: https://my.clevelandclinic.org/health/diseases/17325-patent-ductus-arteriosus-pda. [Last accessed on 2020 May 02].  Back to cited text no. 4
    
5.
Lloyd TR, Beekman RH 3rd. Clinically silent patent ductus arteriosus. Am Heart J 1994;127:1664-5.  Back to cited text no. 5
    
6.
Record FG, Mckcowu T. Observation relating to the etiology of patent ductus arteriosus. Br Heart J 1953;15:376-86.  Back to cited text no. 6
    
7.
Hoffman JI, Kaplan S. The incidence of congenial heart diseases. J AM Cardiol 2002;39:1890-900.  Back to cited text no. 7
    
8.
Thomas CC, Cassels DE. The Ductus Arteriosus. IL: Springfield; 1973. p. 75.  Back to cited text no. 8
    
9.
Bezabih A. Patent ductus arteriosus in adults-A 2 years experience in Tikur Anbassa Hospital, Addis Ababa University College of Health Sciences, School of Medicine. East Cent Afr J Surg 2016;21:17-21.  Back to cited text no. 9
    
10.
Eldeem SM, Ali SH, Abu S, Elaha R. Challenges of percutaneous closure of PDA in adolescents and adult; single center experience-cardiology and angiology: An Int J 2018;7:1-8.  Back to cited text no. 10
    
11.
Hammerman C. Patent ductus arteriosus. Clinical relevance of prostaglandins and prostaglandin inhibitors in PDA pathophysiology and treatment. Clin Perinatol 1995;22:457-79.  Back to cited text no. 11
    
12.
Bonhoeffer P, Borghi A, Onorato E, Carminati M. Transfemoral closure of patent ductus arteriosus in adult patients. Int J Cardiol 1993;39:181-6.  Back to cited text no. 12
    


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