by Robert E. Gross, M.D. and John P. Hubbard, M.D., Boston
JAMA 112(8):377-379, February 25, 1939.
The continued patency of a ductus arteriosus for more than the first few years of life has long been known to be a potential source of danger to a patient for two reasons: First, the additional work of the left ventricle in maintaining the peripheral blood pressure in the presence of a large arteriovenous communication may lead eventually to cardiac decompensation of severe degree. Second, the presence of a patent ductus arteriosus makes the possessor peculiarly subject to fatal bacterial endocarditis. While it is true that some persons have been known to live to old age with a patent ductus of Botalli, statistics have shown that the majority die relatively young because of complications arising from this congenital abnormality. Dr. Maude Abbot[1] presented a series of ninety-two cases which came to autopsy in which it was shown that the patient had a patent ductus arteriosus without any other cardiovascular abnormality. Of these patients, approximately one-fourth died of bacterial endarteritis of the pulmonary artery and an additional one half died of slow or rapid cardiac decompensation. The average age of death of patients in this series was 24 years.
The complications arising from the persistence of a patent ductus arteriosus would seem to make surgical ligation of this anomalous vessel a rational procedure, if such a procedure could be completed with promise of a low operative mortality. Dramatic results have previously been obtained in persons with cardiac enlargement and decompensation resulting from a peripheral arteriovenous aneurysm when the short-circuiting vessels have been ligated or excised[2]. On similar theoretical grounds, future cardiac embarrassment should be averted if a shunt between the aorta and the pulmonary artery could be removed. It would also seem plausible to expect that the shutting off of an anomalous stream of blood pouring into the pulmonary artery would lessen the formation of the thickened endothelial plaques within the pulmonary artery, which are so likely to be the seat of later bacterial infection. The surgical approach to the aortic artch and pulmonary conus having been studied previously in animal experimentation[3], it seemed within reason that a patent ductus could be adequately exposed in man and possibly ligated without further danger. It was therefore decided to undertake the operation in a child who presented the classic signs of a patent ductus arteriosus. At the age of 7 years she already had cardiac hypertrophy, which developed presumably from the embarrassment resulting from the anomalous communication. It was to be expected, therefore, that she would have increasingly severe disability in the future, aside from the danger of having bacterial endarteritis develop.
Report of Case
History. -- L.S., a girl aged 7 1/2 years, entered the hospital Aug. 17, 1938, for study of her cardiac condition. The family history was irrelevant. She was born normally at full term. No cyanosis was noted at birth or during the postnatal period. The records of the hospital where she was born give no information about an examination of the heart at that time. At the age of 3 years she was seen in the cardiac clinic of another hospital, where it was found that she had physical signs suggesting congenital malformation of the heart. At that time she had a precordial thrill and a loud murmur. The carotid pulsations were abnormally marked, and pistol shot sounds could be heard over the brachial and femoral arteries. The blood pressure was recorded in both arms as 104 mm. of mercury systolic and 60 diastolic. There was definite cardiac enlargement, as shown by teleoroentgenograms. The diagnosis made at that time was "congenital malformation of the heart with a patent ductus arteriosus."
During the next four years she was seen in several different hospitals, where the same diagnosis was made. At no time had cyanosis been observed. Dyspnea developed after moderate exercise, and her physical activities had been limited accordingly. She never had peripheral edema or other evidence of cardiac decompensation. Frequently the child had been conscious of "something wrong in the chest" and her mother spontaneously offered the information that she had heard a "buzzing noise" in her daughter's chest when standing nearby.
Physical Examination. -- At the time of admission, the patient was slender and undernourished. The pulsations of the carotid arteries were abnormally forceful. The radial pulse was of the Corrigan type, and a capillary pulsation was readily seen. The veins over the chest were somewhat prominent. There was a precordial bulge. The heart was definitely enlarged by percussion, the enlargement being for the most part to the left. Over the entire precordium there was a prominent coarse thrill which was most intense in the third interspace to the left of the sternum. This thrill was continuous but was accentuated during systole. There was a rough "machinery" murmur heard with maximal intensity over the pulmonic area to the left of the sternum in the second and particularly in the third interspace. It was continuous throughout the cardiac cycle but like the thrill was greatly accentuated during systole. It was transmitted to the left along the third interspace and into the axilla with only slightly diminished intensity. The systolic element was heard faintly over the vessels of the neck and could be heard clearly in the right axilla and over the midthoracic region posteriorly. Blood pressure readings were respectively right arm 115/40, left arm 110/50, right leg 150/55, left leg 140/40 mm. of mercury. There was no clubbing of the fingers and no evidence of peripheral edema. The liver edge was palpable at the costal margin. The examination in other respects was negative.
Laboratory Data. -- A 7-foot x-ray film of the chest showed the transverse diameter of the heart to be 11.7 cm., compared to an internal diameter of the chest of 20 cm. There appeared to be definite enlargement of the left ventricle. There was questionable prominence of the pulmonary artery. A mottled increased density around the lung hili was interpreted as representing circulatory congestion. Fluoroscopic examination showed a "hilar dance." An electrocardiogram was normal, showing no deviation of the axis. The red blood count was 5,080,000 cells per cubic millimeter and the hemoglobin was 85 per cent (Sahli). Circulation time with dehydrocholic acid was 10 and 8 seconds, respectively, on two tests.
Operation. -- August 26, operation was undertaken (by R. E. G.) under cyclopropane anesthesia. The approach to the mediastinum was made through the left pleural cavity anterolaterally. Incision was made through the left third interspace, cutting the third costal cartilage, and the third rib was retracted upward. As the left lung was allowed to collapse inferiorly, an excellent view was gained of the lateral aspect of the mediastinum. The parietal pleura covering the aortic arch and left pulmonic artery was then incised and these structures were directly exposed. A large patent ductus arteriosus was found, which was from 7 to 8 mm. inm diameter and from 5 to 6 mm. in length. A palpating finger placed on the heart disclosed a continuous and very vibrant thrill over the entire organ, which was increasingly prominent as the finger reached up over the pulmonic artery. A sterile stethoscope was employed and an extremely loud continuous murmur was heard over the entire heart. When the stethoscope was placed on the pulmonary artery there was an almost deafening, continuous roar, sounding much like a large volume of steam escaping in a closed room.
A number 8 braided silk tie was placed around the ductus with an aneurysm needle, and the vessel was temporarily occluded for a three minute observation period. During this time the blood pressure rose from 110/35 to 125/90. Since there was no embarrassment fo the circulation, it was decided to ligate the ductus permanently. The ductus was too short to tie double and divide, so that ligation alone was resorted to. When the thread was drawn up tight the thrill completely disappeared. The chest was closed, the lung being reexpanded with positive pressure anesthesia just prior to placing the last stitch in the intercostal muscles.
Postoperative Course. -- The child underwent the operative procedure exceedingly well and showed no signs of shock. Prior to operation blood had been taken from a donor in order to have it ready whenever needed, but the patient's condition was so good that it was not given. There was only mild discomfort on the afternoon of the day of operation, and on the following morning the child was allowed to sit up in a chair. By the third day she was walking about the ward. When the skin sutures were removed on the seventh day the wound was well healed, but because of the interest in the case the child was detained in the hospital until the thirteenth day. After the dressing was removed and the chest could be examined adequately the thrill had completely disappeared, there was a faint systolic murmur in the third left interspace which was not transmitted over the precordium, and no murmur could be heard in the axilla, in the neck or over the back. The daily blood pressures which had been taken prior to operation and subsequent thereto showed a striking change in the diastolic levels, as is shown by the accompanying chart. The average of the daily pressures prior to operation had been 114 systolic and 38 diastolic as contrasted with a postoperative daily average of 108 systolic and 80 diastolic.
Summary
A girl aged 7 1/2 years had a known patency of the ductus arteriosus and beginning cardiac hypertrophy. In the hope of preventing subsequent bacterial endarteritis and with the immediate purpose of reducing the work of the heart caused by the shunt between the aorta and pulmonary artery, the patent ductus was surgically explored and ligated. The child stood the operative procedure exceedingly well. The most objective finding, which indicated that the serious loss of blood from the aorta into the pulmonic artery had been arrested by operation, was a comparison of the preoperative and postoperative levels of the diastolic blood pressure. Prior to operation the daily blood pressure showed an average diastolic level of 38 mm. of mercury as compared with a postoperative diastolic level of 80 mm. of mercury. This is the first patient in whom a patent ductus arteriosus has been successfully ligated.
From the Surgical and Medical Services of the Children's Hospital and the Departments of Surgery and Pediatrics of the Harvard Medical School.
[1] Abbot, Maude E.: Atlas of Congenital Heart Disease, New York, American Heart Association, 1936, pp. 60-61.
[2] Holman, Emile: Arteriovenous Aneurysm, New York, Macmillan Company, 1937, pp. 169-178.
[3] Gross, R. E.: A Surgical Approach for Ligation of a Patent Ductus Arteriosus, New England J. Med., to be published.