Background Patent ductus arteriosus (PDA) is a common complication observed in the premature infant; its management being a controversial issue. The lack of robust evidence of benefit or harms of available treatment options, necessitate the need to balance them out against the likelihood of spontaneous duct constriction, which occurs in approximately a third of extremely premature neonates. Despite the controversy regarding the optimal management of PDA, nearly 70% of preterm infants (less than 28 weeks of gestation) will receive either medical or surgical treatment. The rationale behind this is to decrease the likelihood of developing morbidities associated with prematurity and persistent PDA. These include intraventricular hemorrhage (IVH), bronchopulmonary dysplasia, necrotizing enterocolitis (NEC) and increased mortality.

Various thoracotomy practices have been employed for occlusion of PDA which are not amenable to medical management. Success rates of surgical ligation are reported to be high but it has been associated with significant operative complications. In this study, we assess survival outcomes and operative complications associated with ligation.

Objectives This prospective study focuses on the closure of PDA by mini-thoracotomy in our institution. We report our preliminary experience of using this approach in small premature infants and determining survival outcomes in relation to factors such as gender, birth weight, age, and type of ventilation used intra-operatively.

Methods Between January 2004 and December 2012, 52 consecutive premature infants with an echocardiographic diagnosis of isolated PDA, which are not amenable to medical treatment, were included. Those with chromosomal abnormalities, major cardiac congenital anomalies aside from septal defects, and infants who did not receive mechanical ventilation in the first week of life were excluded. The median gestational age was 28 weeks and the median gestational weight at surgery was 705 g. The median PDA size was 3.8 mm, ranging from 1.6 to 5 mm. Twenty-nine patients were given non-selective ventilation and twenty-three were anesthetized using selective right-lung ventilation using a 2-F balloon catheter for arterial embolectomy. A left lateral mini-thoracotomy was performed in all infants and PDA closure achieved by double ligation using zero silk sutures.

Results The median operative time and mean length of hospital stay were 45 minutes and 90 days, respectively. No major hemorrhage requiring blood transfusion occurred during the surgery. The survival rate until hospital discharge was 88.5%. There were no mortalities associated with the surgery itself. Six (11.5%) neonates died postoperatively because of prematurity (P-value=1.000). Pneumonia and atelectasis were among the few complications encountered post ligation. An association was recognized between ventilation and surgical complications; that is neonates who underwent selective right ventilation did not experience any of the complications mentioned above in comparison to those who were put under non-selective ventilation (P-value <0.001).

Conclusions Closure of PDA by double ligation via a left mini-thoracotomy in small premature infants proved to be safe and effective in providing pediatric surgeons adequate exposure within confined and delicate anatomic spaces. No procedure related mortalities or major complications were encountered. It is a useful option in neonates with failed medical management of PDA especially in preemies where performing VATS is challenging.