Patent Ductus Arteriosus (PDA) Heart Surgery

Patent ductus arteriosus (PDA) heart surgery is required to close a birth defect called PDA inside the heart.

While in the womb a baby's lungs are occupied with fluid, so they receive oxygen directly from the placenta (that develops in the mother’s uterus during pregnancy) instead of lungs. To prevent the supply of blood to the lungs, a blood vessel called ductus arteriosus connects the two arteries - aorta (supplies oxygen-rich blood from the heart to different parts of the body) and pulmonary artery (carries deoxygenated blood from the heart to the lungs for purification) in a foetus. After birth, once the baby starts crying and breathing, air will replace the fluid inside their lungs. The ductus arteriosus will naturally close and allow the supply of blood to the lungs. However, if it fails to close, it can result in PDA. The condition leads to mixing of the oxygenated and deoxygenated blood and, as a result, excess blood will flow through the pulmonary artery to the lungs. This can cause an increase in blood pressure inside the pulmonary artery (pulmonary hypertension) and may lead to permanent damage to the heart.

Healthcare providers close PDA using different approaches such as:

• Medicinal: Your doctor may prescribe medicines like indomethacin to close PDAs. The medication will tighten the PDA and close it. However, this is usually used in premature babies (babies born before completing nine months inside the womb, i.e., 37 weeks)
• Non-medicinal: 
  • Catheterisation procedure: This method uses a catheter (tube) to insert a device that closes the blood vessel. 
  • Surgery: This approach is needed if a baby develops a health problem because of PDA or the catheterisation is unsuccessful.

This surgery is indicated if a PDA has not closed in a newborn in a few days after birth and medical treatment has failed. A small PDA may not show any symptoms. However, in a large PDA, the baby may have the following symptoms:

• Getting tired easily
• Sweating while feeding 
• Poor growth 
• Fast breathing 
• Shortness of breath 
• Forceful and strong pulse
• Not feeding properly

The condition is rarely found in adults, and is usually seen in case of small to moderate size PDA. It is often a coincidental finding in adults when screening for other problems. However. this surgery can be recommended in adults to reduce the risks of:

• Infection
• Enlarged heart
• Pulmonary hypertension
• Irregular heartbeats
• Shortness of breath

The contraindications of PDA heart surgery include:

• Valve (tricuspid and aortic) atresia (when one of the valves in the heart do not form properly)
• Pulmonary artery hypoplasia (incomplete or malformation of the pulmonary artery)
• Transposition of the great arteries (a condition in which the aorta and pulmonary artery are switched in position) 
• Mitral valve atresia (improper development of the mitral valve of heart) along with hypoplastic left ventricle (improper development of the lower left side of the heart) 
• Uncontrolled sepsis

The surgery may not be performed if a baby is less than six months of age and shows no health issues from PDA.

The following preparations are required before this surgery:

• Doctors first check for a heart murmur in the baby using a stethoscope to diagnose a PDA. He/she will order the following diagnostic tests if a heart murmur is heard:
  • Chest X-ray: to view the size of the heart 
  • An echocardiogram (ECG)
  • Ultrasound scan: to check for the size of the PDA
  • Blood tests
• Tell the doctor if the child is taking any medicines (over-the-counter or prescription), minerals, vitamins, and supplements.
• The child may have to be in a fasting condition before the surgery. Your doctor will tell you if water is allowed and how much.
• Adults should stop smoking before a PDA surgery to ensure a quicker recovery. Also, you will have to discontinue blood thinners for a few weeks before the surgery and arrange for a ride to and from the hospital.
• You will have to sign an approval/consent form if you agree to the procedure.

After the admission procedure is completed, an intravenous (IV) line will be started in the patient's arm or hand to supply medicines and fluids during the procedure. General anaesthesia (a sleep-inducing medicine) will also be administered through the IV. The surgical area will be cleaned (and shaved if necessary).

The surgery can be performed in the following ways:

• Open surgery: In the operation theatre, the surgeon will perform the following steps:
  • You or the child will lie on their right side with their arm over their head.
  • The surgeon will make an incision over the skin on the left side of your chest.and separate your ribs to access your heart.
  • He/she will move aside your lung and open the muscles around the heart called pericardium to access PDA. 
  • Once PDA is identified, the surgeon will seal it or tie it using a ligature (cord or wire) and metal clip. 
  • Next, he/she will insert a chest tube in your chest to remove excess air and fluid. 
  • Finally, the surgeon will close the muscles and skin in the area using absorbable stitches.
• Video-assisted thoracic surgical repair: In this approach, a small incision is made in the chest, and the PDA is sealed by visualising inside the chest through a thoracoscope (a device with a camera).
• Catheter-based procedure: This procedure involves the following steps:
  • The surgeon will insert a straw-sized tube called a sheath inside the blood vessel of your groin after making a small incision in the area. 
  • Using this sheath, he/she will insert a catheter (tube) inside the blood vessel to your heart. 
  • The surgeon will then insert a small metal coil or blocking device through the catheter. 
  • This procedure is guided using an X-ray scan called fluoroscopy. 
  • Once the device is placed at the PDA site, he/she will remove the catheter and sheath and cover the incision with a bandage.

The surgery lasts for about 30 minutes. You (or your child) will rest in the recovery room after the surgery. The healthcare provider may prescribe painkillers to reduce pain after the surgery. The chest tube will be removed 24 hours following the procedure. Patients are usually discharged the same day after a catheter-based procedure, in an open procedure, however, a few days of hospital stay is needed.

The following care is needed after the surgery:

• Medications: 
  • Antibiotics will be given to reduce the risk of infection for at least six months after the surgery.
  • Diuretic medicines will be given for a week.
• Activities: 
  • Restrict physical activities for a few days after the surgery.    
  • Avoid lifting heavy objects.
  • Do not let your child lift their arms above the head for a few weeks.
  • Avoid lifting or pulling the child by his/her arms after the surgery.
  • Avoid playing contact sports like football.
  • Ensure to avoid activities that may cause falling on the chest or a blow to the chest.

When to see the doctor?

Visit or call the doctor if you or the child have the following symptoms:

• Shortness of breath 
• Prolonged pauses in breathing 
• Blue or pale discolouration of skin 
• inability to gain weight 
• Fever 
• Chest pain 
• Swelling, redness, or bleeding from the catheter site 
• Puffy eyes or face

PDA heart surgery is known to carry the following risks:

• Bleeding 
• Infection 
• Kidney damage 
• Heart attack 
• Pneumothorax
• Stroke 
• Incomplete closure of the blood vessel
• Paralysis of vocal cords
• Rupture of the blood vessel 
• Migration of the device

Your follow-up will be scheduled two to three weeks after the surgery where the surgeon will check the closure of the PDA using ECG.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.