Anesthesia Challenges in Patent Ductus Arteriosus

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Letter to Editor

Anesthesia Challenges in Patent Ductus Arteriosus Stenting for


Congenital Heart Disease
The Editor, contractility. The decrease in systemic vascular resistance
Ductus arteriosus is communication present between and increase in pulmonary vascular resistance (PVR) can
pulmonary artery and proximal descending aorta. It is be done away with as these will cause further reduction in
essential in fetal life to shunt blood from right ventricle pulmonary blood flow and hypoxia. Factors which lead to
bypassing the underdeveloped lungs. It closes functionally increase in PVR such as hypoxia, hypercarbia, and acidosis
soon after birth and anatomically by days to few weeks. can cause sudden deterioration in clinical condition. Other
Ductal patency may be lifesaving in few cyanotic challenges include hypoglycemia and hypothermia. Warm
congenital heart diseases to maintain pulmonary blood blankets and warm saline for flushing and fluid warmer
flow. Typical duct‑dependent lesions include pulmonary and for intravenous infusion were used in our case. Adequate
tricuspid atresia, critical pulmonary stenosis, and tetralogy hydration needs to be done to reduce viscosity. The
of Fallot with pulmonary stenosis. These patients require role of cardiac anesthetist also extends to transthoracic
either prostaglandin infusion for maintaining ductal patency imaging. Confirmation of diagnosis, correct placement of
or palliative shunt surgeries such as Blalock Taussig (BT) the stent across PDA, adequate flow across stent, and any
shunt. Patent ductus arteriosus (PDA) stenting is an complications such as stent migration have to be looked for
attractive, less invasive procedure and equally effective as while doing TTE.
BT shunt.[1] Reported complications such as acute stent thrombosis,
In the current era, with the advancement in surgical skills pre‑stent ductal spasm, and pulmonary congestion have to
and perioperative care, there has been a growing trend be kept in mind as well.[3]
toward early corrective surgeries for complex congenital PDA stenting is an attractive, less invasive, palliative
heart diseases.[2] Instead of doing staged surgeries, PDA procedure for duct‑dependent complex congenital heart
stenting followed by correct surgery offers a promising diseases where the definitive procedure is to be done
alternative. at slightly later date.[4] Anesthesiologist’s role lies in
We present a case of a 20‑day‑old, 3 kg child who presented maintaining arterial saturation, hemodynamics, securing
to casualty with bluish discoloration. On examination, vascular assess, maintaining temperature, and transthoracic
the child had central cyanosis, tachypnea with continuous imaging, and thorough understanding of underlying
murmur in the left second intercostal space. On transthoracic physiology holds the key.
echocardiography (TTE), the child had corrected transposition Financial support and sponsorship
of great arteries with pulmonary atresia and PDA. The child
was medically stabilized with prostaglandin E1 infusion Nil.
started at 0.05 µg/kg/min and taken up for PDA stenting. Conflicts of interest
24‑gauge peripheral cannula was secured. Oxygen saturation
with Pulse‑oxymeter, noninvasive blood pressure, and There are no conflicts of interest.
temperature monitoring were done. Anesthesia induced Nanditha S, Poonam Malhotra Kapoor,
with 100% oxygen, fentanyl 2 µg/kg, ketamine 2 mg/kg, Kunal Sarin
rocuronium 0.1  mg/kg and maintained with sevoflurane Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
and atracurium. Prostaglandin E1 infusion was continued
Address for correspondence: Dr. Poonam Malhotra Kapoor,
throughout the procedure. 5 F sheath was secured in the Department of Cardiac Anaesthesia, CTC, AIIMS,
femoral vein and 4 F sheath was secured in the femoral New Delhi, India.
artery. 0.5 mg/kg heparin was given, and 3.5 stent was E‑mail: nanditha.iyengar88@gmail.com
inserted in PDA and confirmed by transthoracic echo. With
TTE, correct placement of the stent and continued flow across References
PDA were seen. During the procedure, the child was stable, 1. Kumar P, Datta R, Nair R, Sridhar G. Stent implantation of patent
and saturation improved from 65% to 88%. Prostaglandin E1 ductus arteriosus in a newborn baby. Med J Armed Forces India
infusion was stopped, child reversed and extubated. 2011;67:171‑3.
2. Alwi M. Stenting the ductus arteriosus: Case selection, technique and
Anesthesia for PDA stenting poses unique challenges. possible complications. Ann Pediatr Cardiol 2008;1:38‑45.
Goals include maintaining adequate preload and 3. Buys DG, Brown SC, Greig C. Stenting the arterial duct: Practical

© 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow 389


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Letter to Editor

aspects and review of outcomes. SA Heart J 2017;10:514‑9.


This is an open access article distributed under the terms of the Creative Commons
4. Matter M, Almarsafawey H, Hafez M, Attia G, Abuelkheir MM. Patent Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
ductus arteriosus stenting in complex congenital heart disease: Early and build upon the work non‑commercially, as long as the author is credited and the new
and midterm results for a single‑center experience at children hospital, creations are licensed under the identical terms.
Mansoura, Egypt. Pediatr Cardiol 2013;34:1100‑6.
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DOI:
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How to cite this article: Nanditha S, Kapoor PM, Sarin K. Anesthesia


challenges in patent ductus arteriosus stenting for congenital heart
disease. Ann Card Anaesth 2017;20:389-90.
© 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow

390 Annals of Cardiac Anaesthesia | Volume 20 | Issue 3 | July‑September 2017

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