BEST EVIDENCE TOPIC – CONGENITAL

Interactive CardioVascular and Thoracic Surgery 21 (2015) 532–538 doi:10.1093/icvts/ivv185 Advance Access publication 9 July 2015

Cite this article as: Stankowski T, Aboul-Hassan SS, Marczak J, Cichon R. Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery? Interact CardioVasc Thorac Surg 2015;21:532–8.

Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery? Tomasz Stankowskia, Sleiman Sebastian Aboul-Hassana, Jakub Marczaka,b,* and Romuald Cichonc a b c

Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Department of Cardiac Surgery, Medical University of Warsaw, Warsaw, Poland

* Corresponding author. Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland. Tel: +48-88-3774566; e-mail: [email protected] ( J. Marczak). Received 10 September 2014; received in revised form 9 June 2015; accepted 15 June 2015

Abstract A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether thoracoscopic patent ductus arteriosus (PDA) closure is superior to conventional surgery. Altogether 821 papers were found using the reported search, 11 of which represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Eleven studies included in the analysis consisted of two prospective and three retrospective, non-randomized studies and six case series. Four included studies focused only on preterm infants, three studies enrolled neonates and the other four analysed all age groups from neonates to older children or young adults. There were no differences in mortality between video-assisted thoracoscopic surgery (VATS) and conventional surgery. Two studies suggested that VATS offers shorter operative times. Two papers observed shorter hospital stay, although the other two noted no significant difference. A large prospective trial found VATS to be associated with a lower number of postoperative complications in neonates and infants, whereas other studies suggested no significant differences in short-term postoperative complications. There is little evidence to suggest better musculoskeletal status and cosmesis in neonates following VATS. Conversion from thoracoscopy to thoracotomy described in six papers was seldom and it did not lead to any additional complications. All observational studies confirmed that both techniques are free from major adverse cardiovascular complications and these two techniques can be safely used in all patients qualified for surgical PDA closure. Two studies compared cost-effectiveness between the two techniques; one of them described VATS as significantly more cost-efficient, whereas the other study observed no difference. However, it should be noted that data were provided from different countries and time periods. The results presented suggest that there are no significant differences in early clinical outcomes between VATS and thoracotomy in all age groups. However, where differences have been shown, such as pain, postoperative complications, length of hospital and ICU stay and cost, these favour the VATS approach. Keywords: Video-assisted thoracoscopy • Thoracotomy • Patent ductus arteriosus • Patent ductus arteriosus ligation

INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

patient because of poor clinical condition; therefore, surgical closure is indicated. The parents wonder if VATS closure is as effective as conventional open thoracotomy. You resolve to check the literature to support the advice you give to the parents.

THREE-PART QUESTION Is [video-assisted thoracoscopy] superior to [surgical ligation] in patients with [ patent ductus arteriosus]?

CLINICAL SCENARIO A child with patent ductus arteriosus is referred to your clinic for surgical closure. Transcatheter intervention is not amenable in this

SEARCH STRATEGY The literature review was performed with the use of PubMed interface and Google Scholar database (1950 to September 2014): [video-assisted thoracoscopy OR muscle-sparing posterolateral thoracotomy] AND [ patent ductus arteriosus OR PDA]. ‘Related articles’ function was used in order to enhance the possibility of broadest data retrieval.

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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Table 1: Best evidence papers Patient group

Chen et al. (2011), Pediatr Cardiol, China [2]

302 neonates and infants (2002–2007) with isolated PDA and followed them up until April 2010

Prospective nonrandomized study (level IIb)

1st group—134 VATS clipping 2nd group—168 thoracotomy ligated by threads Exclusion criteria: >5 kg, other cardiac anomalies, severe pulmonary hypertension, complicated PDA. VATS group—PDA diameter >8 mm Preoperative clinical characteristics and demographics were similar in both groups Age: days (range) 134.2 ± 37.6 (7–190) vs 139.1 ± 30.4 (20–188), P = 0.106 Weight: kg (range) 3.5 ± 1.3 (1–5) vs 3.7 ± 2.4 (2.5–5), P = 0.193 Duct size: mm (range) 5.6 ± 1.8 (3.5–8.0) vs 5.8 ± 1.4 (3.5–8.0), P = 0.139

Esfahanizadeh et al. (2013), Life Sci J, Iran [3] Prospective non-randomized study (level IIb)

135 children underwent isolated PDA ligation from February 2003 to March 2012

Outcomes

Key results

Comments

VATS 134 (100)

Thoracotomy 168 (100), P = 1.000

98.2 ± 18.2 5.9 ± 1 1.1 ± 0.2

120.4 ± 29.8, P < 0.001 6.1 ± 1.4, P = 0.140 0, P < 0.001

36.6 ± 3.6

38.4 ± 4.2, P < 0.001

1150 ± 221 15.2 ± 3.2

2415 ± 345, P < 0.001 30.6 ± 4.5, P < 0.001

Total complications, n (%) Death Major bleeding Blood transfusion Recurrent laryngeal nerve dysfunction Pleural effusion Pneumothorax Chylothorax Pneumonia Arrhythmia requiring medication

10 (7.5)

21 (12.5), P = 0.002

0 0 0 0

0 0 1 2

3 2 0 5 0

8 3 0 6 1

Follow-up time, years (range)

5.7 ± 1.2 (3.2–8.2)

5.6 ± 1.1 (3.2–8.2), P = 0.226

Deaths, n (%) Residual shunt, n (%) Scoliosis, n (%) Newly occurring arrhythmias, n (%)

0 (0) 2 (1.5) 0 (0) 0 (0)

0 (0), P = 1.000 10 (6.0), P = 0.049 8 (4.8), P = 0.010 0 (0), P = 1.000

LVD Preoperatively (mm) Postoperatively (mm) P-value

27.1 ± 2.5 22.3 ± 2.8 10 mm Median age, years ± SD: 3.17 ± 3 vs 3.27 ± 3 P = 0.62

Continued

BEST EVIDENCE TOPIC

Author, date, journal and country Study type (level of evidence)

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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Vanamo et al. (2006), J Pediatr Surg, Finland [4] Retrospective non-randomized study (level III)

Patient group

Outcomes

Key results

Median weight, kg (range): 11 (7–16) vs 10 (6–15), P = 0.27

Chylothorax, n (%)

0

Conversion to thoracotomy, n (%)

3 (3.6)

Retrospective cohort study (level III)

Operative time (range) (min) Operating room time (range) (min)

45 (20–125)

67 (40–125), P < 0.05

125 (80–200)

130 (80–270), P = NS

Time in NICU (h) (range)

11 (6.5–72)

24 (2–74), P < 0.05

Duration of pleural drainage (h) (range)

6 (2–192)

48 (12–72), P < 0.05

Hospital stay (days) (range)

4 (3–33)

8 (3–28), P < 0.05

Patients with complications, n (%) Ductal bleeding Chylothorax/pleural effusion Pneumothorax Atelectasis Transient laryngeal stridor Recurrent laryngeal nerve palsy Transient intercostal pain Skin lesion Wound seroma/ postoperative fever

18 (36)

8 (13), P = NS

0 2

1 2

1 2 3

2 2 1

6 (3 transient)

0

1 2 1

0 0 0

Rethoracoscopy because of residual ductal flow on postoperative echocardiography, n

2

Conversion to thoracotomy, n

1

Reoperation through thoracotomy because of residual ductal flow 1 year after the surgery, n (%)

1 (2.0)

1 (1.7)

Hospital mortality, n

TPDAL 0

MST 0

Operating room time (h) P-value

1.3 ± 0.33 0.339

1.4 ± 0.335

Hospital stay (days) P-value

1.33 ± 0.71 0.536

1.8 ± 0.83

Intravenous narcotics (doses) (fentanyl, 0.5–1.0 µ/kg/ dose), P-value

1.22 ± 1.39 0.449

1.75 ± 1.91

2 0

3 0

1st group—60 thoracotomy (1986–1995) using minimum two non-absorbable ligatures 2nd group—50 VATS (1994– 2004) using 1 or 2 vascular clips-12 mm

Maximum diameter of the ductus, mean (range), mm: 5.0 (1.3–10.0) vs 2.9 (1.0–7.0), P < 0.05

Kennedy et al. (1998), J Pediatr Surg, USA [5]

Thoracotomy 0 (0%), P = NS

Hospital mortality, n (%)

Median weight (kg): 10.4 (1–49) vs 10.5 (1.6–65), P = NS

19 non-newborn underwent isolated PDA ligation 1st group—11 patients underwent thoracoscopic PDA ligation (TPDAL). 2 attempts were aborted, 1 for bleeding and 1 for inadequate clip size 2nd group—9 patients underwent posterolateral muscle-sparing thoracotomy (MST) Exclusion criteria: other congenital anomalies

0, P = NS

VATS 0 (0)

110 children underwent PDA ligation

Median age (months): 12 (0–204) vs 15 (0.75–213), P = NS

Comments

Chest tube, n Recurrent laryngeal nerve dysfunction, n

The operative time, duration of recovery room/NICU care, length of hospital stay, duration of pleural drainage— shorter in the VATS group No difference in the operating room time between these groups More complications in the VATS, statistically not significant

Length of operation, hospital stay, number of doses of intravenous narcotics was similar in both groups

Continued

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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Key results

Both groups were similar in: age (mean, 4 years), male to female ratio

Cost ($) P-value

9520 ± 2395 0.497

9720 ± 2854

LVCP, n (%), P-value

VATS 0 (0)

Thoracotomy 19 (18), P = 0.587

6 (100)

85 (82)

Rukholm et al. (2012), J Pediatr Otorhinolaryngol, Canada [6]

This study reviewed 115 infants who underwent PDA ligation surgery between July 2003 and July 2010

Retrospective cohort study (level III)

4 patients were excluded postoperatively due to bilateral vocal cord paralysis

Non-vocal cord paralysis, n (%)

Comments

Type of surgical PDA ligation was not found to be a significant risk factor for LVCP

BEST EVIDENCE TOPIC

Authors compared results of postoperative LVCP 111 patients included in this study (43.2% female, 56.8% male). 1 patient was excluded from the type of surgery analysis, due to missing data 1st group—6 VATS vs 2nd group—104 thoracotomy Nezafati et al. (2011), Asian Cardiovasc Thorac Ann, Iran [7] Retrospective study case series (level IIIb)

2000 patients after VATS PDA closure were reviewed (1997–2008) Exclusion criteria: PDA >9 mm, complicated PDA, endocarditis, calcification of the PDA, pleural adhesions, previous history of left thoracic operations. 29 (1.45%) were excluded and underwent a thoracotomy Mean age: 5.2 years (range, 1 month to 35 years) Mean weight: 9.8 kg (range, 5–68 kg)

Mortality 9 mm Inadequate visualization Ductal wall rupture Missed concurrent coarctation of aorta Late residual shunt

15 (0.75%) 10 (0.50%) 3 (0.15%) 1 (0.05%) 1 (0.05%)

VATS clipping is simple, rapid, cost-effective, and more convenient for the patients VATS leads to a short hospital stay. Low rate of complications and low mortality confirmed safety of this procedure Authors noted one death at 1 month after the surgery because of sepsis

4 (0.20%) (treated by thoracotomy)

55% were female

Villa et al. (2003), Euro J Cardiothoracic Surg, France [8] Retrospective study case series (level IIIb)

754 patients were reviewed from September 1991 to March 2003. All patients underwent PDA closure, 703 using VATS approach Exclusion criteria: PDA >8 mm, previous thoracotomy, presence of calcifications, active infection, aneurysm. 51 (6.7%) were excluded Follow-up visit on: -7–10th postoperative day -After 6 months

Recurrent laryngeal nerve dysfunction Transient (3–5 weeks) Permanent

14 (0.70%)

Operative mortality, n (%)

0 (0)

30-day mortality, n (%)

0 (0)

Operative time (min) Hospital stay Residual patency ductus, n (%) Recurrent laryngeal nerve dysfunction, n (%) Transient, n (%) Persistent, n (%) Pneumothorax, n (%)

13 (0.65%) 1 (0.05%)

20 2 days (range: 1–20 days) 10 (1.4) [8 patients: reVATS; 2 patients (0.3%): thoracotomy] 21 (3.0) 18 (2.6) 3 (0.4) 9 (1.3)

VATS clipping for PDA is a safe approach for all patients from neonates to adults. It is effective in LBWIs group, but these patients are at augmented risk of complicated course VATS is an excellent solution for premature infants. In this patients VATS provides good visualization, also in VLBW and ELBW

Continued

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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Mean age: 3.0 ± 3.8 years (5 days to 33 years) Mean weight: 10.7 ± 8.0 kg (1.2–65 kg)

Transfusion, n (%) Chylothorax, n (%)

Key results

Comments

1 (0.1) 4 (0.6)

25 kg: 6% Hines et al. (2003), Ann Thorac Surg, USA [9] Retrospective study case series (level IIIb)

100 (51 males, 49 females) premature infants were retrospectively reviewed ( June 2006 to May 2002) The procedure was performed by VATS Mean weight: 859 g (from 420 to 1500 g) Mean age: 16 days (from 3 to 51 days) Mean gestational age: 25.6 weeks (from 23 to 31 weeks)

Mortality Intraoperative, n (%) Postoperative (2–148 days) Sepsis Necrotizing enterocolitis Respiratory failure Procedure time Pneumothorax, n (%) Insignificant Without treatment Chest tube Conversion to thoracotomy, n (%) Undiagnosed coarctation Other Transfusion Recurrent nerve injuries, n (%) Transient, n (%) Persistent, n (%) Wound infection, n (%)

Burke et al. (1999), Pediatrics, USA [10] Prospective study case series (level IIIb)

34 low birth weight infants underwent VATS PDA ligation between 1993 and 1996 Median age (range) 15.5 days (1–44) Median weight (range) 930 g (575–2500) Follow-up period 2–323 days

Operative mortality Hospital mortality, n Median surgical time of VATS ligation Range Median surgical time in a similar group of LBWI through thoracotomy Range

0 (0) 15 (15%) 11 (11%) 5 (5%) 3 (3%) 32.8 min (range: 13–53 min) 6 (6) 3 (3%) 3 (3%) 4 (4) 1 (1%) 3 (3%) 0 (0%) 5 (5) 4 (4) 1 (1) 0 (0) 0 2 60 min 31–171 min 35

20 min to 1 h

Median hospital stay Range

56 days 1–186 days

Conversion to open thoracotomy, n (%)

4 (12)

The lowest intraoperative core temperature Postoperative complications

Chylothorax Trace residual ductal flow

Hines reported nil intraoperative mortality. However, 15% postoperative (2–148 days) mortality rate was caused sepsis, necrotizing enterocolitis or respiratory failure

34.8–36.7°C

Length of operation was shorter in thoracotomy patients Surgical PDA closure in premature infants using VATS technique is safe and effective This technique decreased chest wall trauma and reduced the convective heat loss during the surgery VATS technique is contraindicated in: dense left pleural adhesions, a calcified PDA, coagulopathy and severe pulmonary dysfunction

2 (1 NEC: laparotomy + ileostomy and 1 transient vocal cord paresis) 0 2 (5.9%)

Continued

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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Mandhan et al. (2009), Congenit Heart Dis, New Zealand [11]

145 preterm low birth weight infants underwent PDA closure through a left posterolateral thoracotomy with silk (73%) or titanium clips (27%)

Mortality

9 (6.2%) (none of them died because of the surgical intervention)

Morbidity

10 (6.8%)

PDA closure through a left posterolateral thoracotomy in preterm low birth weight infants is safe and provides to minimal morbidity

Intraoperative bleeding [required blood transfusion]

6 (4.1%) [2 (1.4%)]

Mean gestational age: 25.5 ± 2.3 weeks Mean age at the surgery: 14.1 ± 1.8 days Mean birth weight: 837.7 ± 277.2 g Mean weight at the surgery: 881.3 ± 338.1 g Male/female ratio: 1.4:1

Pneumothorax Left RLN injury Injury of left lymphatic ducts Left phrenic nerve injury

1 (0.7%) 1 (0.7%) 1 (0.7%)

BEST EVIDENCE TOPIC

Retrospective study case series (level IIIb)

1 (0.7%) 100%

Follow-up period: success rate of PDA closure

PDA size larger than 4 mm: 1.8% Follow-up period: 3 months to 8 years, average: 40 months Monteiro et al. (2007), Rev Bras Cir Cardiovasc, Brazil [12] Retrospective study case series (level IIIb)

273 (125 males) preterm infants were reviewed. All patients underwent PDA occlusion through muscle-sparing thoracotomy between October 1991 and June 2003

Mortality Intraoperative, n (%) Postoperative (1–51 days) Sepsis Intracranial haemorrhage Necrotizing enterocolitis

Mean age (IQR): 8.55 ± 7.17 days (IQR: 1–34 days)

Mean procedure time (min)

18

Mean gestational age: 29.3 ± 2.84 weeks (IQR: 23– 33 weeks)

Maximum procedure time (min)

30

Mean weight: 1045 ± 528 g (IQR: 490–2450)

Pneumothorax, n (%) Haemorrhage, n (%) Wound infection, n (%)

0 (0) 29 (10.6%) 14 (5.13%) 11 (4.02%)

Thoracotomy is a safe and effective technique for PDA ligation in premature infants

9 (3.3%)

9 (3.3) 4 (1.4) 0 (0)

PDA: patent ductus arteriosus; VATS: video-assisted thoracoscopic surgery; NICU: neonatal intensive care unit; LVEF: left ventricular ejection fraction; PASP: pulmonary artery systolic pressure; LVD: left ventricular end-diastolic diameter; PAD: pulmonary artery diameter; LVCP: left vocal cord paralysis; RLN: recurrent laryngeal nerve; MST: muscle-sparing thoracotomy; CTS: conventional thoracic surgery; LBWI: low birth weight infants; VLBW: very low birth weight; ELBW: extremely low birth weight; NEC: necrotizing enterocolitis; IQR: interquartile range.

SEARCH OUTCOME Eight hundred and twenty-one papers were found using the reported search. Eleven papers were identified that provided the best evidence to answer the clinical question. These are presented in Table 1.

RESULTS Chen et al. [2] performed a prospective comparison between VATS and conventional surgery in neonates and infants. Patients were

divided into two groups according to the preferences expressed by their parents. This study reported nil early and long-term mortality in both groups. VATS demonstrated better technical indices and fewer early complications. Lower prevalence of scoliosis (P = 0.010) and lower residual shunt (P = 0.049) in VATS patients were reported during the follow-up period. In thoracoscopy, the duct was clipped, whereas in thoracotomy PDA was ligated by thread. A higher incidence of residual duct flow or ductal bleeding in conventional surgery could be associated with closure technique rather than surgical approach.

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Esfahanizadeh et al. [3] published a prospective study of 135 children under 12 years of age who underwent an isolated PDA ligation. The authors reported a shorter ICU and hospital stay, more frequent operating theatre extubations, reduced number of chest tube insertions and better overall patient recovery in the postoperative period in VATS patients. Vanamo et al. [4] published their experience with VATS and posterolateral thoracotomy for PDA closure with no perioperative mortality in either group. This study included all paediatric age groups from neonates to older children. In patients submitted to VATS, operative time, the duration of ICU stay, the duration of pleural drainage and the length of hospital stay were significantly shorter than in the thoracotomy group. In VATS patients, a trend towards a higher complication rate was reported. Due to residual duct flow, one patient in each group needed reoperation 1 year after the surgery. Better postoperative results in VATS could have been explained by the more recent period of the surgery. Kennedy et al. [5] performed one of the first comparisons between VATS and thoracotomy in the PDA treatment in nonnewborns. They demonstrated neither differences in the operative time, hospital stay, analgesic score and postoperative complications nor in the mortality. In view of the small number of patients in this study, it is difficult to perform a meaningful statistical analysis. Rukholm et al. [6] evaluated the results of the left vocal cord paralysis (LVCP) in infants who underwent the surgical PDA ligation. LVCP occurred in 18% of thoracotomy patients; however, in VATS no paralysis was observed. Due to the small number of patients in the VATS group, the type of surgery was not found to be a significant risk factor for LVCP (P = 0.587). Nezafati et al. [7] studied 2000 patients performing the largest analysis of patients who underwent a PDA closure using the VATS technique. Patients’ age ranged from 1 month to 35 years. They described outstanding results with 0.05% mortality, mean procedural time of 10 min and a low post-procedural complications rate. Similar results were demonstrated by Villa et al. [8], who analysed over 700 patients from neonates to adults. Zero mortality within 30 days postoperatively and a low rate of complications confirmed the safety of VATS in patients of all age groups. Two studies conducted retrospectively by Hines et al. [9] and prospectively by Burke et al. [10] presented their experience with implementing VATS in preterm infants. There was no perioperative mortality in those two studies, although mortality during the follow-up period was 15% (Hines) and 5.9% (Burke), respectively. Conversion rates were reported in six studies, and ranged from 0.3 and 12%. None of the conversions led to any reported adverse events. Mandhan et al. [11] and Monteiro et al. [12], whose papers focused on a conventional thoracotomy approach, suggested that this technique is both safe and effective in preterm infants. The overall mortality rate was 6.2% in the study by Mandhan and 10.6% in the study by Monteiro; however, none of these deaths happened during the perioperative period.

CLINICAL BOTTOM LINE The above-mentioned papers confirmed that VATS and conventional surgery are equally safe and effective, regardless of the child’s age. Some studies suggest that VATS is associated with shorter operative time, reduced length of hospital and ICU stay and fewer acute complications. Conversion from VATS to conventional surgery is seldom and it does not lead to increased complications. A largersized PDA appears to be the only contraindication to thoracoscopic closure.

Conflict of interest: none declared.

REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Chen H, Weng G, Chen Z, Wang H, Xie Q, Bao J et al. Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants. Pediatr Cardiol 2011;32:386–90. [3] Esfahanizadeh J, Meybodi NA, Shamloo AS, Shakiba AH, Hooshiar A, Tashnizi MA et al. Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus: report of 10 years’ experience. Life Sci J 2013; 10:1068–72. [4] Vanamo K, Berg E, Kokki H, Tikanoja T. Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus. J Pediatr Surg 2006; 41:1226–9. [5] Kennedy AP, Snyder CL, Ashcraft KW, Manning PB. Comparison of musclesparing thoracotomy and thoracoscopic ligation for the treatment of patent ductus arteriosus. J Pediatr Surg 1998;33:259–61. [6] Rukholm G, Farrokhyar F, Reid D. Vocal cord paralysis post patent ductus arteriosus ligation surgery: risks and co-morbidities. Int J Pediatr Otorhinolaryngol 2012;76:1637–41. [7] Nezafati MH, Soltani G, Mottaghi H, Horri M, Nezafati P. Video-assisted thoracoscopic patent ductus arteriosus closure in 2,000 patients. Asian Cardiovasc Thorac Ann 2011;19:393–8. [8] Villa E, Vanden Eynden F, Le Bret E, Folliguet T, Laborde F. Paediatric video-assisted thoracoscopic clipping of patent ductus arteriosus: experience in more than 700 cases. Eur J Cardiothorac Surg 2004;25: 387–93. [9] Hines MH, Raines KH, Payne RM, Covitz W, Cnota JF, Smith TE et al. Video-assisted ductal ligation in premature infants. Ann Thorac Surg 2003; 76:1417–20. [10] Burke RP, Jacobs JP, Cheng W, Trento A, Fontana GP. Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants. Pediatrics 1999;104:227–9. [11] Mandhan P, Brown S, Kukkady A, Samarakkody U. Surgical closure of patent ductus arteriosus in preterm low birth weight infants. Congenit Heart Dis 2009;4:34–7. [12] Monteiro AJ, Canale LS, Rosa RV, Colafranceschi AS, Pinto DF, Baldanza M et al. Minimally invasive thoracotomy (muscle-sparing thoracotomy) for occlusion of ligamentum arteriosum (ductus arteriosus) in preterm infants. Rev Bras Cir Cardiovasc 2007;22:285–90.

Is thoracoscopic patent ductus arteriosus closure superior to conventional surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether thoracoscopic patent ductu...
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