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ORIGINAL ARTICLE Table of Contents   
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 100-103
Is transcatheter closure superior to surgical ligation of patent ductus arteriosus among Nigerian Children?


1 Department of Paediatrics and Child Health; Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Nigeria
2 Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Nigeria
3 Department of Surgery, Cardiothoraxic Unit, Lagos State University College of Medicine, Ikeja, Nigeria
4 Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
5 Tristate Cardiovascular Centre, Cardiothoracic Unit, Babcock University Teaching Hospital, Idi-Ani, Ogun State, Nigeria
6 First Cardiology Consultants, Ikoyi, Lagos, Nigeria

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Date of Web Publication27-Jun-2019
 

   Abstract 

Background: Patent ductus arteriosus (PDA) is common among Nigerian children. It is the second only to ventricular septal defect among congenital heart diseases in Nigeria children. The study centers are the only centers in Nigeria which are able to offer both transcatheter closure of PDA and surgical ligation. The study aims to compare both methods in terms of the demographics of the individuals, cost and outcome. Patients and Methods: Prospective, cross-sectional involving consecutive individuals who had either transcatheter closure or surgical ligation of PDA from June 2010 to January 2014. Individuals were grouped according to the method of closure of their defect. Data on their demographics, size of the defects, cost of treatment and outcome were compared for the two groups. The analysis was done using Microsoft Excel statistical software supplemented by Statistical Package for Social Sciences version 20.0. P < 0.05 was considered statistically significant. Results: A total number of 28 individuals had either surgical ligation or device closure of PDA done at the studied period. The mean age of all the individuals was 4.58 ± 4.20 years with a median age of 3 years. The mean age of individuals that had surgical ligation was 3.40 ± 0.92 years and mean age of those who had transcatheter device closure was 6.69 ± 1.05 years (P = 0.677). Male to female ratio in both groups were 0.4:1. No mortality was recorded in both groups. However, 6 (21.4%) of the surgical patients and 1 (3.57%) of the patient with device closure had complications. The direct cost of the procedure for each of the patient who had device closure of PDA was about $3000 whereas the cost of surgical closure was about $1000. The indirect cost for device closure was about $100 while that of surgical closure was about $5000. Conclusion: Device closure of PDA has lesser risk of complications compared to surgical ligation. Its indirect cost is also cheaper. There is a need for availability and accessibility to device closure of PDA in our environment.

Keywords: Children, ligation, Nigeria, patent ductus arteriosus, transcatheter

How to cite this article:
Animasahun BA, Adekunle MO, Falase O, Gidado MT, Kusimo OY, Sanusi MO, Johnson A. Is transcatheter closure superior to surgical ligation of patent ductus arteriosus among Nigerian Children?. Afr J Paediatr Surg 2018;15:100-3

How to cite this URL:
Animasahun BA, Adekunle MO, Falase O, Gidado MT, Kusimo OY, Sanusi MO, Johnson A. Is transcatheter closure superior to surgical ligation of patent ductus arteriosus among Nigerian Children?. Afr J Paediatr Surg [serial online] 2018 [cited 2019 Jul 23];15:100-3. Available from: http://www.afrjpaedsurg.org/text.asp?2018/15/2/100/261626

   Introduction Top


The incidence of congenital heart disease in Nigeria ranges from 3 to 5 per 1000 births.[1],[2] Patent ductus arteriosus (PDA) is the second-most common congenital heart disease in Nigeria accounting for 22%[3] and 12.1%[4] in reported studies.

The reported incidence of PDA varies because of different population group studied and method used in its detection.[5] Functional closure of PDA occurs within the first 48 h of birth; however, some authorities consider the patency to be abnormal after 3 months of age.[6]

The first clinical attempt at ligating a PDA in a patient that had bacterial endocarditis was by Graybiel et al.[7] in 1938, although the patient died 4th day postoperation of acute gastric dilatation. The first successful ligation was performed by Gross and Hubbard[8] in Boston later in the year 1938, and this led to the advent of PDA ligation.

The first report on transcatheter closure of PDA was first reported it 1967 by Porstmann et al.[9] In Nigeria, the first transcatheter closure of a PDA was done by Animasahun et al.[10] in October 2010.

Studies have been done to compare the outcome and cost implications of both surgical and device closure of PDA.[8],[11],[12] Gray et al.[12] did a retrospective review of referrals from fourteen centers in the USA and Canada. Participants that had device closure had an average hospital stay of 2.4 days compared to 5.7 days in those that had surgical closure. One subject that had surgical closure had a major complications compared to five patients in the device ligation group. Some of the major complications that occurred in individuals that had a device closure include bacteremia and embolization while chylothorax occurred in a patient that had surgical closure. The cost analysis was higher in individuals that had device closure.

Ahmadi et al.[11] in Iran reported a higher morbidity and mortality rate in individuals that had surgical closure of PDA but with a lesser cost implication compare to those that had a device closure.

Zulqarnain et al.[13] in Pakistan reported a lesser complication and length of hospital stay in individuals with PDA that had a device closure. The residual shunt was seen in three and none of the individuals that had surgical ligation and device closure respectively. A higher cost of treatment was observed in individuals that had device closure compared to surgically ligated cases.

In Nigeria, Onakpoya et al.[14] reported a 5-year review of sixteen open cardiac surgical cases in Ile-Ife. In all, eleven of the cases were PDA. Of the subject with PDA, there was a recanalization of the ductus in a subject, two cases of chylothorax occurred, and a subject died few hours postoperation.

With careful literature search, no study has been done to compare the clinical outcome and cost implications of surgical ligation and device closure of PDA in Nigeria. This study is aimed at comparing the profiles of patients who had surgical closure and device closure of PDA in Lagos Nigeria.


   Patients and Methods Top


This prospective, analytical, and cross-sectional study was carried out at the Lagos State University Teaching Hospital (LASUTH) and Reddington Multispecialty Hospital, Lagos Nigeria between June 2010 and January 2014. The Lagos State University Teaching Hospital is a tertiary center that receives patients from different hospitals within and outside Lagos State. The Department of Paediatrics in this center has a well-established cardiology unit with a Paediatric Cardiologist. Reddington Multispecialty Hospital is a highly recognized standard hospital in Nigeria with facilities for cardiac evaluation and some cardiac surgeries.

All individuals had PDA confirmed by a cardiologist using a transthoracic echocardiography. The cardiac evaluation was performed using a Vivid I machine with a transducer frequency of 5MHZ. Subjects were grouped according to the method of closure of their defect. Data on their demographics, size of the defects, cost of treatment, and outcome were compared for the two groups.

Collected data were analyzed using Microsoft Excel and Statistical Package for Social Sciences version 20.0 (IBM). Subjects' demographics were represented as frequency and percentages. Continuous variables were summarized using mean and standard deviation. P < 5% (0.05) was considered statistically significant.


   Results Top


A total number of 28 subjects had either surgical ligation or device closure of PDA done at the studied period. The characteristics of the subjects are highlighted in [Table 1]. Sixteen subjects (57.1%) had surgical ligation and 12 (42.9%) had device PDA closure. The age range of all subjects was 8 months to 16 years. The mean age of all subjects was 4.58 ± 4.20 years with a median age of 3 years with M:F ratio of 1:3. The mean age of subjects that had transcatheter device closure was 6.69 ± 1.05 years while the mean age during surgical ligation was 3.40 ± 0.92 years (P = 0.677). The median age at device closure and surgical ligation was 5.50 and 1.35 years, respectively. Four and five subjects had surgical ligation and device closure respectively after the age of 5 years.
Table 1: Characteristics of the subjects

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Surgical ligation of PDA was done in 12 females (75%) and 4 males (25%) patients. About 76.9% of subjects that had device closure were female and 23.1% were male. The male to female ratio for both device closure and surgical ligation was similar (1:3).

There was no subject that had device closure in infancy. However, six subjects benefitted from surgical ligation during infancy. A higher proportion of subjects had surgical closure at an earlier age compared to those that had device closure as shown in [Figure 1].
Figure 1: Age classification of the different methods of patent ductus arteriosus closure and the number of subjects

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The size of the defect for the patient who had surgical closure was statistically larger with a mean size of 8.5 ± 0.13 mm while those who had device closure had a mean size of 3.6 ± 0.27 mm (P < 0.001).

There was no mortality in both procedures. However, 6 (21.4%) of the surgical patients and 1 (3.57%) of the patient with device closure had complications. One out of the six surgical patients had a low ejection fraction of 40%, postoperative right ventricular dysfunction and elevated blood pressure. Three of the patients had a fever, a patient had sepsis and two cases of residual PDA were seen. The only patient with the device closure who had complication had transient hypertension.

The direct cost of the procedure for each of the patient who had device closure of PDA was about $3000 whereas the cost of surgical closure was about $1000. The indirect cost for device closure was about $100 while that of surgical closure was about $5000. All the procedures were self-funded by the caregivers.


   Discussion Top


In the present study, the mean age of subjects that had transcatheter device closure was higher than the mean age of subjects that had surgical ligation which was statistically significant. Mean age of subjects that had device closure in the present study was similar to the mean value of 3.1 ± 3.4 years of subjects that had intervention in India which was reported by Arodiwe et al.[15]

The mean age of subjects that had surgical ligation in the present study was lower than the reported mean age of 7.1 ± 6.7 years by Onakpoya et al.[14] in Ile-ife. The time of surgical interventions in the reported studies in Nigeria were remarkably higher than a report by Lin et al.[16] in Taiwan where ligation was done at a mean age of 17.4 ± 10 days. Interventions in individuals above 5 years are associated with life-threatening complications such as pulmonary hypertension[17], and this calls for measures that will enhance more accessibility to and availability of interventions for PDA closure in our environment.

Two-thirds of subjects in the current studies are female. This similar higher number of female subjects was reported by Onakpoya et al.[14] and Arodiwe et al.[15] This is not surprising because PDA is commoner in females than males.[17] Patients that had surgical ligation had a longer hospital stay compared to those that had device closure in the present study. This is similar to the finding by Zulqarnain et al.[13] in Pakistan Ahmadi et al.[11] in Iran and Costa et al.[18] in Brazil. The lesser duration of hospital stays in subjects that had device closure is expected because device closure is minimally invasive compared to surgical ligation.

In the present study, a higher percentage of patients that had surgical ligation had complications compared to the group that had a device closure. This is similar to the report by Zulqarnain et al.[13] and Ahmadi et al.[11] where mortality and a higher morbidity were seen in surgically ligated group compared to subjects that had device closure. Residual shunt was seen in the present study in two cases (12.5%) that had surgical ligation and none in the device group. This is similar to the finding of Zulqarnain et al.[13] where residual shunt was seen in 1.5% of surgically intervened group and none of those that had a device closure. The outcome of transcatheter closure of PDA in Nigeria in the present which was commenced in the year 2010 is encouraging. In comparison to device closure on Nigerian children that travelled to India to have the surgery,[15] there was no failure of procedure in the current study and complication such as protrusion of the device into the aorta did not occur.

Device closure is more expensive than surgical ligation as seen in the present study and studies by Zulqarnain et al.[13] and Ahmadi et al.[11] However, prolonged hospital stay, higher risk of complications and the cost of its management in patients that had surgical ligation makes device closure of PDA a better option. There is a need for embracement of transcatheter closure of ductus in our environment to reduce the morbidity and mortality that is more associated with surgical ligation. There is a need for an intense intervention of health financing in Nigeria where out of pocket is still mostly what is in existence. Insurance scheme will enhance early intervention with a more preferable device closure technique that will translate to reduction of morbidity and mortality that can occur from PDA.


   Conclusion Top


Device closure of PDA has lesser risk of complications compared to surgical ligation. There is need for availability of and accessibility to device closure in our environment

Acknowledgments

We gratefully acknowledge the subjects who participated in this study, their parents and caregivers including other staff who were involved in their care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gupta B, Antia AU. Incidence of congenital heart disease in Nigerian children. Br Heart J 1967;29:906-9.  Back to cited text no. 1
    
2.
Ibadin MO, Sadoh WE, Osarogiagbon W. Cogenital heart diseases at the University of Benin Teaching Hospital. Niger J Paediatr 2005;32:29-32.  Back to cited text no. 2
    
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Jaiyesimi F, Antia AU. Congenital heart disease in Nigeria: A ten-year experience at UCH, Ibadan. Ann Trop Paediatr 1981;1:77-85.  Back to cited text no. 3
    
4.
Sadoh WE, Uzodimma CC, Daniels Q. Congenital heart disease in Nigerian children: A multicenter echocardiographic study. World J Pediatr Congenit Heart Surg 2013;4:172-6.  Back to cited text no. 4
    
5.
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-900.  Back to cited text no. 5
    
6.
Elsheikhi RG, Darweish AZ, Elsetiham AZ, Kamel H. Comparative study between real time dimensional echocardiogram and angiography in elevation of patent ductus arteriosus, a single center experience. J Saudi Hear Assoc 2014;26:204-11.  Back to cited text no. 6
    
7.
Graybiel A, Strieder JW, Boyer NH. An attempt to obliterate the patent ductus arteriosus in a patient with subacute bacterial endateritis. Am Heart J 1938;15:621-4.  Back to cited text no. 7
    
8.
Gross RE, Hubbard JP. Surgical ligation of a patient ductus arteriosus of first successful case. JAMA 1939;112:729-31.  Back to cited text no. 8
    
9.
Porstmann W, Wierny L, Warnke H. Closure of persistent ductus arteriosus without thoracotomy. Ger Med Mon 1967;12:259-61.  Back to cited text no. 9
    
10.
Animasahun BA, Johnson A, Ogunkunle OO, Idowu S, Bode-Thomas F, Maheshwari S, et al. Transcatheter closure of patent ductus arteriosus: Report of the first case in Nigeria. Afr J Med Med Sci 2012;41:327-30.  Back to cited text no. 10
    
11.
Ahmadi A, Sabri M, Bigdelian H, Dehghan B, Gharipour M. Comparison of cost effectiveness and post operative outcome of device closure techniques for treatment of patent ductus arteriosus. ARYA Atheroscler 2014;10:37-40.  Back to cited text no. 11
    
12.
Gray DT, Fyler DC, Walker AM, Weinstein MC, Chalmers TC. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. The patient ductus arteriosus closure comparative study group. N Engl J Med 1993;329:1517-23.  Back to cited text no. 12
    
13.
Zulqarnain A, Younas M, Waqar T, Beg A, Asma T, Baig MA, et al. Comparison of effectiveness and cost of patent ductus arteriosus device occlusion versus surgical ligation of patent ductus arteriosus. Pak J Med Sci 2016;32:974-7.  Back to cited text no. 13
    
14.
Onakpoya UU, Ogunrombi AB, Aladesuru AO, Okeniyi JA, Adenekan AT, Owojuyigbe AM. Trans-thoracic open ligation of a persistent ductus arteriosus in Ile-Ife, Nigeria. Niger J Cardiol 2015;12:8-12.  Back to cited text no. 14
    
15.
Arodiwe IO, Diele DK, Chinawa JM, Gouthami V, Murthy KS, Obidike EO, et al. Clinical study of trans-catheter closure of patent ductus arteriosus with occlude devices among children aged 9 months to 18 years. Int J Trop Dis Health 2014;4:31-44.  Back to cited text no. 15
    
16.
Lin YC, Huang HR, Lein R, Yang PH, Su WJ, Chung HT. Management of patent ductus arteriosus in term or near term neonate with respiratory distress. Paediatr Neonatol 2010;51:160-5.  Back to cited text no. 16
    
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Clatworthy HW, McDonald VG. Optimal age for surgical closure of patent ductus arteriosus. JAMA 1958;167:444-8.  Back to cited text no. 17
    
18.
Costa RN, Pereira FL, Ribeiro MS, Pedra SR, Succi F, Macques P, et al. Percutaneous vs. surgical treatment of patent ductus arteriosus in children and adolescents. Rev Bras Cardiol Invasiva 2012;20:315-23.  Back to cited text no. 18
    

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Correspondence Address:
Dr. Barakat Adeola Animasahun
Department of Paediatrics and Child Health, Lagos State University College of Medicine, 1-5 Oba Akinjobi Lane, Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajps.AJPS_53_17

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