Discussion
A double ductal system is produced by the persistence of the distal
segment of the sixth left and right aortic arch,6presenting as an isolated bilateral duct or associated with congenital
heart disease, such as congenital absence of one of the pulmonary
arteries, among others.3
Due to its presentation at different ages and with different stages of
pulmonary hypertension, it is important to determine the appropriate
therapeutic approach, without a consensus on its management. Thereby,
Batlivala et al.7 highlight the importance of an early
diagnosis and intervention to optimize long-term results, recommending
the initial diagnosis with cardiac catheterization or magnetic resonance
imaging to adequately identify the anatomy and perform pulmonary
unifocalization early, coinciding with Varghese et
al.8 that recognition of the anatomy is essential
since it proposes reconnection in patients with origin of RPA from the
brachiocephalic trunk with a flap from the MPA.
Krammoh et al.5 propose a two-stage strategy, with the
placement of an intraductal stent followed by direct surgical
reconnection or a prosthetic graft, coinciding with the series by Mery
et al,9 where they performed centralization, a
surgical connection between the MPA and RPA, in a single stage in 2
patients. With the remaining 8 cases, an intraductal stent was placed in
2 of the cases and 6 were treated with a systemic-to-pulmonary shunt. In
a second surgical procedure 7 patients were later corrected with
centralization, highlighting the rehabilitation of the pulmonary artery
branches as an effective measure to restore the affected blood flow.
The critical factor that determines the treatment strategy is the size
of the affected pulmonary artery, as determined by Trivedi et
al.10 who found that the best strategy for patients
with hypoplasia of RPA and a wide left ductus arteriosus and pulmonary
hypertension, was the hybrid therapy with two stages: right intraductal
stent and closure with a ductal occluder device of the left ductus
arteriosus, facilitating the growth of RPA with normalization of
pulmonary pressures and finally performing surgical centralization with
a vascular graft with cardiopulmonary bypass similar to the proceedings
in our center.
In conclusion, due to the low incidence of this defect, and its delay in
diagnosis and treatment, it is important to determine the best
therapeutic strategy, a situation that in our center carried the
therapeutic success of the two patients presented.
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