Pre-existing left pulmonary artery stenosis and other anomalies associated with device occlusion of patent ductus arteriosus

Left Pulmonary Artery Occlusion Following Device Closure of Patent Ductus Arteriosus in Premature Infants

Background

Device closure of a patent ductus arteriosus (PDA) is rapidly evolving, with the Amplatzer Piccolo Occluder (Abbott) receiving US Food and Drug Administration approval and becoming the first device approved for PDA closure in patients ≥700 g. We report on the first known cases of complete left pulmonary artery (LPA) occlusion following Piccolo closure of a PDA in premature infants.

Methods

Retrospective chart analysis of PDA closures.

Results

We have performed over 50 cases of Piccolo device closure of the PDA in preterm neonates in the past 2 years, with these 2 cases representing our only complications (4%). This represents a total complication rate similar to or lower than most centers that have published data for this procedure.

Conclusions

Although rare, severe LPA obstruction can be seen in premature infants following device closure of the PDA. The Piccolo device is designed to ideally remain entirely intraductal. Although our device selection appeared to provide a device short enough for the given ductal length, we recommend, whenever possible, giving consideration to using the shortest possible device. We also recommend increasing the frequency of echocardiographic surveillance to weekly studies if at any time the imaging demonstrates an increase in the degree of obstruction/turbulence.

The incidence of recurrent laryngeal nerve injury resulting in vocal cord paralysis following interventional congenital catheterisation procedures

BACKGROUND

Recurrent laryngeal nerve injury leading to vocal cord paralysis is a known complication of cardiothoracic surgery. Its occurrence during interventional catheterisation procedures has been documented in case reports, but there have been no studies to determine an incidence.

OBJECTIVE

To establish the incidence of left recurrent laryngeal nerve injury leading to vocal cord paralysis after left pulmonary artery stenting, patent ductus arteriosus device closure and the combination of the procedures either consecutively or simultaneously.

METHODS

Members of the Congenital Cardiovascular Interventional Study Consortium were asked to perform a retrospective analysis to identify cases of recurrent laryngeal nerve injury after the aforementioned procedures. Twelve institutions participated in the analysis. They also contributed the total number of each procedure performed at their respective institutions for statistical purposes.

RESULTS

Of the 1337 patients who underwent left pulmonary artery stent placement, six patients (0.45%) had confirmed vocal cord paralysis. 4001 patients underwent patent ductus arteriosus device closure, and two patients (0.05%) developed left vocal cord paralysis. Patients who underwent both left pulmonary artery stent placement and patent ductus arteriosus device closure had the highest incidence of vocal cord paralysis which occurred in 4 of the 26 patients (15.4%). Overall, 92% of affected patients in our study population had resolution of symptoms.

CONCLUSION

Recurrent laryngeal nerve injury is a rare complication of left pulmonary artery stent placement or patent ductus arteriosus device closure. However, the incidence is highest in patients undergoing both procedures either consecutively or simultaneously. Additional research is necessary to determine contributing factors that might reduce the risk of recurrent laryngeal nerve injury.

Left recurrent laryngeal nerve palsy following aortic arch stenting: A case report

BACKGROUND

Aortic arch stenting is continuously emerging as a safe and effective option to alleviate aortic arch stenosis and arterial hypertension.

CASE SUMMARY

We present a 15-year-old girl with aortic arch hypoplasia who had undergone implantation of an uncovered 22 mm Cheatham-Platinum stent due to severe (native) aortic arch stenosis. On follow-up seven months later, she presented a significant re-stenosis of the aortic arch. A second stent (LD Max 26 mm) was implanted and both stents were dilated up to 16 mm. After an initially unremarkable post-interventional course, the patient presented with hoarseness five days after the intervention. MRI and CT scans ruled out an intracranial pathology, as well as thoracic hematoma, arterial dissection, and aneurysm around the intervention site. Laryngoscopy confirmed left vocal fold paresis attributable to an injury to the left recurrent laryngeal nerve (LRLN) during aortic arch stenting, as the nerve loops around the aortic arch in close proximity to the area of the implanted stents. Following a non-invasive therapeutic approach entailing regular speech therapy, the patient recovered and demonstrated no residual clinical symptoms of LRLN palsy after six months.

CONCLUSION

Left recurrent laryngeal nerve palsy is a rare complication of aortic arch stenting not previously reported.

Patent ductus arteriosus closure using the Amplatzer® vascular plug II for all anatomic variants

OBJECTIVES

To evaluate the safety and efficacy of the Amplatzer® Vascular Plug II (AVPII) for closure of the patent ductus arteriosus (PDA).

BACKGROUND

The PDA has significant anatomic variation. No device has proven applicable to all PDAs. Previous case reports and small series have documented limited use of the AVPII for some PDA types. We describe the largest and most diverse experience using the AVPII.

METHODS

A retrospective analysis of patients undergoing percutaneous PDA closure between 01/01/2009 and 05/01/2012 was performed. The PDA was characterized, measured, and the device chosen was listed. Deployment technique, complications and procedural results were recorded.

RESULTS

Sixty-seven procedures were performed. The AVPII was utilized for 43 (64.2%), 15 (20.9%) had coils, 7 (10.4%) had the AGA duct occluder, and 3 (4.5%) were referred for surgery. The AVPII was placed in infants as young as 2 months and 4.2 kg. AVPII size ranged from 4 to 10 mm. All PDA types were closed. Retrograde and antegrade deployments were performed, using the outer disc as a "retention skirt" to secure the device and improve occlusion. Three patients were up-sized prior to release. All deployments were successful; 89% "in-lab" and 100% closure on postprocedural echocardiogram. There were no complications.

CONCLUSIONS

We report the largest experience with the AVPII for PDA closure. The device was used in all morphologic types and small patients. It is low profile, easily repositioned, and had excellent results without complications. We contend that this is the most versatile device currently available.

Left recurrent laryngeal nerve palsy secondary to left pulmonary artery stent in a child

We report a 10-year-old girl who developed persistent hoarseness after stent placement for the treatment of left pulmonary artery stenosis. Laryngoscopy performed 21 months after stent placement revealed left vocal cord paralysis, presumed secondary to compression of the left recurrent laryngeal nerve by the stent. Pediatric cardiologists should be reminded of this possible rare complication after stent placement.

Large tortuous patent ductus arteriosus with proximal left pulmonary artery hypoplasia

A 3-year-old male child was diagnosed with patent ductus arteriosus. The evaluation of this patient by computed tomography (CT) angiography revealed a big tortuous patent ductus arteriosus and proximal left pulmonary artery stenosis. Successful elective surgical repair was undertaken.