Transcatheter occlusion of the patent ductus arteriosus in infants: Experimental testing of a new Amplatzer device

Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies

INTRODUCTION

With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced.

AREA COVERED

This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed.

EXPERT OPINION

There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.

Patent ductus arteriosus: From pharmacology to surgery

Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.

Percutaneous Closure of the Patent Ductus Arteriosus in Very-Low-Weight Infants

In view of the known complications of drug therapy and open surgical ligation, and the potential for prolonged patent ductus arteriosus (PDA) exposure to be harmful, health care practitioners have sought new approaches to achieve definitive ductal closure. Interest in percutaneous (catheter-based) PDA closure has emerged within the neonatal community as a viable treatment option, because it has been fueled by recent procedural and device modifications, as well as mounting feasibility and safety data. Herein, we provide a contemporary review of percutaneous PDA closure among infants at the crux of the medical debate-very-low-weight infants (≤1,500 g), including: 1) characterization of traditional PDA treatments (drug therapy, open surgical ligation) and conservative (nonintervention) management options; 2) a general overview of the major procedural steps of percutaneous ductal closure, including efforts to reduce thrombotic complications and the emergence of a novel US Food and Drug Administration-approved device; 3) a systematic review and meta-analysis to better understand risk profiles of percutaneous PDA closure in this population; and 4) discussion of current gaps in our understanding of optimal PDA care, including the critical need for well-designed, randomized, controlled clinical trials.

Update on shunt closure in neonates and infants

Introduction: Cardiac defects that result in shunting are the most common types of congenital heart anomalies. Although these lesions can be simple, they can cause significant hemodynamic changes and can be challenging to manage in neonates and infants. Over the recent decades, the development of new transcatheter techniques and devices has made it safe and feasible to manage such defects when indicated, even in the smallest of patients. Understanding these interventional procedures is essential in order to manage those patients.Areas covered: In this article, we review the techniques and experience for closure of atrial septal defects, ventricular septal defects, patent ductus aarteriosus,as well as coronary arteriovenous malformations and fistulas in neonates and infants. Literature review of PubMed articles was performed through January 2021, with focus on the latest data and results of the usage of interventional techniques in treating these lesions specifically in this age-group.Expert opinion: Significant shunting lesions can be particularly challenging to manage in neonates and infants. Newer lower profile devices will likely continue to be developed in the future, allowing their use for transcatheter interventions in even smaller patients and those with more complex anatomy.

The Outcomes of Transcatheter Closure in Patients with Patent Ductus Arteriosus at Haji Adam Malik General Hospital, Indonesia

BACKGROUND: Patent ductus arteriosus (PDA) is one of the most common acyanotic congenital heart diseases. The incidence of PDA is approximately 1 in 500 full-term neonates. The current management of PDA includes pharmacological and surgical treatments. Transcatheter closure is a preferable PDA treatment than pharmacological intervention, for medications have a higher failure rate in premature infants. Several studies have reported the efficacy and safety of transcatheter closure in smaller and lower-weight infants. AIM: This study aims to describe the outcomes of transcatheter closure of PDA, which are complete closure, migrating device, and residuals, while also investigating factors that might affect these outcomes. METHODS: A descriptive cross-sectional study was conducted from January to March 2018 in the pediatric cardiology outpatient clinic of Haji Adam Malik Hospital, Medan, Indonesia. All PDA patients who underwent transcatheter closure were included in this study. We collected patients’ demographic data (age and sex), PDA size (categorize into large, moderate, and small), and PDA closure outcomes from medical records. The collected data were then analyzed with SPSS. RESULTS: One hundred and two children were included in this study, comprised 34 (33.3%) males and 68 (66.7%) females, with a mean age of 4.3 (±4.02) years old and the mean size of the defects 4.4 (±2.25) mm. Transcatheter closure with Lifetech® PDA Occluder was performed in 95 (93.1%) and MFO® in 7 (6.9%) patients. Small residuals were found in three patients, device migration was found in one patient. No relationship was found between the size of PDA and the outcomes measured. CONCLUSION: We concluded that transcatheter closure remains an effective treatment for PDA, with a considerable success rate.

Innovations in Congenital Interventional Cardiology

This article aims to summarize some of the key advances in congenital interventional cardiology over the past few years, from novel imaging technologies, such as virtual reality, fusion imaging, and 3-dimensional printed models, to newly available devices and techniques to facilitate complex procedures including percutaneous pulmonary valve replacement and hybrid procedures. It is an exciting time for the field, with rapid development of techniques, devices, and imaging tools that allow a minimally invasive approach for many congenital cardiac defects with progressively less radiation and contrast doses.

Percutaneous device closure of pediatirc patent ductus arteriosus through femoral artery guidance by transthoracic echocardiography without radiation and contrast agents

Background

For many years, percutaneous interventional occlusion of congenital patent ductus arteriosus (PDA) has been completed using radiation and contrast agents. In this study, transthoracic echocardiography without radiation and contrast agents was used to complete percutaneous occlusion of pediatric PDA.

Methods

Thirty-two children (8 males and 24 females) with normal heart function and no other intracardiac deformities were diagnosed with PDA (20 funnel type; 12 tube type), One patient had peripheral facial paralysis, 1 patient had epilepsy, and 1 case had multiple cervical deformities. All procedures were performed in the surgical operating room (without Digital Subtraction Angiography (DSA) equipment) under basic anesthesia through the femoral artery pathway. The procedures were guided by transthoracic echocardiography (TTE) by establishing an orbit with a catheter through the femoral artery to thepatent ductus arteriosus,pulmonary artery and right ventricle. A suitable ventricular septal defect occluder was placed using the femoral artery approach,and the treatment effect was evaluated by echocardiography after occlusion. The Outpatient follow-up was performed at 1, 3 months after the operation.

Results

All cases had successful closure of PDA, which took only 35.6 ± 6.4 min. The diameter of the device was 4.8 ± 2.3 mm, and the heart murmur disappeared. There was no shunt between the left pulmonary artery and the descending aortic artery, and the length of hospitalization was 3.4 ± 0.5 days. No other incisions were needed in 32 cases. No occluder was removed, and no residual shunt was found after operation; moreover, no ICU stay was needed, and the mean hospital stay was 3.4 ± 0.5 days. No residual shunt was found at the 1-, 3-month follow-up visit.

Conclusions

PDA closure guided by transthoracic echocardiography via femoral artery puncture is a minimally invasive procedure that avoids injuries due to radiation and contrast agents. This method has wider application prospects in pediatrics.

Patent ductus arteriosus in preterm infants: is early transcatheter closure a paradigm shift?

The optimal management approach of the patent ductus arteriosus (PDA) in premature infants remains uncertain owing the lack of evidence for long-term benefits and the limited analyses of the complications of medical and surgical interventions to date. In recent years, devices suitable to plug the PDA of premature infants (including extremely low birthweight, <1000 g) have become available and several trials have demonstrated successful and safe transcatheter PDA closure (TCPC) in this population. Whether TCPC represents a paradigm shift in PDA management that will result in improved short- and long-term outcomes, less bronchopulmonary dysplasia, improved neurodevelopment, or better long term renal function remains to be seen. Careful rigorous study of the potential benefits of TCPC in this highly vulnerable population in the context of well-designed adequately powered trials is needed prior to widespread adoption of this approach.

Transcatheter closure of the patent ductus arteriosus at a public sector hospital in Soweto, South Africa: a review of patient outcomes over 15 years

BACKGROUND

Methods of closing patent ductus arteriosus (PDA) have evolved over time. We review this development in our setting.

METHODS

This was a retrospective analysis of children who had transcatheter PDA closure at Chris Hani Baragwanath Hospital between 1993 and 2008.

RESULTS

Over 15 years, 1 254 PDAs were diagnosed, of which 293 required intervention; 139 patients had transcatheter closure, the median age was 1.8 years (interquartile range = 1-4.5 years) and 66% were female (92/139). Mean PDA diameter was 3.2 mm (standard deviation = 1.6 mm), with an average 2:1 shunt. Transcatheter closure was performed using COOK^® Flipper coils (n = 93) or Amplatzer^™ devices (n = 46). Early occlusion rates for coils were 52% (39/75) and late occlusion occurred in 91% (68/75) of patients. For Amplatzer devices, early occlusion rates were 94% (33/35) and late occlusion was 100%. Amplatzer^™ devices, available since 2003, were overwhelmingly used in the later years.

CONCLUSIONS

Transcatheter PDA closure was safe and effective in this setting, with outcomes similar to reports elsewhere.

Preliminary results of the CeraflexTM PDA occluder and device behaviour during releasing

INTRODUCTION

The CeraFlexTM PDA occluder is a new flexible device with a unique delivery system that may be beneficial with regard to not changing the device position after releasing. We prospectively evaluate the efficacy of the device and also the device behaviour patterns during release.

METHODS

The study included 21 patients. Their median age was 1.2 years (from 6 months to 28 years) and weight was 9.6 kg (from 5.4 to 82 kg). All of the ducts were conical except one atypical ductus. Median ductal diameter at the pulmonary end was 3.8 mm (from 2.2 to 8.2 mm). The ductus was closed using an antegrade approach, but special attention was paid to the patterns of device behaviour during and just after releasing.

RESULTS

Three different modes of device behaviour were observed during and just after releasing: (1) Neither difficulty nor change of position in 13 patients (62%), (2) a little difficulty in releasing but no change of position in 6 (29%), and (3) change of the device position in 2 (9%). There was no residual shunt on the next day except in one patient, in whom late device embolisation occurred. The device was retrieved and another, bigger device implanted.

CONCLUSION

The CeraFlexTM PDA occlude device seems to be safe and efficacious for patent ductus arteriosus closure. Its unique delivery system generally fixes the device in a stable position that does not change after release (91%). Minor difficulty in releasing is not uncommon; however, the major disadvantage is the need for larger sheaths for delivery.

Transcatheter occlusion of the patent ductus arteriosus in premature infants weighing less than 1200 g

OBJECTIVES

Over the last few decades different strategies have been proposed to treat persistent ductal patency in premature infants. The advent of the Amplatzer Duct Occluder II Additional Size (ADOIIAS) provided the potential to close the patent ductus arteriosus (PDA). Opinions differ on the significance and treatment of PDA in premature neonates. Because surgical ligation and medical therapy both have their drawbacks, interventional catheterisation can be considered as an alternative means of closing the ductus arteriosus. Our aim was to analyse the feasibility, safety and efficacy of this device in premature infants weighing <1200 g at procedure.

METHODS

Eighteen premature infants underwent transcatheter closure. The procedure was performed in the catheterisation laboratory by venous cannulation without angiography. The position of the occluder was directed by X-ray and ultrasound. We looked at procedural details, device size selection, complications and short-term and mid-term outcomes.

RESULTS

Eighteen infants born at gestational ages ranging between 23.6 and 29+6 weeks (mean±SD 25+6±3 weeks) underwent transcatheter PDA closure. Their mean age and weight at the time of the procedure was 20 days (range 8-44 days) and 980 g (range 680-1200 g), respectively. The mean PDA and device waist diameters were 3.2±0.6 mm (range 2.2-4 mm) and 4.5±0.6 mm, respectively, and the mean PDA and device lengths were 4.3±1.2 mm (range 2-10 mm) and 2.5±0.9 mm, respectively. Complete closure was achieved in all but one patient. There was no device migration. One patient developed a left pulmonary artery obstruction. Three infants died. Two deaths were related to complications of prematurity and one to the procedure.

CONCLUSIONS

Transcatheter closure of a PDA is feasible in very low weight infants with ADOIIAS and is an alternative to surgery. Success requires perfect selection and placement of the occluder.

Radiation dose in paediatric cardiac catheterisation: A systematic literature review

OBJECTIVES

It is believed that children are more sensitive to ionising radiation than adults. This work reviewed the reported radiation dose estimates for paediatric cardiac catheterisation. A systematic literature review was performed by searching healthcare databases for studies reporting radiation dose using predetermined key words relating to children having cardiac catheterisation. The quality of publications was assessed using relevant Critical Appraisal Skills Programme questions and their reported radiation exposures were evaluated.

KEY FINDINGS

It is only in recent years that larger cohort observations have been undertaken. Although radiation dose from paediatric cardiac catheterisation has decreased in recent years, the literature indicated that it remains varied and potentially substantial.

CONCLUSION

Standardisation of weight categories and procedure types such as those recommended by the PiDRL project could help compare current and future radiation dose estimates.

Are the AMPLATZER Duct Occluder II Additional Sizes devices dedicated only for smaller children?

AIMS

The aim of this study was to present our experience with the AMPLATZER Duct Occluder II Additional Sizes (ADOIIAS) for the closure of different types of patent ductus arteriosus (PDA) in patients of various age groups.

METHODS AND RESULTS

A group of 103 patients, in whom the PDA (diameter below 3.5 mm) was closed using the ADOIIAS, was analysed. The median age of treated patients was 3.0 years (from 0.1 to 24 years), and 55 patients (53.4%) were older than three years. Ductal anatomy defined by angiography showed type A in 42 patients (40.8%), type C in six patients (5.8%), type D in 21 patients (20.5%), and type E in 34 patients (33.0%). In two cases, embolisation of the device occurred shortly after implantation. Both occluders were retrieved percutaneously. One death occurred in a neonate four days after ADOIIAS implantation (not related to the procedure: multi-organ failure). Total occlusion of PDA was confirmed in all patients the day after the procedure. No protrusion of the device into the aorta or pulmonary artery was observed in any patient during follow-up.

CONCLUSIONS

The use of the ADOIIAS is a good therapeutic option for the treatment of selected PDA. The implant may be successfully substituted for coil implantation in all age groups.

Computed tomography-based survey of the vascular anatomy of the juvenile Göttingen minipig

Over the past 50 years, image-guided procedures have been established for a wide range of applications. The development and clinical translation of new treatment regimens necessitate the availability of suitable animal models. The juvenile Göttingen minipig presents a favourable profile as a model for human infants. However, no information can be found regarding the vascular system of juvenile minipigs in the literature. Such information is imperative for planning the accessibility of target structures by catheterization. We present here a complete mapping of the arterial system of the juvenile minipig based on contrast-enhanced computed tomography. Four female animals weighing 6.13 ± 0.72 kg were used for the analyses. Imaging was performed under anaesthesia, and the measurement of the vascular structures was performed independently by four investigators. Our dataset forms a basis for future interventional studies in juvenile minipigs, and enables planning and refinement of future experiments according to the 3R (replacement, reduction and refinement) principles of animal research.

Transcatheter closure of PDA in premature babies less than 2 kg

Objective:

Our hypothesis was that percutaneous PDA closure in babies less than 2 kg was a safe and effective method. The aim of this study is to share our experience in transcatheter PDA closure in infants whose body weight is less than 2 kg in order to support our hypothesis.

Methods:

Between July 1997 and October 2014, 382 percutaneous PDA closures were done in our center. Nineteen patients who weighed less than 2 kg were included in this retrospectively study. The other inclusion criteria were 1) being symptomatic and PDA was thought as a possible contributor of medical state and 2) persistence of PDA after medical closure treatment. Patients who had sepsis and bleeding diathesis were excluded. According to size and shape of PDA, different types of devices were used such as detachable coils and Amplatzer duct occluders. Data was expressed as mean (SD) or median (minimum–maximum). Comparisons of means and medians were performed with Student’s t-test and with Mann–Whitney U test, respectively.

Results:

The median patient age and weight were 32 days and 1603 g (range 910–2000 g) respectively. Mean PDA diameter was 3.2±1.3 mm. Morphology of PDA was type A in 7 patients, type C in 10, type E in 1, and type B in 1 patient. There were no reported major complications. Stenosis of left pulmonary artery was detected in four patients, all of which resolved in 6 months follow-up.

Conclusion:

Percutaneous PDA closure in babies less than 2 kg is a safe and effective method that can be an alternative to surgery. Main distinguishing feature of this study is that it includes the largest cohort of patients less than 2 kg whose PDA closed percutaneously.

Identifying Gaps in Technology for Congenital Interventions: Analysis of a Needs Survey from Congenital Interventional Cardiologists

We carried out a device-needs survey to evaluate the gaps in device and equipment availability for congenital interventional cardiologists. As the complexity and demand for more complete solutions to congenital heart lesions increase, there is a growing need for modification and development of devices and equipment to support this endeavor. The survey was sent out via e-mail to members of the Congenital Cardiovascular Interventional Study Consortium and the Society for Cardiac Angiography and Interventions with a reach of over 350 congenital interventionalists. Responses were received from 68 cardiologists in 8 countries. In terms of the most desired device, 41 % ranked bioresorbable stents as their first choice from a list of 12 possible devices. Similarly, 23 % ranked large covered stents as their first choice. Twenty-seven percent of participants believed bioresorbable stents would have the greatest potential to improve morbidity of their patients, with another 27 % reporting that covered stents would have the greatest impact. Fifty percent of participants reported that they would like to see large covered stents available in their country. These data point toward a perceived need for the development/approval of bioresorbable stents for the pediatric age group, as well as the need to approve the use of large covered stents in the pediatric age group in the USA.

Ductal closure with radiofrequency energy: the first in-human report

BACKGROUND

Vascular obstruction is one of the complications of radiofrequency ablation. Following our previous report on the use of radiofrequency energy for vascular closure in an animal model in this journal, we herein present the first ever in-human report. Patient and method The patient was a 3-year-old boy, who received a permanent endocardial pacemaker for congenital complete heart block. He also had a conical patent ductus arteriosus. The ductus was occluded with radiofrequency energy on the arterial side with no complications.

CONCLUSION

Closure of patent ductus arteriosus and probably other problematic small vessels could be achieved with radiofrequency energy. Further experience will elucidate the future scope of this novel technique.

Transcatheter closure of patent ductus arteriosus in under 6 kg and premature infants

BACKGROUND

Transcatheter closure of a patent ductus arteriosus (PDA) has always been considered risky for infants weighing <6 kg and preterms. We present our findings regarding transcatheter closures of PDA.

METHODS

The inclusion criteria were a weight of <6 kg and the presence of PDA symptoms. The study subjects were divided into two groups: <6 kg and premature infants.

RESULTS

A total of 69 infants were included. The mean ages and weights of the <6 kg and the preterms were 5.4 ± 2.7 months and 30.3 ± 19.9 days, and 4.6 ± 0.8 and 1.7 ± 0.3 kg, respectively. Type C PDAs were most frequently observed in the premature group, and type A was in <6 kg. Sixteen of the patients were premature infants, and 81.2% of them had an extremely low birth weight. All of the premature infants had comorbidities, and had been receiving respiratory support therapy. Transcatheter closure was successfully completed in 81.2% of the premature infants and 94.3% of the <6-kg infants. Major complications occurred in 4 patients (one death and three device embolizations). The patient's age was found to be the main risk factor. The most frequently used device was the Amplatzer duct occluder II in additional sizes (84.6%) in the preterms and the Amplatzer duct occluder I (34%) and II (34%) in the <6-kg group.

CONCLUSION

The transcatheter closure of PDA is relatively safe and effective in preterms and in infants <6 kg. The selection of a suitable device based on the type of PDA is critical to the success of the procedure.

Transcatheter closure of coronary artery fistulae: initial human experience with the Amplatzer Duct Occluder II

OBJECTIVES

To evaluate the efficacy and safety of the new device Amplatzer Duct Occluder II (ADO II) for the closure of coronary artery fistulae (CAF) with coronary anomaly.

BACKGROUND

Transcatheter device closure is an alternative treatment for selective patients with CAF. The currently available reports regarding the closure of CAF with the ADO II are limited.

METHODS

From April 1, 2011 to July 15, 2012, 5 patients (3 males and 2 females) aged from 3 years to 27 years old (median age 5 years old) underwent CAF closure with the ADO II. The immediate and short-term outcomes were evaluated.

RESULTS

ADO II was deployed via the femoral vein (2 cases), femoral artery (1 case), brachial artery (1 case), and radial artery (1 case). There were no complications during all the procedures. The median fluoroscopy and procedural times were 20 and 39 minutes, respectively. Immediate trivial and mild residual shunt was present in one patient, respectively, but disappeared 24 hours after the procedure, and there was no recanalization at a median follow-up of 6 months.

CONCLUSIONS

The new device ADO II was safely deployed with complete resolution of CAF shunt with tortuous coronary artery to the drainage. The reduced sheath sizes and softer shape of this device allow for venous or arterial approach. The ADO II might be a preferable alternative device for closure of small-tortuous CAFs.

Comparison of the efficacy of different-sized Amplatzer duct occluders (I, II, and II AS) in children weighing less than 10 kg

The transcatheter closure of patent ductus arteriosus (PDA) may cause more complications in small children. Amplatzer (St. Jude Medical, Plymouth, MN) has produces three types of devices for ductal occlusion: the Amplatzer duct occluder I (ADO I) and II (ADO II) and the recently introduced ADO II additional sizes (ADO II AS). We performed this study to determine the efficacy and complication rates in children who weigh <10 kg for the three types of devices used in our clinic. Between February 2007 and March 2012, 77 patients weighing <10 kg had their PDAs occluded with ADOs. The mean age of the patients was 0.76 ± 0.44 years (range 17 days-2 years), and their mean weight was 6.73 ± 2.05 (range 1.2-9.9) kg. In total, 54 girls (70.1 %) and 23 boys (29.9 %) with a mean pulmonary ductus diameter of 2.55 ± 1.0 (1.08-5.94) mm were included in the study. The ADO I was used in 26 patients (33.8 %); the ADO II was used in 43 patients (55.8 %); and the ADO II AS was used in 8 patients (10.4 %). The mean ages of patients with the ADO I, ADO II, and ADO II AS were 1.07 ± 0.48, 0.66 ± 0.31, and 0.28 ± 0.17 years (p < 0.05), respectively. Their mean weights were 7.86 ± 1.45, 6.50 ± 1.85, and 4.36 ± 2.49 kg (p < 0.05), respectively. Their mean narrowest ductal diameters were 3.11 ± 0.96, 2.25 ± 1.06, and 2.33 ± 1.01 mm (p < 0.05), respectively. The use of the ADO II and ADO II AS was found to be more common in type C defects. One patient with the ADO I and 5 patients with the ADO II (7.8 %) developed varying degrees of left pulmonary artery stenosis or iatrogenic aortic coarctation. In 1 patient, the ADO II AS was replaced with the ADO II due to a significant residual shunt observed during the procedure. Each of the ADOs has its own advantages and disadvantages. Although the ADO I is convenient for medium- and large-sized defects, the ADO II and ADO II AS can be used both anterogradely and retrogradely. The ADO II AS is safe and efficient to use in small infants.