Transthoracic echocardiography as an alternative major guidance to angiography during transcatheter closure of patent ductus arteriosus: technical feasibility and clinical relevance

Transesophageal echocardiography-guided percutaneous patent ductus arteriosus closure without fluoroscopy

OBJECTIVES

A retrospective study was performed to summarize the experience of transcatheter closure of patent ductus arteriosus (PDA) through the right femoral vein under the guidance of transesophageal echocardiography (TEE).

METHODS

From January 2019 to September 2021, 75 children who underwent PDA closure through the right femoral vein under the guidance of TEE were included. The guide wire and delivery sheath were inserted through the ductus arteriosus into the descending aorta via the right femoral vein, and the occluder was subsequently deployed. After discharge, all patients were required for outpatient follow-ups at 1, 3, 6 and 12 months.

RESULTS

In this group, patients were older than 10 months of age and body weight greater than 8 kg. Among 75 cases with PDA, 63 were tubular type and 12 were conical type. The mean operative time was 40.2 ± 7.3 min. The size of PDA occluder ranged from 4-6 to 12-14 mm. The mean hospital stay was 5.5 ± 0.5 days. One month after discharge, there were 4 cases with a mild residual shunt. Eventually, the residual shunt was not observed during 3, 6, and 12 months of follow-up.

CONCLUSIONS

PDA closure under the guidance of TEE can be performed through the right femoral vein successfully and effectively. This procedure has no contrast agent usage, radiation exposure, or open incisions.

How can stretched ductus diameter be predicted from angiographic diameter?

BACKGROUND

An appropriate size of device for patent ductus arteriosus (PDA) could be chosen by a stretched PDA size. We propose prediction of stretched size from intact PDA size.

METHODS

A total of 361 patients was enrolled. Intact size was measured on angiography before closure, and stretched size was the narrowest diameter immediately after device implantation.

RESULTS

The median patient age was 2.8 years. Intact diameter and stretched diameter were 3.6 ± 1.4 mm and 5.1 ± 1.3 mm. The difference and difference ratio were 1.5 ± 0.8 mm and 51.3 ± 38.1% and had negative linear correlations with age (P<0.001). Patients were divided into four groups; < 2 years old (159), 2-15 years old (68), 15 - 40 years old (72), and ≥ 40 years old (62). Among groups, difference and difference ratio were significantly different. Stretched diameter was inferred by the following formulas: stretched diameter = 0.660ⅹintact diameter + 2.791 (<2 years old); = 0.971ⅹintact diameter +0.058ⅹage +1.131 (2-15 years old); = 0.790ⅹintact diameter +2.263 (15 - 40 years old); and = 0.837ⅹintact diameter +1.353ⅹBSA -0.096 (≥40 years old).

CONCLUSIONS

Stretched PDA diameter can be predicted from intact diameter and might be helpful for safe PDA closure especially in small infants.

Transcatheter Closure of Patent Ductus Arteriosus under Echocardiography Guidance: A Randomized Controlled Noninferiority Trial

Background

Percutaneous occlusion under fluoroscopy guidance has become the preferred method for the treatment of patent ductus arteriosus (PDA). To avoid radiation exposure and contrast agent use, PDA occlusion under transthoracic echocardiography (TTE) guidance was conducted.

Objectives

We assessed the hypothesis that the success rate of percutaneous PDA occlusion under TTE was noninferior to that under fluoroscopy guidance.

Methods

In this single-center trial, 100 patients were randomly assigned in a 1 : 1 ratio to the TTE group (n = 50) or to the fluoroscopy group (n = 50). The primary endpoint was the success rate of occlusion, with the noninferiority margin set at 8% for the between-group difference in intention-to-treat analysis. Secondary endpoints were hospitalization duration, cost, procedure time, and rate of adverse events including occluder migration, hemolysis, peripheral vascular complications, and residual shunt at 1-month and 12-month follow-up.

Results

Patient, defect, and device characteristics were similarly distributed between groups. The success rate of occlusion was 98% for the TTE group and 100% for the fluoroscopy group (absolute difference: -2%; 95% confidence interval: -5.9% to 1.9%). Cost and procedure duration were significantly lower in the TTE group, without adverse events in either group at a median of 12.0 months (range, 10.0-15.5 months) of follow-up.

Conclusion

Percutaneous PDA occlusion can be performed via TTE guidance safely and effectively, and the success rate of the TTE-guided procedure was noninferior to that under fluoroscopy guidance, with reduced cost and procedure time. The trial is registered with http://www.chictr.org.cn (ChiCTR-ICR-15006334).

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.

Clinical study of stand-alone transthoracic echocardiography-guided percutaneous occlusion of patent ductus arteriosus

Objective:

We aimed to investigate the feasibility and safety of stand-alone transthoracic echocardiography-guided percutaneous occlusion of patent ductus arteriosus (PDA) without the use of X-ray equipment.

Methods:

From January to December 2015, we performed stand-alone transthoracic echocardiography-guided percutaneous PDA occlusion using an occluder delivered via a delivery sheath introduced via femoral vein access without the use of X-ray equipment in 12 PDA patients.

Results:

PDA occlusion was successfully performed in all 12 patients. The procedure duration ranged from 30 to 110 min (50.4±22.8 min), and the size of the implanted occluder ranged from 12 to 20 mm (15.2±2.8 mm). No occluder migration, residual shunt, or thrombotic complications were observed in the perioperative period. There was no clinical death, hemolysis, infection, or embolism during patients’ hospitalization and the follow-up period.

Conclusion:

Stand-alone transthoracic echocardiography-guided percutaneous PDA occlusion without the use of X-ray equipment is a safe and effective procedure.

Transcatheter perimembranous ventricular septal defect closure under transthoracic echocardiographic guidance without fluoroscopy

Background

Transcatheter device closure has become an alternative therapy for ventricular septal defect (VSD). This study aimed to investigate the feasibility and safety of transcatheter perimembranous VSD (pm-VSD) closure under transthoracic echocardiography (TTE) guidance alone.

Methods

Between October 2012 and July 2016, 118 patients with pm-VSD underwent an attempt of transcatheter device closure for pm-VSD through the femoral artery under TTE guidance alone. Patients were followed-up at 1, 3, 6, and 12 months after the procedure and yearly after discharge.

Results

The mean age was 11.7±12.5 years (range, 1.0-53.0 years) and the mean body weight was 32.2±21.6 kg (range, 11.5-102.0 kg). The mean diameter of the VSD was 4.0±1.1 mm (range, 3.0-8.0 mm). Transcatheter device closure under TTE guidance alone was successful in 111 patients. The average procedural time was 44.9±7.3 minutes (range, 29.0-65.0 minutes). All 111 patients were followed-up for 3.4±2.3 years. At the last follow-up, two patients had a residual shunt smaller than 2 mm, seven patients had right bundle branch block (RBBB) including one patient with complete RBBB, six patients had mild or less tricuspid regurgitation, and two patients still had trivial aortic regurgitation including one patient that had it before the procedure. Occluder malposition, complete atrioventricular block, or other complications were not observed.

Conclusions

Transcatheter pm-VSD closure can be successfully performed under TTE guidance alone with outcomes similar to those achieved with fluoroscopic guidance in selected patients with weight more than 10 kg and VSD smaller than 8 mm. However, long-term follow-up in a large number of patients would be necessary.

Echocardiographic Versus Angiographic Assessment of Patent Arterial Duct in Percutaneous Closure: Towards X-ray Free Duct Occlusion?

Device selection and procedural guidance for percutaneous ductal closure strongly rely upon angiographic and echocardiographic imaging. Current literature recognises 2D echocardiography as an essential tool for diagnosis and assessment but does not define a consistent methodology to optimise ductal measurement. There is little research comparing echocardiography with gold standard angiography for ductal measurement. Proving 2D echocardiographic ductal measurement to be equivalent to angiography could pave the way for its use as the primary modality in image guidance for percutaneous closure of the ductus. This was a retrospective study of 100 consecutive paediatric patients who underwent percutaneous ductal closure. Echocardiographic images were studied to determine ductal (a) morphology (b) dimensions (length, aortic ampulla, pulmonary end, minimum diameter) (c) size of device that would be appropriate for closure. These data were compared to corresponding measurements generated by angiographic images. Inter and intra-observer ratings were calculated to assess levels of agreement. There were significant differences between the imaging methods in classifying the morphological sub-type and ductal measurements (p < 0.005), except for length which was not found to be significantly different between modalities. Prediction of device selection from angiographic images showed excellent agreement (weighted k = 0.81). Predictions based on echocardiographic images showed a poor level of agreement (weighted k = 0.14). We found poor correlation between echocardiography and angiography for measurement, morphological assessment and device selection. Based on our findings, percutaneous arterial duct occlusion without angiographic guidance in this age group cannot be advocated.

Transthoracic Echocardiography-Guided Percutaneous Patent Ductus Arteriosus Occlusion: A New Strategy for Interventional Treatment

INTRODUCTION

Percutaneous patent ductus arteriosus (PDA) occlusion has become the preferred therapeutic option, which uses fluoroscopy as the guidance. To reduce the x-ray exposure, PDA occlusion using the Amplatzer Duct Occluder II (ADO II) under guidance of transthoracic echocardiography only was conducted. This single center study aims to access the safety and efficiency of this new strategy.

METHODS AND RESULTS

From June 2013 to May 2015, 63 consecutive PDA patients underwent transthoracic echocardiography-guided PDA occlusion through the femoral artery. Outpatient follow-up was conducted at 1, 3, and 6 months, and yearly. Sixty-two patients successfully underwent echocardiography-guided percutaneous PDA occlusion. One patient was converted to minimally invasive transthoracic occlusion due to failure of delivery sheath passage through tortuous PDA. Mean procedure duration was 24.3 ± 7.0 minutes; ADO II diameter averaged 4.6 ± 0.9 mm; 8 cases showed traces of residual shunt immediately after operation which resolved after 24 hours; and mean hospital stay was 3.4 ± 0.5 days. There was no occluder migration, hemolysis, pericardial effusion, pulmonary branch or aortic stenosis at mean 13.5 ± 4.8 months follow-up.

CONCLUSIONS

This study demonstrated that percutaneous PDA occlusion can be successfully performed under guidance of transthoracic echocardiography only and appears safe and effective while avoiding radiation and contrast agent use.