Results of anterograde transcatheter closure of patent ductus arteriosus using single or multiple Gianturco coils

Percutaneous Closure of Patent Ductus Arteriosus in Infants 1.5 kg or Less: A Meta-Analysis

OBJECTIVE

To investigate technical success and safety of percutaneous patent ductus arteriosus closure in infants ≤1.5 kg.

STUDY DESIGN

A systematic review and meta-analysis was performed. Data sources included Scopus, Web of Science, Embase, CINAHL, Cochrane, and PubMed from inception to April 2020. Publications were included if they had a clear definition of the intervention as percutaneous patent ductus arteriosus closure in infants ≤1.5 kg. Data extraction was independently performed by multiple observers. Primary outcome was technical success and secondary outcomes were adverse events (AEs). Subgroup analysis was performed in infants ≤6.0 kg. Data were pooled by using a random-effects model.

RESULTS

We included 28 studies, including 373 infants ≤1.5 kg and 69 studies enrolling 1794 infants ≤6.0 kg. In patients ≤1.5 kg, technical success was 96% (95% CI, 93%-98%; P = .16; I² = 23%). The overall incidence of AE was 27% (95% CI, 17%-38%; P < .001; I² = 70%) and major AEs was 8% (95% CI, 5%-10%; P = .63; I² = 0%). There were 5 deaths related to the procedure (2%; 95% CI, 1%-4%; P = .99; I² = 0%); 4 of these deaths occurred in infants <0.8 kg. The probability of technical failure was inversely related to age at the time of the procedure (OR, 0.9; 95% CI, 0.830-0.974; P = .009). Weight at intervention has decreased over time and procedural success has increased.

CONCLUSIONS

Percutaneous patent ductus arteriosus closure is feasible in infants ≤1.5 kg with few major AEs. The procedural success rate is high, despite performing the intervention in smaller patients.

PROSPERO REGISTRATION

CRD42020145230.

[Thoracoscopic clipping of patent ductus arteriosus: position of surgery in the era of transcatheter procedures]

AIM

To describe single-center evolution of the procedure and to evaluate the results of thoracoscopic clipping of patent ductus arteriosus (PDA) with diameter over 3,0 mm in term infants weighting over 4,0 kg.

MATERIAL AND METHODS

Thoracoscopic clipping of PDA has been performed in 140 patients for the period from March 2012 to March 2018 in Meshalkin National Medical Research Center. Mean age was 4.0 years (range 3 months - 13 years), mean body mass index - 15.4±2.2 kg/m².

INCLUSION CRITERIA

PDA size 3.5-10 mm, Qp/Qs >1,3/1,0, weight 4.0-40 kg. Mean PDA size was 4.6±0.9 mm (range 3.5-8.0 mm), mean pulmonary artery pressure - 34.3±5.8 mm Hg, mean systemic/pulmonary flow Qp/Qs - 1.6±0.3. All patients underwent successful PDA closure through four-port technique under endotracheal general anesthesia and no need for pleural drainage.

RESULTS

Mean procedure time was 24.5±15.5 min. In 29 (20,7%) cases we used titanium clips, in 11 (79.3%) - polymer locking ligating clips. There was 1 conversion to mini-thoracotomy. There were no deaths, bleeding or any other life-threatening complications. 94 (67.1%) patients were weaned from ventilator within operating theatre, in other 46 (32.9%) patients mean ventilation time in ICU was 1.3±1.0 hours. In-hospital postoperative complications: pneumothorax - 2 (1.4%) cases, recurrent laryngeal nerve dysfunction - 1 (0.7%), false croup - 1 (0.7%). There were 2 residual leakages in 2 (1.4%) patients in 10 and 6 months after titanium clip deployment. Both of them underwent transcatheter closure using the coil. Considering these cases all following patients underwent PDA closure by polymer locking ligating clips with no cases of residual leakage.

CONCLUSION

Thoracoscopic PDA closure by polymer locking ligating clip is safe and effective technique for surgical management of PDA with diameter over 3.0 mm in term infants weighting over 4.0 kg.

Patent ductus arteriosus closure using Occlutech® Duct Occluder, experience in Port Elizabeth, South Africa

Background:

Percutaneous closure of patent ductus arteriosus (PDA) has become standard therapy. Experience with the Occlutech® Duct Occluder is limited.

Methods:

Data regarding ductal closure using Occlutech® Duct Occluder were reviewed and prospectively collected. Demographics, hemodynamic and angiographic characteristics, complications, and outcomes were documented.

Results:

From March 2013 to June 2016, 65 patients (43 females and 22 males) underwent percutaneous closure of the PDA using Occlutech® Duct Occluder. The median age of the patients was 11 months (range, 1–454 months) and the median weight was 8.5 kg (range 2.5–78 kg). The mean pulmonary artery median pressure was 27 mmHg (range, 12–100 mmHg) and the QP: Qs ratio median was 1.8 (range, 1–7.5), with a pulmonary vascular resistance mean of 2.7 WU (standard deviation [SD] ±2.1). Thirty-two patients had Krichenko Type A duct (49%); 7, Type C (11%); 4, Type D (6%); and 22, Type E (34%). The ductal size (narrowest diameter at the pulmonic end) mean was 3.5 mm (SD ± 1.9 mm). The screening time mean was 17.3 min (SD ± 11.6). Out of 63 patients with successful closure of the PDA using Occlutech® Duct Occluder, there were 15 patients with small PDAs; 25 with moderate PDAs, and 23 with large PDAs. In one patient, the device dislodged to the descending aorta, and in two patients, to the right pulmonary artery immediately following deployment, with successful percutaneous (two) and surgical (one) retrieval. Complete ductal occlusion was achieved in all 63 patients on day one.

Conclusion:

The Occlutech® Duct Occluder is a safe and effective device for closure of ducts in appropriately selected patients.

Percutaneous Patent Ductus Arteriosus (PDA) Closure During Infancy: A Meta-analysis

CONTEXT

Patent ductus arteriosus (PDA) is a precursor to morbidity and mortality. Percutaneous (catheter-based) closure is the procedure of choice for adults and older children with a PDA, but use during infancy (<1 year) is not well characterized.

OBJECTIVE

Investigate the technical success and safety of percutaneous PDA closure during infancy.

DATA SOURCES

Scopus, Web of Science, Embase, PubMed, and Ovid (Medline) were searched through December 2015 with no language restrictions.

STUDY SELECTION

Publications needed to clearly define the intervention as percutaneous PDA closure during infancy (<1 year of age at intervention) and must have reported adverse events (AEs).

DATA EXTRACTION

The study was performed according to the Systematic Reviews and Meta-Analysis checklist and registered prospectively. The quality of the selected studies was critically examined. Data extraction and assignment of AE attributability and severity were independently performed by multiple observers. Outcomes were agreed on a priori. Data were pooled by using a random-effects model.

RESULTS

Thirty-eight studies were included; no randomized controlled trials were found. Technical success of percutaneous PDA closure was 92.2% (95% confidence interval [CI] 88.8-95.0). Overall AE and clinically significant AE incidence was 23.3% (95% CI 16.5-30.8) and 10.1% (95% CI 7.8-12.5), respectively. Significant heterogeneity and publication bias were observed.

LIMITATIONS

Limitations include lack of comparative studies, lack of standardized AE reporting strategy, and significant heterogeneity in reporting.

CONCLUSIONS

Percutaneous PDA closure during infancy is feasible and associated with few catastrophic AEs; however, the limitations constrain the interpretability and generalizability of the current findings.

Patent ductus arteriosus with persistent pulmonary artery hypertension after transcatheter closure

Objectives

To observe the change in pulmonary artery systolic pressure (PASP) of patients with persistent pulmonary arterial hypertension (PAH) after patent ductus arteriosus (PDA) occlusion.

Background

After occlusion of PDA in patients with PAH, some patients still tend to suffer from persistent PAH.

Methods

A chest X-ray, an electrocardiogram, and an echocardiogram were performed on nine patients at 24 hours, 1 and 6 months, and 1 year serially.

Results

There was a significant fall (P<0.05) in mean PASP after occlusion (to 59.3±12.7 mmHg). However, the aortic pressure and systemic arterial oxygen saturation changed slightly (P>0.05). During the follow up, there was a further fall in the PASP in five patients (No 1, 5, 6, 7, and 8). Four patients (No 2, 3, 4, and 8) showed the evidence of worsening PAH and were treated with sildenafil. Patient 2 died from acute right heart failure after a period of 11 months from the time of transcatheter closure, triggered by pulmonary infection.

Conclusion

Some patients with borderline hemodynamic data with PDA and PAH can deteriorate or keep sustained PAH after PDA closure. The treatment of permanent closure to these patients must be cautious.

Left Ventricular Dysfunction after Closure of Large Patent Ductus Arteriosus

Changes in left ventricular dimensions and performance were studied in 43 patients after transcatheter occlusion or surgical ligation of patent ductus arteriosus. The patients were assigned to 2 groups based on their ductal diameter: ≥ 3.1 mm to group A ( n = 27) and ≤ 3 mm to group B ( n = 16). The mean age and weight of the groups were comparable. Before intervention, group A had a significantly larger mean left ventricular end-diastolic diameter than group B, while all patients had normal shortening fraction and ejection fraction. Within 1 month after intervention, left ventricular end-diastolic diameter showed a trend towards regression while shortening fraction and ejection fraction decreased significantly in group A. There were no significant changes in these parameters in group B. Between 1 and 6 months after intervention, left ventricular performance improved in most of the group A patients who were followed up. We conclude that closure of large ductus arteriosus in children leads to significant immediate deterioration of left ventricular performance, which appears to recover within a few months. Echocardiographic study before hospital discharge is recommended in these patients. Serious deterioration of ventricular performance after closure may warrant the use of angiotensin converting enzyme inhibitors.

Percutaneous Occlusion of Patent Ductus Arteriosus with Controlled-Release Coil

We evaluated the efficacy of the controlled-release Cook coil for percutaneous patent ductus arteriosus occlusion. Between October 1994 and December 1997, 45 consecutive patients with patent ductus arteriosus underwent cardiac catheterization and coil occlusion was attempted in 41, of whom 37 had Cook coils. A single coil was deployed in 34 of these patients and 2 or more coils were deployed in 3, with successful occlusion in 36 (97%). Immediate complete angiographic closure was achieved in 15 (41%), 18 (49%) had a trivial residual shunt, and 3 had a mild residual shunt on post-occlusion aortograms. Color Doppler echocardiography 24 hours after the procedure, revealed no detectable shunt in 33/36 (92%) and only a trivial residual shunt in 3 (8%) patients. Thus, 86% of patients with residual shunts immediately after occlusion had no evidence of residual shunts by 24 hours. No evidence of residual shunt or obstruction of the left pulmonary artery or the descending aorta was present at a mean follow-up of 26 months We concluded that Cook coils are a safe and cost-effective modality for percutaneous occlusion of patent ductus arteriosus with a high success rate and favorable intermediate-term follow-up.

A Retrospective Study of 1,526 Cases of Transcatheter Occlusion of Patent Ductus Arteriosus

Background:

Patent ductus arteriosus (PDA) is one of the most common congenital heart diseases and began to get treated by transcatheter occlusion since 1997 in China. Since then, several devices have been invented for occluding PDA. This study aimed to evaluate the technical feasibility, safety, and efficacy of transcatheter occlusion of PDA with different devices.

Methods:

One thousand five hundred and twenty-six patients (537 boys, 989 girls) with PDA from January 1997 to September 2014 underwent descending aortogram and transcatheter occlusion procedure. We retrospectively analyzed data of these patients, including gender, age, weight, size and morphology of PDA, and devices used in transcatheter occlusion, outcomes, and postoperational complications.

Results:

Median age and median weight were 4.0 years (range: 0.3–52.0 years old) and 15.3 kg (range: 4.5–91.0 kg), respectively. Mean ductal diameter, aortic ductal diameter, ductal length, and pulmonary artery pressure were 3.50 ± 2.15 mm, 10.08 ± 2.46 mm, 7.49 ± 3.02 mm, and 30.21 ± 17.28 mmHg, respectively. Morphology of PDA assessed by descending aortogram was of type A in 1428 patients, type B in 6 patients, type C in 79 patients, type D in 4 patients, and type E in 9 patients according to the classification of Krichenko. Of all the 1526 patients, 1497 patients underwent transcatheter PDA closure, among which 1492 were successful. Devices used were Amplatzer duct occluder I (ADO I, 1280, 85.8%), Cook detachable coils (116, 7.8%), ADO II (ADO II, 68, 4.6%), muscular VSD occluder (12, 0.8%), and Amplatzer vascular plug (16, 1.0%).

Conclusions:

Excellent occlusion rates with low complication rates were achieved with all devices regardless of PDA types. With transcatheter occlusion technique and devices developing, more patients with PDA can be treated with transcatheter closure both safely and efficiently.

Long-term clinical experience with Amplatzer Ductal Occluder II for closure of the persistent arterial duct in children

OBJECTIVES

To describe the long-term clinical experience and follow-up with the Amplatzer Ductal Occluder II (ADO II) in children.

METHODS

All patients undergoing attempted transcatheter closure of patent arterial duct (PDA) with the ADO II were included. Data collected included demographic, clinical, and echocardiographic parameters.

RESULTS

From March 2008 until March 2013, 62 patients with a median age of 1.2 years (range 0.43-11.1 years) and median weight of 9 kg (range 4.7-31.4 kg) underwent the procedure. The median measurement for minimal ductal diameter was 2.7 mm (range 1.3-5 mm). An ADO II was implanted in 60 patients (96.8%). Two patients had significant residual shunting following deployment of the ADO II and underwent closure with the Amplatzer ductal occluder I (ADO I) during the same procedure. In six patients, the initial ADO II was unsatisfactory, and after recapture a different size ADO II was deployed. Device embolization of the ADO II to the pulmonary artery occurred in 6.7% of patients. Of these, one underwent surgical closure and three were closed with an ADO I. Complete occlusion on echocardiography was noted prior to discharge in 87.5% of the deployed occluders and 100% at first follow-up. Five year follow-up (n = 25) revealed a 100% occlusion rate. There were three cases of persistent mild left pulmonary artery stenosis at long-term follow-up.

CONCLUSIONS

The ADO II is effective for occlusion of PDA with variable anatomy from either arterial or venous approaches with a low profile delivery system. Stable occluder position is highly dependent on accurate device sizing, good quality imaging to visualize device configuration after deployment and operator experience.

Biomaterials and design in occlusion devices for cardiac defects: a review

This review examines the biomaterials used in occlusion devices for cardiac defects, and how the choice of these materials is dictated by design. Specifically, the devices used in three major applications, the atrial septal defect, the ventricular septal defect and the patent ductus arteriosus, are examined critically. A number of different devices are available, with varied performance in deployment and sealing. There is no device in any of the three categories that satisfies fully the range of requirements, and all have associated complications. The type and rate of complications are different among different devices. The short-term (immediate) complications are addressed by immediate retrieval. For longer-term complications, most of which can be fatal, currently only surgical retrieval and replacement are possible. Most of these longer-term complications can be alleviated by the use of fully degradable devices, which will eliminate concerns regarding the use of metals inside the heart, and if fully endothelialized, also minimize migration concerns. On the other hand, the lower moduli of currently available biodegradable materials need to be augmented. Improvements in the stiffness required for deployment can be accomplished with the use of fillers, nano- or micro-sized, and an example of this are radiopaque fillers.

Transcatheter closure of patent ductus arteriosus

More than three decades have passed since the introduction of transcatheter devices for closure of patent ductus arteriosus, and many occluders have been made available since then. The ideal requirements of any procedure are a user-friendly technique, optimum success rate, no residual anomaly, minimal morbidity/mortality, and comparability or superiority to the existing conventional modality of treatment. With various advancements in device design, delivery and assisted systems, the tremendous procedural safety and effectiveness, along with low cost and widespread availability of these devices makes transcatheter closure of patent ductus arteriosus a preferred therapeutic modality in all age groups, with decreasing demographic trends of surgical management.

Amplatzer®Duct Occluder device: a new technology for the closure of the moderate-to-large-sized patent ductus arteriosus

The Amplatzer Duct Occluder is a novel device designed to allow for the transcatheter closure of virtually all sized patent ductus arteriosuses. Prior technologies have been cumbersome and challenging to deploy with somewhat less than ideal closure rates associated with their use. This article summarizes the present knowledge about the Amplatzer Duct Occluder device and its various indications. With the introduction of this device as well as the use of embolization coils, all but the neonatal patent ductus arteriosuses can now be safely, consistently and successfully closed in the cardiac catheterization laboratory.

Ductal closure using the Amplatzer duct occluder type two: experience in Port Elizabeth hospital complex, South Africa: cardiovascular topic

OBJECTIVE

To report outcomes in percutaneous ductal closure using the Amplatzer duct occluder type two (ADO II).

METHODS

Records of patients admitted for percutaneous closure of patent ductus arteriosus (PDA) were reviewed.

RESULTS

From May 2009 to July 2012, 36 patients were assigned to closure using the ADO II. There were 21 females and 15 males. The median age was 16.5 (2-233) months; median weight, 8 (3.94-39.2) kg; and median height, 75 (55-166) cm. The mean pulmonary artery pressure was 24.4 (± 10.4) mmHg, the pulmonary blood flow:systemic blood flow (Qp:Qs) ratio was 2.25 (± 1.97), and mean pulmonary resistance (Rp) was 1.87 (± 1.28) Wood units. The mean ductal size was 2.74 (± 1.3) mm. In 30 patients the device was delivered through the pulmonary artery. Thirty-three patients achieved complete closure by discharge (day one).

CONCLUSION

The ADO II is capable of closing a wide range of ducts in carefully selected patients. Our findings are comparable with other studies regarding ductal closure rates.

Estimation of patent ductus arteriosus diameters by colour Doppler echocardiography in children

OBJECTIVE

To investigate whether accurate estimation of the diameter of the patent ductus arteriosus can be obtained by colour Doppler echocardiography.

METHODS

The minimum and maximum diameters of the patent ductus arteriosus were measured by colour Doppler echocardiography and compared with its angiographic size.

RESULTS

We studied 40 patients, aged between 4 months and 18 years. The measured pulmonary side diameter in echocardiography was 33.6% larger than that in angiography, and the aortic side was 7.8% smaller. We found a correlation between the measurements of the minimum and maximum size of the patent ductus arteriosus (r = 48.8 and 52.6) by colour Doppler echocardiography and angiographic findings, respectively.

CONCLUSION

Colour Doppler echocardiography significantly overestimates the minimum size of the patent ductus arteriosus; therefore, reconsideration of the respective size is suggested.

Interventional occlusion of congenital vascular malformations

BACKGROUND

New materials and devices have been used in the management of cardiac malformations. In this paper, we present our experience with interventional occlusion of congenital vascular malformations.

METHODS

Between January 1997 and December 2005, 139 patients with congenital vascular malformations who had undergone interventional occlusion in the Children's Hospital, Zhejiang University School of Medicine were studied. The clinical data of the patients were retrospectively reviewed including pre-operative evaluation, surgical procedures, immediate complete closure rate, short-term complications, and short-term outcome.

RESULTS

Of the 139 patients, 126 had patent ductus arteriosus, and successful deployment was achieved in 121 of the 126 patients (96%, 121/126). Six patients had coronary artery fistula and 14 different coils were used for embolization; the immediate complete closure rate was 83.3%, and the complete closure rate after one month was 100%. The abnormal vessels of 3 patients with pulmonary sequestration were completely occluded using four 0.038-inch Gianturco coils. In 3 patients with aortopulmonary collaterals, 14 abnormal vessel branches were occluded with sixteen 0.038-inch Gianturco coils, reaching a closure rate of 100%. One patient with pulmonary arteriovenous fistula was occluded successfully with two 0.038-inch Gianturco coils.

CONCLUSIONS

Transcatheter closure using coils is a safe and effective alternative to surgical ligation in the management of congenital vascular malformations in children. Selection of appropriate coils is important to achieve a better outcome.

Transcatheter closure of patent ductus arteriosus: experience with a new device

Transcatheter closure is the preferred method of treatment of patent ductus arteriosus (PDA). Detachable coils are widely used to close small ducts, while the Amplatzer duct occluder (ADO) is generally employed for moderate or large ducts. Recently a new device, the Amplatzer duct occluder II (ADO II), a nitinol flexible mesh, with a symmetrical design to provide high conformability for treatment of all types of PDA, has received the European Community mark approval. We report on one of the first experience, four cases (1 male, 3 female, age ranging from six months to seven years old) with different type and size of PDA treated with the new device. The use of this new Amplatzer duct occluder in our experience has the advantage of ease and safety of placement, conformability, stability, low profile catheters, adaptability for long ducts as in type E.

Preclosure pressure gradients predict patent ductus arteriosus patients at risk for later left pulmonary artery stenosis

The objective of this study was to evaluate the incidence of pre-existing catheterization left pulmonary artery (LPA) gradients and correlation of these gradients with later LPA stenosis after successful patent ductus arteriosus (PDA) occlusion. We performed a single-center review of 130 patients with PDA closure from October 1993 to February 2005. We analyzed the pre-PDA closure LPA pressure gradients at catheterization to determine if these were predictive of late LPA stenosis. On follow-up, a V (max) >2 m/s by echocardiogram (transthoracic echocardiography; TTE) was considered indicative of possible LPA stenosis. Left lung perfusion of <35% was considered diagnostic of significant LPA stenosis. Post PDA closure, possible LPA stenosis by TTE was seen in 8 of 128 patients (6.25%). Seven of these eight had precatheter LPA gradients >7 mm Hg. Five of these had perfusion scans, three of the five had significant LPA stenosis, and two underwent LPA angioplasty. Patients with LPA catheter gradients >7 mm Hg were more likely to have possible LPA stenosis by TTE, significant LPA stenosis by lung scan, and intervention with LPA angioplasty. In conclusion, a preclosure main pulmonary artery-to-LPA pressure gradient >7 mm Hg was found in all patients who developed significant LPA stenosis on follow-up after transcatheter PDA closure. It appears likely that these patients have LPA abnormality rather than stenosis caused by the PDA occlusion device. Patients with preclosure LPA gradients >7 mm Hg should undergo follow-up evaluations for detection of significant stenosis and may require treatment if an important flow abnormality is documented.

Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava

Transcatheter closure of patent ductus arteriosus (PDA) using various occluders and coils via femoral vein is a well established therapeutic option. However, in patients with interrupted inferior vena cava (IVC) it is not feasible to close the PDA percutaneously using traditional methods. We present a nine-year-old girl with IVC interruption in whom percutaneous closure of PDA was successfully accomplished via the transjugular approach.

Target-controlled infusion of propofol combined with variable rate infusion of remifentanil for anaesthesia of a dog with patent ductus arteriosus

An 18-month-old Lurcher was anaesthetized for surgical ligation of a patent ductus arteriosus using a target-controlled infusion (TCI) of propofol and a variable rate infusion of remifentanil. Before anaesthesia, radiographic and echocardiographic examination indicated that the dog had left-sided congestive heart failure and impaired left ventricular systolic function. Ramipril and furosemide were administered pre-operatively. Following pre-anaesthetic medication with morphine, 0.5 mg kg(-1), by intramuscular injection, and pre-oxygenation, remifentanil was infused for 5 minutes at 0.2 microg kg(-1) minute(-1), followed by induction of anaesthesia using intravenous propofol administered by TCI, set at a target concentration of 3.5 microg mL(-1) of propofol in blood. Tracheal intubation was performed and 100% oxygen delivered through a non-rebreathing (Bain) system and then a circle system in the operating theatre. Anaesthesia was maintained with propofol and remifentanil, adjusted according to clinical requirements. Peri-operative analgesia consisted of intercostal bupivacaine nerve block, with meloxicam, morphine and remifentanil.

Transcatheter closure of moderate to large patent ductus arteriosus with the Amplatzer duct occluder

OBJECTIVES

To investigate the acute and follow-up results of transcatheter closure of moderate to large patent ductus arteriosus (PDA) with the Amplatzer duct occluder.

METHODS

Between April 2000 and June 2005, 237 patients underwent attempted transcatheter closure of PDA, of whom Amplatzer duct occluder was used in 68 patients with moderate-to-large-sized PDA (45 females, with ages ranging from 56 days to 75 years, median 3.3 years). Moderate to large PDA is defined as ductus diameter > or =2.5 mm (> or =3 mm in early phase of this study) in infants and young children, or > or =4 mm in adolescents and adults. The size of device selected was generally at least 1-2 mm larger than ductus diameter.

RESULTS

The ductus diameter ranged from 2.5 to 8.5 mm (4.1 +/- 1.3 mm). Amplatzer duct occluder was successfully deployed in 66 out of 68 patients. The size of device deployed ranged from 4 to 12 mm (6.3 +/- 1.6 mm). The causes of failure in the 2 patients included calcification of ductus resulting, in failure in advancing a sheath to descending aorta in 1 and kinking of a Cook sheath in the other. Distal embolization of the device occurred several hours later in one. After the device was retrieved percutaneously, the patient was sent to surgery. No other significant complications occurred. In the 3-month follow-up, complete occlusion was achieved in all patients. No patient had left pulmonary artery stenosis.

CONCLUSIONS

Transcatheter closure of moderate-to-large-sized ductus with Amplatzer ductus occluder is effective and safe.

Transcatheter closure of patent ductus arteriosus with severe pulmonary arterial hypertension in adults

BACKGROUND

Surgical closure of patent ductus arteriosus (PDA) with severe pulmonary arterial hypertension in adults carries higher risk than in children.

OBJECTIVES

To investigate the application of self-expandable occluders for transcatheter closure of PDA associated with severe pulmonary arterial hypertension in adults, and the assessment of immediate and short-term results.

METHODS

29 adult patients (6 men, 23 women) underwent attempted transcatheter closure of PDA at a mean (standard deviation (SD)) age of 31.1 (11.4) years (range 18-58 years) and a mean (SD) weight of 54.1 (7.1) kg (range 42-71 kg). On the basis of haemodynamic and clinical data obtained before and after trial occlusion, the final duct occlusion was determined and carried out. Radiographs of the chest, electrocardiograms and echocardiograms were used for follow-up evaluation of the treatment within 1 day, 1 month and 3-6 months after successful closure.

RESULTS

20 of the 29 patients had successful occlusion (group 1), and 9 patients failed (named group 2). In group 1, in which occlusion was successful, mean (SD) pulmonary arterial pressures decreased markedly after trial occlusion: 78 (19.3) mm Hg (range 50-125 mm Hg) before occlusion and 41 (13.8) mm Hg (range 23-77 mm Hg) after occlusion. Systemic arterial oxygen saturation was found to be >90% in 19 patients and <90% in the remaining patient before inhalation of oxygen, and >95% during inhalation of oxygen or after occlusion in all 20 patients. In group 2, the occlusion was not successful, because in two patients the device was not available; another two patients showed worsening of symptoms. The other five patients showed increased pulmonary arterial pressures after trial closure; their mean (SD) pulmonary arterial pressures increased by 10.3 (6) mm Hg (4-16 mm Hg) after trial occlusion, and systemic arterial oxygen saturation was 85.5% (2.6%) (range 82.6-88%) before inhalation of oxygen and 94.7% (1.7%) (range 90.7-99.1%) during inhalation of oxygen. In group 1, the dimensions of the left atrium, left ventricle and pulmonary artery increased considerably in 3-6-months of follow-up compared with those of preocclusion.

CONCLUSIONS

Transcatheter closure is an effective treatment for adults with PDA associated with reversible severe pulmonary arterial hypertension. Further research is needed for the evaluation of long-term results.

Initial clinical experience in transcatheter closure of large patent arterial ducts in infants using the modified and angled Amplatzler duct occluder

OBJECTIVE

To establish the feasibility and efficacy of closing large patent arterial duct in infants, using the modified and angled variants of the Amplatzer duct occluder.

BACKGROUND

Closure of large patent arterial ducts by inserting devices in sick and underweight infants, particularly those weighing around 5 kilograms, remains a challenge. Bigger devices require larger delivery sheaths and may cause obstruction either to the aorta or left pulmonary artery. Negotiating a large device is difficult or impossible, as the sheath gets kinked. Because of these problems, such underweight infants with large ducts who are failing to thrive, and in left ventricular failure with associated lesions, are typically referred for surgery, often leading to higher morbidity and mortality.

METHODS

We attempted to close such large patent arterial ducts using the new Amplatzer occluder, modified with single layer of polyester, and the angled occluder, with no polyester material, inserted through a specially braided kink-resistant sheath.

RESULTS

Closure was achieved in 10 infants, with mean age of 8.2 months, mean weight of 5.5 kilograms, the lowest weighing 3.9 kilograms. The mean size of the patent ducts was 6.3 millimetres, with the largest measuring 8.6 millimetres. We implanted 6 modified and 4 angled occluders. In one patient, suffering from hydronephrosis, a 14/12 angled device embolized and was retrieved, but the patient died. In the remaining patients, all ducts were closed completely, with no obstruction to either the aorta or left pulmonary artery. On follow up, all showed excellent clinical improvement.

CONCLUSION

Complete closure of very large patent arterial ducts is now possible, even in very sick and underweight infants, using the large but low profile custom-made angled or modified versions of the Amplatzer occluder.

Outcome of percutaneous transarterial coil occlusion in patients with isolated patent ductus arteriosus using an upstream-and-push maneuver

BACKGROUND

There are limited data on the outcome of percutaneous transarterial coil occlusion for isolated patent ductus arteriosus (PDA) in Taiwan. This study evaluated the 2-year outcome of 52 patients with isolated PDA who received percutaneous transarterial coil occlusion by an upstream-and-push maneuver.

METHODS

From July 1997 to June 2002, a total of 52 patients (25 infants, 27 children) underwent occlusion of PDA with standard Gianturco coils. There were 39 females and 13 males. Patient age ranged between 7 days and 14 years, and weight was between 3 and 45 kg. Percutaneous transarterial coil occlusion was performed by an upstream-and-push maneuver. Chest auscultations, chest radiographs, and Doppler echocardiography were performed in all patients within 24 hours, and 1, 3, 6, 12 and 24 months after coil occlusion.

RESULTS

Mean PDA diameter at the pulmonary end was 2.34 +/- 1.00 mm (range, 1.00-4.80 mm). Angiographic classification was megaphone type in 32 patients, window type in seven, tubular type in six, aneurysmal type in three, and elongated conical type in four. Complete PDA occlusion was performed with a single coil in 41 (79%) patients and with multiple coils in 11 (21%). The mean ratio of pulmonary to systemic blood flow was 1.95 +/- 0.95 (range, 1.10-5.80) before the procedure, and 1.02 +/- 0.04 (range, 1.00-1.20) after the procedure (p < 0.001). Immediate occlusion of the ductus was achieved 15 minutes after the procedure in 44 (85%) patients. Occlusion was achieved in 92% of patients within 24 hours and in 100% of patients by the 1-month follow-up. Follow-up at 24 months after the procedure revealed no complications.

CONCLUSION

Percutaneous transarterial coil occlusion with 5-loop Gianturco coils can be effectively and safely achieved in patients with a PDA minimum diameter < 5 mm.

Guidewire and catheter manipulation without coil placement to close minimal patent ductus arteriosus

BACKGROUND

Transcatheter coil closure (TCC) is safe and effective for most patients with PDA, but coil associated complications may occasionally be encountered. For occlusion of minimal PDA (<1 mm), we employed a closure protocol with guidewire and catheter manipulation.

METHODS

Between April 2000 and September 2004, 38 patients with a minimal PDA were classified into two groups according to the occlusion method at our institution. Group A consisted of 11 patients (age range 0.7 to 3.5 years; mean age 1.6 years) who underwent guidewire and catheter manipulation. Group B consisted of 27 patients (age range 0.5 to 2.7 years; mean age 1.3 years) who underwent TCC of PDA.

RESULTS

In group A (a PDA 0.4-0.9 mm), 9 (82%) patients had successful closure, and two (18%) patients failed the manipulation. No patient had complications during the procedure or follow-up. In group B (a PDA 0.5-0.9 mm), 26 (96%) patients had successful closure and 1 (4%) patient failed the attempt at TCC. No adverse events of coil closure was found during follow-up. Compared to the patients in group B, those in group A differed significantly in terms of procedure time. There were no significant differences in age, sex, body weight, PDA size, fluoroscopy time, success rate, and complication rate.

CONCLUSIONS

Our results indicate that the manipulation is safe and effective for patients with minimal PDA. The manipulation technique can be tried before TCC in patients with minimal PDA.

A strategic approach to transcatheter closure of patent ductus: Gianturco coils for small-to-moderate ductus and Amplatzer duct occluder for large ductus

OBJECTIVE

To investigate the effectiveness of the strategy of transcatheter occlusion with the Gianturco coil for small-to-moderate sized ductus and with Amplatzer duct occluder (ADO) for large ductus.

PATIENT AND METHODS

For ductus closure, the following strategy was applied: ADO was used in large ductus: infants and young children weighing < 15 kg with a ductus diameter > or = 3 mm and in older children or adults with a ductus diameter > or = 4 mm and coils were employed in patients with small-to-moderate sized ductus. During a 3-year period, this strategy was applied in 136 patients. The results were compared between 214 patients (group I) undergoing ductus closure using only coil before application of this strategy and strategic closure in 136 patients (group II). Each group was divided into 2 subgroups: subgroup A with large ductus and subgroup B with small-to-moderate ductus. There were 54 patients in subgroup IA, 160 in subgroup IB, 33 in subgroup IIA and 103 in subgroup IIB, respectively.

RESULTS

In group I, PDA occlusion was successful in 207 (96.7%) and failed in 7 (6 of group IA and 1 of group IB). In group II, ductus closure was successful in 134 patients (98.5%) (32/33 with ADO and 102/103 with coils). There was no significant difference in success rate between group I and II. Distal embolization occurred in 19 patients of group I and in 2 of group II, respectively (19/214 vs. 2/136, P < 0.01). There was no significant difference in success rate between group IA and IIA but the distal embolization rate was higher in group IA than IIA (13/54 vs. 1/33, P=0.014). Left pulmonary artery stenosis was found exclusively in 9 patients of group I at the 6-month follow-up (P < 0.05). Nine patients in group I required second intervention to achieve complete occlusion.

CONCLUSIONS

The strategy of ductus closure worked well by reducing embolization rate, incidence of left pulmonary artery stenosis and the need of second intervention.

Transcatheter closure of a large patent ductus arteriosus in a young child using the Amplatzer duct occluder

The Amplatzer duct occluder (ADO) provides a safe and effective therapy for patients with moderate- to large-sized patent ductus arteriosus (PDA), but there have been few reports of transcatheter closure of very large PDAs in young children and infants. We report a successful transcatheter closure of a very large PDA, 10.5 mm in diameter at the narrowest point, with a 14/12-mm ADO. To our knowledge, this is the largest PDA ever closed by an interventional method in such a young child.

The efficacy and safety of the Amplatzer ductal occluder in young children and infants

BACKGROUND

We have used the Amplatzer ductal occluder for transcatheter closure of large persistently patent arterial ducts, and used our experience to assess the safety and efficacy of the device in young children and infants.

METHODS AND PATIENTS

We used the Amplatzer ductal occluder prospectively in 43 patients with large patent arterial ducts, reviewing our experience to identify any problems or complications.

RESULTS

The procedure proved successful in 42 of the patients. We achieved complete occlusion of the duct in 33 (78.5 per cent) of the patients on the day of insertion. In 6 additional patients, complete occlusion occurred 1 week to 6 months after the procedure. Trivial leaks persisted in 2 patients, while one had a significant residual leak. Problems were encountered in 7 patients. The procedure failed in one, a device was wasted in 2, pulled through in 3, while we experienced kinking of the long Mullins sheath, being unable to retrieve the device, in one patient. Minor complications occurred in 6 patients, finding flow at a peak velocity of 2.2 metres per second in the descending aorta in 2 patients, and at 2.5 metres per second in 2 further patients, and flow at 2.5 metres per second in the pulmonary arteries of two patients. One patient experienced a major complication due to excessive bleeding. Out of the 14 patients suffering adverse events, 13 weighed less than 10 kilograms. This rate of problems and complication in these patients weighing less than 10 kilograms was significantly higher than in the patients weighing more than 10 kilograms.

CONCLUSION

Transcatheter occlusion of moderate to large patent arterial ducts with the Amplatzer ductal occluder device is safe and effective, with a high rate of complete occlusion. Problems and minor complications may be encountered in children weighing less than 10 kilograms. If the device is to be deployed completely in the ductal ampulla, and to avoid descending aortic obstruction, the size of the retention flanges of the occluder should not exceed the largest diameter of the patent arterial duct.

Diagnosis and management of acyanotic heart disease: part II -- left-to-right shunt lesions

In this review, the clinical features and management of most commonly encountered acyanotic, left-to-right shunt lesions are discussed. Patients with small defects, especially in childhood, are usually asymptomatic while moderate to large defects in infancy may present with symptoms. Hyperdynamic precordium, widely split and fixed second heart sound, ejection systolic murmur at the left upper sternal border and a mid-diastolic flow rumble at the left lower sternal border are present in atrial septal defects, holosystolic murmur at the left lower border is characteristic for a ventricular septal defect whereas a continuous murmur at the left upper sternal border is distinctive for patent ductus arteriosus. Clinical diagnosis is not usually difficult and the diagnosis can be confirmed and quantitated by non-invasive echocardiographic studies. Whereas surgical intervention was used in the past, transcatheter methods are increasingly used for closure of atrial septal defect and patent ductus arteriosus. Small ventricular septal defects may not need to be closed whereas medium and large defects may require surgical closure. Transcatheter closure of both muscular and membranous ventricular septal defects is feasible by transcatheter methodology, but these techniques are experimental at the time of this writing.

Advanced embolization techniques

The techniques of transcatheter embolization of unwanted blood vessels in patients with congenital heart disease have evolved considerably during the past 25 years. There are many different anatomical lesions requiring different approaches and devices. The main types of devices used can be classified into particles, coils, and plugs. It is important for the operator to be familiar with a range of these devices. The results of transcatheter embolization are usually excellent, and technical problems and complications can usually be overcome by attention to detail and persistence. The types of devices in common use and their clinical applications are discussed.

Transcatheter closure of persistent ductus arteriosus with the Amplatzer duct occluder in very young symptomatic children

OBJECTIVES

To analyse safety, efficacy, and follow up results of percutaneous closure of persistent ductus arteriosus (PDA) in very young symptomatic children.

PATIENTS AND DESIGN

Between March 2000 and March 2003, of 197 patients treated at the authors' institution 18 were symptomatic children aged < or = 3 years old. Seven of these children were < or = 1 year old. Indications for closure were failure to thrive (12 patients) and frequent respiratory infections (six patients). The procedure was carried out under heavy sedation with fluoroscopic control. The Amplatzer duct occluder device was used. Basal physical examinations and echocardiograms were performed before the procedure and at follow up (three, six, and 12 months and yearly thereafter).

RESULTS

Mean (SD) age was 18.3 (10) months and mean (SD) weight at closure was 9.1 (2.2) kg. Neither death nor any major complications occurred. Complications occurred in three patients aged < or = 1 year. Two patients had a mild inguinal haematoma. One patient had femoral artery thrombosis that was successfully treated by intravenous urokinase. The mean (SD) follow up was 12.8 (8.5) months. No problems occurred. Patients with recurrent respiratory infections had no significant recurrences and children who had failed to thrive had significantly increased growth.

CONCLUSIONS

In experienced hands, percutaneous closure of moderate to large PDA in very young symptomatic children is safe, effectively closes the PDA, and solves clinical problems.

Obstruction of the Aorta and Left Pulmonary Artery After Gianturco Coil Occlusion of Patent Ductus Arteriosus

We report an unusual case of simultaneous obstruction of the left pulmonary artery and descending thoracic aorta after Gianturco coil occlusion in a 15-month-old boy. The diagnosis was made by echocardiography and cardiac angiography. At surgery, thrombi coating on the protruded parts of the Gianturco coil in the pulmonary artery and aorta were found.

Multicenter USA Amplatzer Patent Ductus Arteriosus Occlusion Device Trial

OBJECTIVES

We sought to review and report initial and one-year efficacy and safety results of the multicenter USA Amplatzer ductal occluder (ADO) device trial.

BACKGROUND

Transcatheter closure of a moderate to large patent ductus arteriosus (PDA) using conventional techniques is challenging. The ADO can close a PDA up to 12 mm in diameter.

METHODS

From September 1999 to June 2002, 484 patients were enrolled in 25 U.S. centers. Forty-five (9%) of 484 patients did not have ADO implantation, because the PDA was too small or because of elevated pulmonary resistance. The median age of the patients at catheterization was 1.8 years (range 0.2 to 70.7 years), and weight was 11 kg (range 4.5 to 164.5 kg).

RESULTS

The median PDA minimal diameter was 2.6 mm (range 0.9 to 11.2 mm); 76 (17%) of 439 were larger than 4.0 mm. Median pulmonary artery mean pressure was 20 mm Hg (range 7 to 80 mm Hg). The ADO was implanted successfully in 435 (99%) of 439 patients, with a median fluoroscopy time of 7.1 min (range 2.9 to 138.4 min). Angiographic demonstration of occlusion was seen in 329 (76%) of 435. This increased to 384 (89%) of 433 on post-catheterization day 1, with occlusion documented in 359 (99.7%) of 360 at one year. At the last evaluation in all patients at any time, PDA closure was documented in 428 (98%) of 435 patients. There have been two cases of partial left pulmonary artery occlusion after ADO implantation and no cases of significant aortic obstruction.

CONCLUSIONS

Moderate to large PDAs can be effectively and safely closed using the ADO device, with excellent initial and one-year results. This device should obviate the need for multiple coils or surgical intervention for these defects.

Comparison of percutaneous closure of large patent ductus arteriosus by multiple coils versus the Amplatzer duct occluder device

This study compared the efficacy and costs of the most used approaches for percutaneous closure of large patent ductus arteriosus, that is, multiple coils and the Amplatzer duct occluder (ADO) device. From April 2000 to September 2003, 47 patients underwent closure of large, symptomatic patent ductus arteriosus (diameter 4.6 +/- 3.0 mm/m(2); QP/QS 2.1 +/- 1.9) with multiple Cook detachable coils (n = 19) or the ADO device (n = 28). The multiple coil approach was significantly cheaper (1,389 +/- 168 vs 3,811 +/- 38, p <0.0001) but as effective as the ADO device over a mid-term follow-up (occlusion rate 89.5% vs 96.4%, p = NS).

Interventional treatment of patent ductus arteriosus in 2004

In 2004, the interventional treatment of patent ductus arteriosus (PDA) is definitive and curative. In current practice, coils are used for smaller PDA, and devices are employed for larger PDA. Developing technologies offer small improvements in control and results, but do not appear to promise major changes in practice. This review summarizes the current and emerging interventional technologies directed at PDA closures.

Echocardiographic predictors of failure in patients undergoing coil occlusion of patent ductus arteriosus

In this study, we sought to determine whether the risk of failure of coil occlusion of patent ductus arteriosus (PDA) could be predicted on the basis of echocardiographic variables. The echocardiographic characteristics of patients in whom PDA coil occlusion failed were compared with those in whom the procedure was successful. A total of 5 variables were evaluated: PDA diameter (PDAd); indexed PDAd; PDA shape; left ventricular end-diastolic diameter; and the presence of flow reversal in the descending aorta. We found that 2 variables related to the size of the duct (PDAd and PDAd/body surface area), and 2 related to the magnitude of the shunt (left ventricular end-diastolic diameter and flow reversal) were positively associated with failure (P <.05). PDAd and flow reversal had the greater effect in each group and remained significant when they were put into a logistic regression model to predict failure (P =.004 and.053, respectively). In conclusion, echocardiographic variables can predict risk of failure in patients undergoing PDA coil occlusion.

Amplatzer Device closure of Atrial Septal Defects and Patent Ductus Arteriosus: Initial Experience

Surgical closure of Atrial Septal Defects (ASD) and Patent Ductus Arteriosus (PDA) can be performed successfully with low mortality. However, the morbidity associated with general anaesthesia, thoracotomy, cardiopulmonary bypass, postoperative monitoring in the intensive care unit, several days of hospital stay and the requirement of blood products is considerable. The expense associated with this morbidity, operative scar and the psychologic trauma to the patient and parents are additional disadvantages of surgery. Hence, the closure of these defects by transcatheter methods with various devices has been evaluated worldwide. We report the initial experience at our centre with closure of secundum ASDs and large PDAs with the Amplatzer Septal Occluder and Amplatzer Duct Occluder.

Advantages and disadvantages of coils for transcatheter closure of patent ductus arteriosus

Different coils have been used to close the patient ductus arteriosus (PDA). In small- and moderate-sized PDA, coils are an adequate alternative to surgery and/or to other devices. The aim of the study is to review and discuss the advantages and disadvantages of using coils (excluding PFM coils PFM Medical, Germany) to close PDA. Cambier was the first to successfully close a PDA using a Gianturco coil. To date, thousands of patients worldwide have undergone transcatheter closure of PDA using this or other types of coils. The use of coils is analyzed with regard to costs in comparison with other therapeutic modalities; techniques--anterograde, retrograde approach, selection of coil size--in relation to the size of the PDA and the available sizes of coils; efficacy of the rate of complete occlusion and the need for reocclusion; and safety in relation to embolization rate, other complications including hemolysis, left pulmonary artery LPA stenosis and coarctation. It is concluded that coils are a cheap alternative for the occlusion of PDA in the small-to-moderate PDA. The technique can be learned quite quickly, it has a high rate of complete occlusion, and has an acceptable rate of safety. The disadvantages include a moderate rate of coil embolization and of hemolysis in patients with residual shunt after coil occlusion in large PDAs. When more than one coil is used, the potential for developing LPA stenosis is high.

Transcatheter occlusion of patent ductus arteriosus using a new angled Amplatzer duct occluder: initial clinical experience

In the present study, we report the initial clinical experience with the new angled Amplatzer duct occluder (ADO) for the percutaneous closure of patent ductus arteriosus (PDA). Percutaneous closure of PDA using standard ADO in infants and in patients with small PDA ampulla is difficult, or even impossible, due to protrusion of the aortic disk into the descending thoracic aorta. The aortic disk of an angled ADO is angled at 32 degrees to the body of the device and concave toward the aorta to prevent protrusion of the disk into the aorta. Percutaneous closure of PDA was attempted in nine patients with a median age of 5.2 years (range, 0.5-12.7) and median weight of 20 kg (range, 4.9-55). Selection of the occluder and the implantation technique were similar to the standard ADO. The minimal PDA diameter ranged from 2.1 to 3.7 mm (median, 2.5 mm). Occluders were successfully implanted in all patients. Immediate complete PDA closure was achieved in all patients. There were no complications. The new angled ADO is a safe and effective device for PDA closure, particularly suitable for infants and patients with small PDA ampulla. Further studies and long-term follow-up are necessary to confirm our initial experience.