OBJECTIVE--To assess the efficacy, feasibility, and most appropriate timing of the implantation of a second Rashkind arterial duct occluder because of persistent flow after the first device. DESIGN--A prospective serial Doppler study of patients after the insertion of a Rashkind arterial duct occluder including a subgroup in whom a second device was implanted. SETTING--A tertiary referral centre for congenital heart disease. PATIENTS--144 patients aged 7 months to 67 years (median 3.38 years) who underwent transcatheter occlusion of patent arterial duct, 20 of whom had attempted implantation of a second device. INTERVENTIONS--Implantation of a second device alongside the first was attempted in 20 of the patients with persistent residual flow. MAIN OUTCOME MEASURES--Successful implantation of a second device, the incidence of complications, and the achievement of complete occlusion on follow up Doppler echocardiography. The time to complete occlusion in the whole group and factors predictive of persistent leak were also analysed. RESULTS--Second devices were successfully implanted in 19 of 20 first attempts and in the remaining patient at the second attempt. Complete occlusion was found in 19 patients at a mean follow up of eight months. The complications included fracture of a guidewire requiring femoral arteriotomy for its removal in one patient and embolisation of a device in another. With a single device, persistence of residual flow six months after implantation and malposition of the device on the aortogram after implantation were predictive of continuing residual patency. CONCLUSIONS--Implantation of a second device is safe, feasible, and effective and should be considered when residual flow persists beyond six months, or if malposition of the first device causes complications such as haemolysis.
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