Original articleTranscatheter closure of patent ductus arteriosus in pediatric patients
A “double disk” occlusion device (Rashkind PDA occluder system) has been designed to allow transcatheter closure of patent ductus arteriosus (PDA). During a 3-year period, we examined 37 infants and children (not premature neonates) with PDA as their only significant cardiovascular defect. Seventy-eight percent of these patients were considered potential candidates for the use of the PDA occlusion device, and it was successfully placed in all but 2 of 27 patients who underwent cardiac catheterization (PDA too small in one and too large in one). Only one of the remaining 25 patients had a significant residual shunt after placement of the device, which therefore was removed in the catheterization laboratory before surgical ligation of the PDA. There was no clinical evidence of a residual PDA in any patient. The duration of hospitalization was less than 24 hours for each of the last 20 procedures. Echocardiography demonstrated return to normal chamber dimensions in all patients, but a tiny, clinically undetectable residual leak around the device was found in three patients by Doppler evaluation. The transcatheter procedure was preferred over surgery by more than 90% of families and can be completed with a much shorter hospitalization than surgical ligation. We conclude that transcatheter closure of patent ductus arteriosus is feasible in the majority of children with PDA.
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Cited by (62)
Interventional cardiac catheterization in congenital heart disease
2017, Presse MedicaleLe cathétérisme interventionnel occupe une place croissante dans la prise en charge des cardiopathies congénitales. Depuis l’atrioseptostomie de Rashkind effectuée au milieu des années 1960 dans la transposition de gros vaisseaux, de nombreuses techniques ont émergé. Pour beaucoup d’entre elles, il s’agit de fermer avec un obturateur (double disque, bouchon, coil…) un shunt cardiaque ou extracardiaque qui induit le plus souvent un hyperdébit pulmonaire : fermeture de communication interauriculaire, de communication intraventriculaire, de canal artériel. Pour d’autres, il s’agit de lever un obstacle valvulaire ou vasculaire : dilatation de la valve pulmonaire ou aortique, voire d’une coarctation de l’aorte. Pour les sténoses vasculaires, l’angioplastie avec une sonde à ballonnet peut être associée à la mise en place d’endoprothèse. Enfin depuis une dizaine d’années, l’implantation de valve cardiaque est réalisée : tout d’abord la valve pulmonaire avec la valve Melody™ (Medtronic) ou la valve Sapien™ (Edwards Lifesciences), mais probablement à l’avenir la plupart des valves avec du matériel adapté en utilisant très souvent des techniques hybrides, c’est-à-dire combinant un cathétérisme avec une chirurgie. Les techniques de cathétérisme se sont aussi développées grâce aux progrès de la fluoroscopie qui peut actuellement être associée à d’autres techniques d’imagerie (échocardiographie, IRM ou scanner) afin d’accroître les informations sur le plan anatomique. Le cathétérisme interventionnel a encore de beaux jours devant lui avec le développement de nouveaux matériels ou techniques (3D « printing », « tissue engineering », nano-techniques). Il semble que d’une chirurgie à cœur ouvert, beaucoup de gestes pourraient à l’avenir être effectués à cœur fermé en associant le cathétériseur au chirurgien cardiaque et en créant ainsi une nouvelle discipline en cardiologie.
Interventional cardiac catheterization has a major place in the management of congenital heart disease. Since the Rashkind atrioseptostomy in mid-1960s, many techniques have been developed. For some, it is necessary to close a cardiac or extracardiac shunt using occluder (double disc system, plug, coil…): closure of atrial septal defect, ventricular septal defect or patent arterial duct. For others, it is necessary to treat a valvular or vascular stenosis using a balloon catheter: dilatation of the pulmonary or the aortic valve, dilatation of aortic coarctation. For vascular stenosis, balloon angioplasty may be associated with stent implantation. Moreover, since more than 10 years, valve implantation can be performed: initially for pulmonic valve (the Melody™ valve from Medtronic or the Sapien™ valve from Edwards Lifesciences); but probably, most of the valves in the future could be implanted using appropriate tools and hybrid techniques combining cardiac catheterization and surgery. All these techniques were developed because of progress in fluoroscopy, and more recently association of different imaging techniques (echocardiography, MRI and CT) provides more information about the true anatomy. Interventional cardiac catheterization will continue to increase with use of new tools as 3D printing, tissue engineering and nano-techniques. It seems that from correction with open-heart surgery, many lesions could be repaired in future by hybrid techniques without opening the heart.
Amplatzer device closure of atrial septal defects and patent ductus arteriosus: Initial experience
2003, Medical Journal Armed Forces IndiaCitation Excerpt :The feasibility of nonsurgical closure of the PDA was demonstrated when Porstmann et al [16] in 1967 reported closing a PDA with an Ivalon plug in a 17 year old boy without thoracotomy. Subsequently, a number of devices and coils have been used for catheter closure of PDA with varying degrees of success [17–25]. The major drawbacks of these devices and coils are the high incidence of residual shunt, the sometimes complex delivery systems and their unsuitability for larger PDAs.
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.
The Amplatzer duct occluder: Experience in 209 patients
2001, Journal of the American College of CardiologyCitation Excerpt :In all three cases the device was removed at the time of surgical ligation. Transcatheter PDA closure is now a well-established procedure, that is, performed frequently (1–6), with conventional surgery generally reserved for patients with a large duct or symptomatic preterm infants. A number of devices and techniques have been in clinical use with varying degree of popularity and success since Porstmann et al. (12)introduced the Ivalon plug nearly three decades ago.
OBJECTIVES
The aim of the study was to assess the safety and efficacy of the Amplatzer ductal occluder (ADO) in transcatheter occlusion of patent ductus arteriosus (PDA).
BACKGROUND
Transcatheter closure of small to moderate sized PDAs is an established procedure. The ADO is a self-expandable device with a number of salutary features, notably its retrievability, ease of delivery via small 5F to 7F catheters and a range of sizes suitable even for the larger PDAs.
METHODS
Between November 1997 and August 1999, the ADO was successfully implanted in 205 of 209 patients with PDA. The inclusion criteria for this device occlusion method were patients with clinical and echocardiographic features of moderate to large PDA, weighing ≥3.5 kg as well as asymptomatic adolescents and adults with PDA measuring ≥5.0 mm on two-dimensional (2D) echocardiogram. Occlusion was achieved via the antegrade venous approach. Follow-up evaluations were performed with 2D echocardiogram, color-flow mapping and Doppler measurement of the descending aorta and left pulmonary artery velocity at 24 h and 1, 3, 6 and 12 months after implantation.
RESULTS
Two hundred and five patients had successful PDA occlusion using this device. The patients were between two months and 50 years (median 1.9) and weighed between 3.4 kg and 63.2 (median 8.4). Infants made up 26% of the total patients. The PDA measured from 1.8 to 12.5 mm (mean 4.9) at the narrowest diameter. Forty-four percent of patients achieved immediate complete occlusion. On color Doppler the closure rates at 24 h and 1 month after implant were 66% and 97%, respectively. At 6 and 12 months all except one patient attained complete occlusion. Device embolization occurred in three patients; in two this was spontaneous, and in the other it was due to catheter manipulation during postimplant hemodynamic measurement. Mild aortic narrowing was seen in an infant.
CONCLUSIONS
Patent ductus arteriosus occlusion using ADO is safe and efficacious. It is particularly useful in symptomatic infants and small children with relatively large PDA. Embolization can be minimized by selection of appropriate sized devices, and caution should be exercised in infants <5 kg.
Intravascular hemolysis following percutaneous occlussion of the ductus arteriosus
1999, Revista Espanola de CardiologiaEl cierre percutáneo del ductus arterioso persistente se ha convertido en una terapéutica segura y eficaz, pero no exenta de complicaciones.
Presentamos el caso de un niño de dos años que fue sometido al cierre percutáneo de un ductus arterioso persistente mediante un dispositivo tipo «coil». Veinte horas después desarrolló un cuadro hemolítico grave asociado con la persistencia de shunt residual y acidosis metabólica por tubulopatía renal que mejoró al retirar el dispositivo.
La embolización pulmonar del material implantado y la hemólisis son las dos complicaciones más importantes en el cierre percutáneo del ductus arterioso persistente. Esta última es poco frecuente (0,5%), siempre se asocia a shunt residual y es excepcional que se acompañe de deterioro tubular renal. Los casos leves pueden resolverse espontáneamente. Cuando la hemólisis es severa es necesaria la retirada del dispositivo y la intervención quirúrgica del ductus arterioso persistente.
Transcatheter occlusion of patent ductus arteriosus has become a safe and succesful technique, but it’s not free of complications.
We present the case of a two-year-old boy who underwent routine transcatheter closure of his patent ductus arteriosus, using a «coil» device. Twenty hours later he developed severe persistent hemolysis in association with residual ductal flow. Patient’s clinical situation became stable when the device was removed. Pulmonary embolization of the device and hemolysis are the main complications of percutaneous closure of the patent ductus arteriosus. Hemolysis occurs rarely (0.5%) and is always associated with the presence of residual ductal flow. Several approaches to this problem have been described. Mild cases may require no intervetion; however, when severe hemolysis is present, removal of the device may be needed, proceeding with surgical repair of the patent ductus arteriosus.
Ductal closure by rashkind device in adults: Comparative results
1999, Revista Espanola de CardiologiaIntroducción. El cierre del conducto arterioso persistente mediante dispositivo de Rashkind es una alternativa a su corrección quirúrgica en niños y, sin embargo, existe escasa información sobre su utilidad en adultos.
Método. Entre 1990 y 1996 se sometieron al cierre ductal 127 pacientes estudiando el resultado retrospectivamente. Según la edad se clasificaron en 105 pacientes menores de 14 años (niños) y 22 pacientes mayores de 14 años (adultos). El cierre se analizó mediante aortograma inmediato y ecocardiograma-Doppler color a las 24 h y a los 6 y 12 meses.
Resultados. De los adultos, 19 se encontraban asintomáticos (86%) y en 13 (59%) los ductus eran silentes. Encontramos cocientes QP/QS similares (1,61 ± 0,47 en adultos frente a 1,49 ± 0,51 en niños), pero presiones pulmonares mayores en niños (12,50 ± 2,97 frente a 16,84 ± 5,88 mmHg; p = 0,003). En adultos, la anatomía ductal favorable (tipos A y B de Krichenko) fue más frecuente (el 91 frente al 73%; p = 0,06) y el diámetro ductal significativamente mayor (3,03 ± 1,50 frente a 2,41 ± 0,96 mm; p = 0,009). En dicho grupo se usaron más frecuentemente dispositivos de 17 mm (el 91 frente al 61% p = 0,02). No se produjeron complicaciones (embolización, endarteritis, hemólisis o estenosis de ramas pulmonares) en adultos frente a un 4,72% por embolización en niños. Se logró el cierre más frecuentemente en adultos principalmente en los primeros controles: el 55 frente al 34% (p = 0,09), y el 82 frente al 69%, el 91 frente al 77% y el 95 frente al 83% (p > 0,10). El análisis multivariante identificó a la edad superior a 14 años como predictor independiente de cierre.
Conclusión. Nuestra experiencia sugiere que el cierre ductal con dispositivo de Rashkind en adultos es seguro y tanto o más eficaz que en niños a pesar de tratarse generalmente de ductus asintomáticos y silentes.
Introduction. Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demostrated in children, however a few results have been reported of occlusion in adults.
Method. From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Rasking device. Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were estudied retrospectively. The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echo-cardiograms.
Results. The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus. Similar QP/QS (1.61 ± 0.47 in adults vs 1.49 ± 0.51) was calculated although pulmonary pressure was superior in children (12.50 ± 2.97 vs 16.84 ± 5.88 mmHg; p = 0.003). In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 ± 1.50 vs 2.41 ± 0.96 mm; p = 0.009). In adults 17 mm umbrella were used more frequenly (91 vs 61%; p = 0.02). Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children. The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77 % and 95% vs 83% (p > 0.10). Multivariate analysis identified age as an independent predictor of complete occlusion.
Conclusion. Our experience in transcatheter occlusion of persistent ductus arteriosus with Rash-kind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.
Interventional cardiac catheterization
1999, Pediatric Clinics of North AmericaOver the past decade, the focus of the pediatric catheterization laboratory has changed dramatically from its primary diagnostic function to a conduit for therapeutics. Although the first application of such catheter interventions was described more than 44 years ago by Rubio-Alvarez and Limon-Larson,145 not until 1966, when Rashkind and Miller132 described the technique for percutaneous creation of an atrial septal defect in the setting of complete transposition of the great arteries, did such catheter maneuvers decisively affect patient management.82, 134, 135, 136 Today, therapeutic catheterization techniques have replaced conventional surgery for many lesions. New methods, tested through research protocols in specialized centers, combined with continuous critical evaluation of established techniques, continue to ensure improved and sustained results. The primary consideration of practicing pediatric cardiologists should not be whether such techniques are possible to perform, but whether their clinical utility, morbidity, and mortality justify a nonsurgical approach for patients. Unsuccessful outcomes, including complications and nondefinitive outcomes, may in part yield to experience and improvements in technique.
Therapeutic interventions, such as cardiac surgery, have three principal objectives: (1) improvement or preservation of cardiac function, (2) improvement in longevity, and (3) maintenance or improvement in the quality of life (QOL). Catheterization interventions may be corrective, reparative, or palliative. Catheter therapies may also be applied as adjuncts to surgery. Cooperation has developed between pediatric cardiologists and pediatric cardiac surgeons in planning staged repairs of complex congenital heart disease (CHD). This type of cooperation will increase and is already contributing to far better outcomes for many complex congenital heart lesions.