Novel use of the Amplatzer plug for closure of a patent ductus arteriosus.
We report the novel use of an Amplatzer vascular plug for closure of a large tubular patent ductus arteriosus in a small child.
Ductus Arteriosus, Patent↗
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Transcatheter closure of the patent arterial duct using the Flipper coil in a premature infant weighing 1,400 g: a case report.
A symptomatic 1,400 g premature triplet underwent successful transcatheter coil embolization of patent arterial duct using the umbilical artery. One 3 mm x 3 cm Flipper coil was used with no angiographic residual shunt. To the best of our knowledge, this is one of the smallest preterm infants to undergo this transcatheter procedure.
Cardiac Catheterization↗
Transcatheter closure of patent ductus arteriosus with Nit-Occlud coils.
The detachable coils have been successfully used for transcatheter occlusion of small- to moderate-sized patent ductus arteriosus (PDA). We report our experience regarding the use of the Nit-Occlud coils (NOCs) for transcatheter PDA and major aortopulmonary collateral (MAPCA) occlusion. Single NOCs were used to close PDA in 26 patients, and one small and two large MAPCAs in two patients. Mean age and weight of the patients were 7.7 +/- 5.4 years and 20.6 +/- 11.6 kg. Mean minimum duct diameter was 2.8 +/- 0.8 mm; ampulla, 8.7 +/- 2.4 mm; and PDA length, 9.3 +/- 4.4 mm. Mean pulmonary artery pressure ranged from 9 to 51 mm Hg and pulmonary/systemic flow ratio from 1.1 to 5.8. Ductal shape was conical in 24 patients. Route of approach was venous in 23 and arterial in 3. Successful coil implantation was achieved in 24/26 (92.3%). Mean procedure and fluoroscopy time were 67.2 +/- 22.1 and 14.9 +/- 6.5 min. The three MAPCAs were also successfully occluded using NOC Medium and Flex. Postimplantation angiograms revealed no leak in 3, a trace or small leak in 17, and a medium leak in 4 patients. Mean follow-up was 7 +/- 5 months. Complete occlusion was achieved in 17/24 (71%) at 24 hr, 19/24 (79%) by 1 month, 13/15 (87%) by 3 months, 14/15 (93%) by 6 months, and 10/11 (90%) by 12 months postprocedure. Hemolysis, late embolization, duct recanalization, and flow disturbances were not observed. Transcatheter occlusion of moderate-sized PDAs and MAPCAs using NOCs seems to offer a safe, simple, and controlled method in pediatric patients.
Adolescent↗
Inadvertent stenting of patent ductus arteriosus with Amplatzer Vascular Plug.
We report a 12-month old patient who presented for murmur evaluation after percutaneous closure of type C patent ductus arteriosus (PDA) using a 10 mm Amplatzer Vascular Plug (AGA Medical Corporation, Golden Valley, MN) at an outside institution. Echocardiography revealed a large left-to-right shunt through the implanted device, inadvertently stenting the PDA instead of closing it. The patient underwent repeat catheterization with successful coil implantation within the Amplatzer Vascular Plug, completely eliminating the large residual ductal shunt. Although challenging, this case illustrates the technique of implanting coils within this occlusion device. This case also illustrates that occlusion of type C PDA utilizing the Amplatzer Vascular Plug may not only result in incomplete occlusion but also create a potentially worse clinical situation in which the PDA is stretched larger and stented open. Without consideration of simultaneous coil implantation within this device, use of the Amplatzer Vascular Plug might be contraindicated in type C PDA, because there may be no way to ensure successful closure by the Vascular Plug alone.
Cardiac Catheterization↗
Noninvasive assessment of indomethacin therapy in patent ductus arteriosus in preterm infants.
We performed 138 serial two-dimensional (2-D), M-mode, and Doppler echocardiographic studies to assess the efficacy of intravenous indomethacin (INDO) therapy for patent ductus arteriosus (PDA) in 41 preterm infants. Nine infants expired without sufficient echo data to warrant inclusion in the study. Of the remaining 32 infants, 12 (Group 1) required ligation despite INDO therapy, 18 (Group 2) responded to INDO or spontaneously closed their PDAs, and 2 were transferred to other hospitals with their PDAs still open and were lost to follow-up. The presence of PDA was verified by 2-D echo visualization of the ductus (high parasternal short-axis views) and Doppler demonstration of high velocity ductal flow toward the main pulmonary artery. The ratio of PDA lumen to aortic root inner diameter (Ao) was measured as well. Indication for surgical ligation was failure of the PDA to close after 3 or more courses of INDO. In Group 1, the PDA/Ao ratio was 0.45 +/- 0.10 standard error of the mean (SEM) pre-INDO, and 0.40 +/- 0.12 SEM post-INDO (immediately before ligation). In Group 2, the PDA/Ao ratio was 0.42 +/- 0.11 SEM pre-INDO, and 0.19 +/- 0.14 SEM at the end of INDO course (p less than 0.001), with 12 infants showing no ductal flow by Doppler. Follow-up six months after INDO therapy has shown no residual murmurs or other evidence of PDA in any INDO-closed infant. Five of the 18 infants have undergone repeated echocardiographic studies, all of which were negative for PDA patency or flow.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta↗
Transcatheter closure of a patent ductus arteriosus in an elderly patient with the Gianturco-Grifka vascular occlusion device.
This paper reports the unusual case of a 76-year-old woman who was discovered to have a hemodynamically significant patent ductus arteriosus following uneventful mitral valve replacement, utilizing cardiopulmonary bypass. The shunt was successfully eliminated using a new transcatheter device, thereby obviating the need for further surgery. The patient did not have calcification within the ductus, making diagnosis prior to surgery more difficult.
Aged↗
Echocardiographic detection and management of patent ductus arteriosus in neonates with respiratory distress syndrome: a two-and one-half year prospective study.
A prospective 2 1/2 year study of 50 infants with combined respiratory distress syndrome (RDS) and patent ductus arteriosus (PDA) was undertaken to determine whether echocardiographic measurements combined with clinical assessment could be used to select those infants who needed cardiac treatment. From a pilot study, criteria were adopted to use digoxin in the treatment of infants with evidence of congestive cardiac failure and/or a left atrial dimension 1.5 times normal size, and to ligate the PDA in those with unremitting congestive cardiac failure and a left atrial dimension persistently twice normal. Left atrial, left ventricular, and aortic dimensions, left atrial to aortic ratio, and mean Vcf were echocardiographically determined. Forty-six per cent of the 50 infants with PDA required digoxin administration, and 18 per cent of the total group was operated. The long-term mortality for the total group was 12 per cent (6 of 50) and mortality was 33 per cent (3 of 9) for the operated group. Results showed that absolute left atrial dimension, particularly if recorded in two dimensions, most accurately predicted those infants who would develop congestive cardiac failure or failure that would become medically unmanageable.
Aorta↗
Necrotizing tracheobronchitis in patent ductus arteriosus-dependent cyanotic congenital heart disease.
We report 2 patients with necrotizing tracheobronchitis (NTB) associated with patent ductus arteriosus-dependent cyanotic congenital heart disease. The pathologic findings suggest that hypotension and decreased tracheo-bronchial perfusion were the major contributing factors in the development of NTB. Necrotizing tracheobronchitis developed in infants with pulmonary atresia and Ebstein's anomaly with pulmonary stenosis. Both infants required prostaglandin E1 infusion from early infancy, and presented with sudden onset of dyspnea and hypercapnea. In one infant, NTB developed prior to mechanical ventilation. In the other infant, NTB developed after 4 days of mechanical ventilation. Care of both infants involved minimal pressures and FiO(2), adequate humidification, and optimal temperature of inspired gases; these factors probably did not play a role in the development or worsening of NTB. Both infants had hypotension and hypoxemia. These factors could have contributed to the development of NTB because of decreased perfusion pressure and tissue hypoxia. As the area of necrosis and its severity correlated with the area of blood supply served by the specific feeding arteries, we speculate that tissue hypoperfusion was the major cause of NTB.
Bronchitis↗
Video surgical technique for interruption of patent ductus arteriosus in children and neonates.
Classical surgical interruption of PDA has partially been replaced by trans catheter endovascular closure since 1971. We describe a new technique for PDA closure by video surgery. With the patient under general anesthesia and intubated, two 5 mm holes were made through the left thoracic wall. A video camera and specially devised surgical tools were introduced, such as scissors, dissecting forceps, clip appliers. The ductus was dissected and two titanium clips were applied, completely interrupting the ductus. 282 patients were operated on from April 1991. Mean age was 20 months (range 1 month to 17 years) and mean weight was 13 kg (range 1.2 to 65 kg) Twenty-one had associated lesions not necessitating immediate surgical treatment. All had successful closure of the patent ductus with the video-assisted technique. 6 patients had recurrent laryngeal nerve injury (5 transient, 1 permanent). The usual hospital stay was from 48h to 72h. There were no other complications and no deaths. Video surgery is a rapid, safe and successful technique for closure of the patient ductus arteriosus. The technique is feasible in low-weight and premature infants.
Adolescent↗
Patent ductus arteriosus and neonatal death in prostaglandin receptor EP4-deficient mice.
The physiological role of the prostaglandin E2 receptor EP4 subtype was investigated by generation of EP4-deficient-mice by gene targeting. Loss of the EP4 receptor was not lethal in utero, but most EP4 (-/-) neonates became pale and lethargic approximately 24 h after birth and died within 72 h. Less than 5% of the EP4 (-/-) mice survived and grew normally more than a year. Histological examination revealed that the ductus arteriosus in dead neonates remained open, while it was partially closed in the survivors. In situ hybridization study showed that EP4 mRNA was strongly expressed in the ductus. These results suggest that neonatal death is at least partly due to patent ductus arteriosus and that the EP4 receptor plays a role in regulation of the patency of this vessel. They also indicate that normal function of the EP4 receptor is essential in neonatal adaptation of the circulatory system.
Animals↗
Percutaneous transcatheter coil occlusion of the patent ductus arteriosus aided by the nitinol snare: further observations.
PURPOSE: To assess the safety and efficacy of the nitinol snare to aid in the delivery of a Gianturco coil in percutaneous occlusion of a patent ductus arteriosus (PDA). METHODS: Seventeen patients (mean age 8.2 years) underwent catheterization and coil occlusion of a PDA (mean minimum diameter 1.9 mm). A nitinol snare was used to deliver and position the coil in the ductus. RESULTS: A single Gianturco coil was placed successfully in all patients, resulting in complete ductal occlusion documented by aortic angiography. Color echocardiography documented a trivial residual shunt in one patient who had no audible cardiac murmurs following the procedure. There was no hemodynamic or echocardiographic evidence of left pulmonary artery obstruction. There were no complications and all patients were discharged within 24 hr following the procedure. CONCLUSIONS: Percutaneous coil occlusion of the PDA is safe and effective. Snare-controlled coil delivery eliminates the risk of coil dislodgement and optimizes coil position.
Adult↗
Spring coil embolization of a patent ductus arteriosus in an adult.
To date, coil embolization has been reserved for occlusion of the small patent ductus arteriosus (PDA) because of potential dislodgement of the coils. We report a case of a larger, hemodynamically significant PDA in an adult which was successfully closed by two spring coils using a "crossed catheter" technique for coil delivery.
Adult↗
Arteriovenous malformation of the great vein of Galen associated with patent ductus arteriosus. Report of three cases and review of the literature.
The arteriovenous malformation of the vein of Galen (AVG), composed of a fistula between medium to large arteries and the vein of Galen, is frequently fatal in the neonatal period. We now report three cases of infants with AVG and associated patent ductus arteriosus (PDA), and review the literature for these associated findings. The presence of a PDA can result in severe vascular derangement in the postoperative period, and further complicate management of these infants. Analysis of this abnormal central circulation may contribute to a better understanding and therefore outcome for this unfortunate group of patients.
Cerebral Veins↗
Aneurysm of a patent ductus arteriosus in an adult.
An adult patient with a spontaneous aneurysm of a patent ductus arteriosus was successfully treated. The lumen of the aneurysm communicated with the distal aortic arch and the pulmonary artery. Closure of the pulmonary arterial orifice of the ductus arteriosus and replacement of the inferior wall of the distal aortic arch and proximal descending aorta with prosthetic graft were performed under partial cardiopulmonary bypass using a centrifugal pump. The postoperative recovery was uneventful.
Diagnostic Imaging↗
Abnormal blood flow patterns in renal arteries of small preterm infants with patent ductus arteriosus detected by Doppler ultrasonography.
Blood flow velocities and pulsatory indices in both renal arteries (RAs) and in the internal carotid artery (CAI) were measured by pulsed Doppler ultrasonography in ten preterm infants with patent ductus arteriosus (PDA), before and after surgical ligation. The results obtained in the RAs were compared to those found in a reference group of 22 stable preterm infants. In the RAs the diastolic steal volume of the PDA led to a marked decrease in diastolic blood flow velocity (range 3 to -23 cm/s). Seven infants showed retrograde diastolic flow, whereas only three infants had these flow patterns in the CAI. In the RAs, the peak systolic blood flow velocities (range 56 to 135 cm/s) exceeded the values found in the reference group by 85% on average. The pulsatility indices reached values of above 1,00. In spite of the increase in systolic flow velocities before surgery, the time mean of maximum velocities was significantly lower than those measured after surgery and in the reference group. After PDA ligation, blood flow velocities normalized. The present study shows that a large PDA may induce abnormal flow patterns even in the RAs. These flow patterns may predispose to renal hypoperfusion and subsequent impairment of renal function.
Blood Flow Velocity↗
Effects of prolonged versus acute indomethacin therapy in very low birth-weight infants with patent ductus arteriosus.
Indomethacin has proven effective in closing the patent ductus arteriosus (PDA) in most low birth weight (LBW) neonates with this disorder. Early reopening of the ductus is a problem and often leads to the need for surgery. Prolonged use of indomethacin for several days has been suggested as a means to alleviate this problem. The present study was designed to determine if prolonged therapy over 5 days is more effective than a two-dose regimen in preventing reopening of the PDA. Seventy neonates were randomized for either prolonged therapy over 1 week or to receive two doses of indomethacin. All infants were given two doses of indomethacin 0.15 mg per kg, 12h apart. The maintenance group received an additional 0.1 mg per kg daily for 5 days. Ten days after the infants' initial dose of indomethacin, 6 of 22 in the nonmaintenance group as compared to 0 of 22 in the maintenance group had reopening of their ductus arteriosus. Ten infants in the maintenance group eventually had the ductus reopen at a median of 29, range 11-66 days compared to a median of 3, range 2-44 days in the nonmaintenance group. Significantly fewer babies in the maintenance group had a grade II-IV intraventricular hemorrhage compared to the nonmaintenance group. There was no other significant difference in the two groups in the incidence of necrotizing enterocolitis, retrolental fibroplasia or death. Indomethacin given over 5 days is effective for closure of the ductus arteriosus and will prevent reopening until after the acute clinical course in babies under 1500 g; however, the overall incidence of reopening was not different.
Cerebral Hemorrhage↗
Sensitivity, specificity and predictive value of clinical findings, m-mode echocardiography and continuous-wave Doppler sonography in the diagnosis of symptomatic patent ductus arteriosus in preterm infants.
By means of probability analysis we have compared the diagnostic value of clinical symptoms, m-mode echocardiographic measurements and peripheral arterial flow, assessed by continuous-wave Doppler, in preterm infants with symptomatic patent ductus arteriosus (PDA). Data were obtained in 29 infants with PDA and in 29 controls. The most sensitive clinical finding was a hyperactive precordium. Bounding pulses and a heart murmur were absent in 15% and 20%, respectively of the patients with PDA. M-mode echocardiographic measurements were rather specific for the detection of a PDA but less sensitive. Diastolic backflow in the brachial and femoral arteries was present in the majority of patients with PDA and absent in about 67% of the controls. The values in probability analysis, however, were too low to base a therapy on these findings. The highest sensitivity and specificity (100% each) was found for a disturbed cerebral blood flow with absent or retrograde diastolic perfusion estimated by Doppler sonography.
Blood Flow Velocity↗
Indomethacin and cerebral blood flow in premature infants treated for patent ductus arteriosus.
Central blood flow (CBF) was estimated by an intravenous 133-xenon technique in six preterm infants before and after administration of indomethacin for closure of patent ductus arteriosus. CBF fell in all infants (range 12%-40%), the mean fall was 24% (P less than 0.005). Though none of the infants showed signs of impaired cerebral function during or following the injections, the results do not indicate whether or not the use of indomethacin is a potential hazard.
Cerebrovascular Circulation↗