Download Amplatzer device closure of Patent Ductus Arteriosus (PDA) : A case

Case Report
Amplatzer device closure of Patent Ductus
Arteriosus (PDA) : A case report
Salam ABMA
The ORION Medical Journal 2007 Sep;28:505-507
Abstract
Patent Ductus Arteriosus (PDA) is one of the
common congenital cardiac anomalies found
in neonate & children1. Surgical closure of
PDA has long been established but
nonsurgical device closure of this defect is
also emerged as the first choice in many
centers through out the world. We selected a
case of PDA of moderate size with mild
pulmonary hypertension in a six years old
young girl for device closure with Amplatzer
Duct Occluder (ADO). Diagnosis &
appropriate sizing of the PDA was determined
with Echo-Color-Doppler study prior to the
procedure. PDA size was pulmonary end 4.5
mm, aortic end 8 mm & length 12 mm. We
selected an ADO device size of pulmonary
end 6 mm, length 8 mm, aortic retention skirt
12 mm with a sheath size of 7 F.
Angiocardiography was done to visualize the
ductus & as well as for haemodynamic
assessment by using Pigtail & NIH catheters.
According to Krichenko A, et al (fig-1), PDA
morphological class was A-2, found suitable
for device closure2. Right Judkin's catheter
was used for guiding wire to pass through
PDA into descending aorta. Then the device
was deployed successfully at first attempt into
PDA, which was occluded immediately as
shown in subsequent checkup descending
aortogram. No residual shunt, no migration,
no LPA stenosis was seen in follow-up
Echocardiography.
The
patient
was
discharged from the hospital one day after the
procedure with follow-up advice.
Introduction
Patent Ductus Arteriosus (PDA) is a
congenital cardiac malformation, which may
be in an isolated form or in association with
Dr. A.B.M. Abdus Salam, MBBS, MD, FCPS
Associate Professor & Head, Department of
Paediatric Cardiology, National Institute of
Cardiovascular Diseases, Dhaka, Bangladesh.
The ORION. Vol 28, September 2007
other cardiac anomalies. Other than in
obligatory duct dependant pulmonary
circulation, PDA should be closed either by
surgery or with device3.
PDA Classifications
PDAs have been classified into five types
TYPE A- The most common (65% in one large
series), a funnel-shaped ductus with a localized.
narrowing at the pulmonary artery junction.
TYPE B- The next most common (18%), includes
funnel-shaped PDAs with an aortic ampulla.
TYPE C- Tubular shape.
TYPE D- Oval shape with both aortic and
pulmonary ampullae.
TYPE E- Other bizarre forms.
Figure 1: Krichenko's PDA classification
The incidence of an isolated PDA is 1 in 2500
to 5000 live birth & 9-12 % of all congenital
heart diseases. It is nearly two times more
common in female than in male4. Ductus
originates from one of the 6th paired aortic
arch5. Physiological closure of the ductus
occurs within few hours of birth but
anatomical closure takes 2-3 days in effect &
finally turns into a fibrous ligamentous
arteriosus within one month6. It may remain
open in premature neonate but why it persists
patent in term neonate, exact cause is not
known.
Hypoxia,
acidosis
&
high
prostaglandin level are the predisposing
factors for the persistent of patent ductus
arteriosus7.
Surgical closure is the established method of
treatment for PDA but device closure is
emerging as an alternative attractive &
effective mode of remedy for it avoiding
surgical scar on the chest8,9. Recently less
invasive method of PDA closure using video
assisted thoracoscopic surgery is also
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effective. It can be done in smaller infant10,11.
Tremendous research & modifications are
occurring in devices for nonsurgical closure
of congenital heart defects like isolated ASD,
VSD & PDA. In 1967, Portsmann W, Wierny
L, et al first reported percutaneous
transfemoral closure of patent ductus
arteriosus as an alternative to surgery. Since
then, several modes were tried including
Rashkind's double umbrella PDA occluder,
various kinds of coils like Gianterco coils,
Cook's detachable coils & finally cardioseal
& Amplatzer methods12-18.
Generally smaller PDA (<2.5mm) is closed
with coils; moderate to large PDA (>2.5 mm
to 8 mm) should be closed with Amplatzer
Duct Occluder. Tiny PDA & very large PDA
particularly Krinchenko type C, D & E should
be sent for surgical closure19. As the devices
are not cost effective, in developing countries
like Bangladesh, there are few cases found
economically fit for device closure. In our
country, Fatema NN et al have performed few
cases of PDA device closure in last 2 years20.
This was the first case of Amplatzer device
closure of PDA at NICVD, which led to write
this case reporting.
Case history
Luna, 6 yrs old, female child from Sylhet,
admitted in pediatric cardiology unit of
National Institute of Cardiovascular Disease
(NICVD) Hospital, with the complaints of
palpitation, exertional dyspnoea & repeated
RTI with growth retardation. On examination,
she was ill looking with below average body
built, mildly pale, RR-20/m, HR-92/m, body
weight- 12 kg, having thrill & continuous
murmur in the pulmonary area. She was
clinically diagnosed as a case of PDA. On
investigations, CXR-Mild Cardiomegaly,
ECG-Mild LVH. Echo-Doppler (Fig-2)-LA,
LV & PA-Dilated, moderate PDA, Size-4.5 X
8 X 12 mm with PPG-65 mmHg & L-R shunt,
Mild PAH (PASP-28 mmHg). We planned
for Amplatzer device (Fig-3) closure of her
PDA
Figure 2: Echo-doppler & Figure 3: Amplatzer device
with ADO size of pulmonary end 6 mm (1.5
mm more than PDA pulmonary end diameter)
x aortic end size 8 mm & length 7 mm.
Accordingly; She was admitted at NICVD in
pediatric cardiology unit on 25th December,
2006 & was taken to Cath Lab on the
following morning for the procedure.
Procedure
Patient was given sedation with injection
diazepam & ketamine along with atropine.
Proper sterilization of groin area was done
along with draping. Femoral vein & artery
access were achieved as routinely with 5F
sheaths.
Although,
Echocardiography
confirmed that there was no other shunt
anomaly other than PDA, right & left heart
catheterization was performed in routine
fashion with NIH & Pigtail catheters along
with pressure, oxymetry & haemodynamic
study. PDA was visualized by a descending
aortogram passing a pigtail catheter via
femoral artery in lateral view (Fig-4). PDA
shape
Figure 4: Aortogram showing PDA
corresponds to Krinchenko type A 2 that is
funnel shaped. Measurements of PDA
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correspond
measurements.
to
echocardiography
catheter & all the sheaths were removed with
proper haemostasis.
The Pigtail catheter was kept in situ. The
selected size of the Amplatzer Duct Occluder
was suitable for the patient. A J-tipped guide
wire was introduced through the PDA into the
descending aorta. Here we used right Judkin's
as a guiding catheter. The delivery sheath was
introduced onto the exchange wire up to
descending aorta & wire removed. Position of
the tip of the sheath was confirmed by a test
injection of contrast medium. The delivery
cable was passed through the loader & the
device was mounted on to the tip of the cable
and screwed in clockwise direction. Then the
device was immersed into saline water &
slowly pulled into the loader. Then the loader
along with the device on the tip of the
delivery cable within it was forwarded by
pushing through the sheath without any
rotation into the descending aorta. Only the
retention skirt of the device was first
deployed & pulled firmly against the aortic
orifice of the PDA. It was seen in fluoroscopy
as well as tugging sensation of aortic
pulsation was clearly felt. Check descending
aortogram was done using Pigtail catheter to
see the well-seated position of the device into
the aortic ampulae. The delivery sheath was
then gradually withdrawn deploying the
cylindrical portion of the device in the PDA
while applying slight tension.
Fluoroscopy time required was 15 minutes &
the whole procedure time was 45 minutes.
Injection Ceftriaxone (50 mg/kg) & tablet
Aspirin (75mg/kg) were given. On the
following day, Echo-Color-Doppler was done
(Fig-6) & seen that there was no residual
shunt & no LPA stenosis (PPG- 4.5 mm Hg,
Peak Velocity-1.2 m/sec). The patient was
discharged with oral aspirin & penicillin with
follow up advice after1, 3 & 6 months.
Again check descending aortogram was done
& recorded on cine a power injection through
the Pigtail catheter using 1 cc per kilogram of
contrast at 12 ml per second at 400 psi in
35/35 degree LAO cranial view to visualize
the length of the device whether it protruded
into LPA. As there was no residual shunt &
no migration into LPA, we deployed the
device by screwing counter clockwise the
plastic vise fixed with the cable, which along
with sheath was slowly withdrawn. Another
check aortogram with the help of pigtail
catheter was performed after 10 minutes (Fig5), but there was no trace of residual shunt
due to 100% occlusion of the ductus & no
aortic obstruction was seen (Fig-5), so the
The ORION. Vol 28, September 2007
Figure 5:
Aortogram after
diployment of
device
Figure 6:
Echo
shows no
residual
shunt & no
LPA
stenosis
Discussion
Patent ductus arteriosus is a common
congenital cardiac shunt anomaly, which must
be closed either by surgery or with
nonsurgical device procedure, because of its
haemodynamic effects & the potential risk of
infective endarteritis. Gross & Hubbard in
1938 performed first surgical ligation of PDA,
since then it is the established method of
treatment21. But, there was reported 1-3.5%
mortality in surgical closure of PDA & comorbidity like, recurrent laryngeal nerve
palsy with hoarseness of voice, recanalisation
of PDA with residual shunt & ultimately an
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ugly scar mark on the chest are not
infrequent22. So the pediatric cardiologists
were trying to close PDA in cath. labs with
various interventional methods since early
age. Finally Rashkind W, Wierny L et al,
after 30 years of first surgical procedure,
successfully closed the PDA with device in
1967 & historically started the era of pediatric
interventional procedure for congenital heart
disease12.
Now a days, device closure is the first choice
for PDA treatment in many centers except
very tiny & very large, bizarre PDA, which
are sent for surgical closure8,9,23,24. Different
kinds of devices are in use with variable
outcome & success rate but ideally, coils are
suitable & cost effective for smaller PDA
(pulmonary end diameter up to 2.5 mm),
amplatzer duct occluder for moderate to large
(pulmonary end diameter up to 10 mm) PDA.
USFDA recommended Amplatzer method in
May 14th, 2003 as a safe & alternative way to
close PDA25. As it is very costly in
comparison to surgery, we are getting less
number of patients suitable for device closure
of PDA in our center, although it is the only
tertiary level government cardiac hospital
having both pediatric cardiology & pediatric
cardiac surgery units. This was the first case
we have done successful PDA device closure
with Amplatzer. In multicentre case series (n
= 435) study by Pass et al (2004) showed that
angiographic immediate total occlusion was
seen in 76% cases & after 24 hours 89% cases,
along with one case of mortality due to device
embolization26.
In India, Shrivastava S, Marwah A,
Radhakrisnan et al (2000) reported a series of
PDA device closure with spring coils &
amplatzer duct occluder. They had the
experiences of 55% immediate closure, 89%
delayed closure, 9.5% LPA stenosis due to
inappropriate sizing of the device with
migration in to LPA in amplatzer group. They
had also 1% failure to deploy the amplatzer
into the PDA9,23. But in our case, there was
immediate total occlusion after the
deployment of the device without any residual
The ORION. Vol 28, September 2007
shunt or any LPA stenosis. There were no
single minor adverse effects in our case. The
key to immediate success depends upon the
accurate determination of size of the PDA by
Echocardiography, specially viewing it in
modified ductal cut window, in which PDA is
well visualized 27. PDA with severe
pulmonary hypertension can also be closed
safely with amplatzer duct occluder in the
same sitting after calculating PVR, if it is
below 8 wood units28,29.
Although it is an easy & safe procedure, there
are few warnings & few contraindications. It
should not be tried in-patient below 6 months
of age & below 6 kg of body weight. Device
should be removed if it extends > 3 mm into
LPA (or LPA flow is > 3.0 m/s). MRI using
magnetic field > 1.5 Telsa unit should be
avoided after device closure. Endocarditic
prophylaxis should be carried at least for 6
months.
Conclusion
Amplatzer device closure of moderate to large
PDA is an alternative new mode of
nonsurgical
quite
safe
&
effective
interventional treatment. Device closures of
congenital heart defects, particularly isolated
PDA, ASD (secondum), and VSD (muscular)
are now possible in our center. Although,
these are costly procedures, but some of our
peoples are affordable who used to buy them
from other countries at the expense of our
hard earned foreign currency, which we want
save providing the services in most economic
way at National Institute of Cardiovascular
Disease (NICVD), Dhaka, Bangladesh.
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