Frequency of occurrence of residual ductal flow after surgical ligation by color-flow mapping

Repeat use of occluding spring coils to close residual patent ductus arteriosus

Recent studies have shown that small- and moderate-size patent ductus arteriosus (PDA) may be closed with occluding spring coils. As with other percutaneous devices, a low incidence of residual PDAs has been observed in medium-term follow-up. This report describes experience with closing residual PDA by repeat use of occluding spring coils.

Video-assisted thoracoscopic surgery for congenital heart disease

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery, but applications in children with congenital heart disease have been limited. We report the development of video-assisted thoracic surgery procedures for neonates and infants with cardiovascular disease. Endoscopic instruments and techniques for pediatric cardiovascular procedures were designed and tested in the animal laboratory. Forty-eight operations were subsequently performed in 46 pediatric patients ranging in age from 2 hours to 14 years (median 9 months), weighing from 575 grams to 54 kg (median 8.5 kg). Clinical applications included seven different surgical procedures: patent ductus arteriosus interruption in infants (n = 26) and premature neonates (n = 5), vascular ring division (n = 8), pericardial drainage and resection (n = 3), arterial and venous collateral interruption (n = 2), thoracic duct ligation (n = 2), epicardial pacemaker lead insertion (n = 1), and diagnostic thoracoscopy (n = 1). There was no operative mortality. Technical success, defined as a video-assisted procedure completed without incising chest wall muscle or spreading the ribs, was achieved in 39 of 48 procedures (82%), with thoracotomy required to complete nine procedures. Most patients (22/25, 88%) undergoing elective ductus ligation were extubated in the operating room and discharged from the hospital within 48 hours of the operation. Eight of the last 10 patients having ductus ligation were discharged on the first postoperative day. Residual ductal flow was assessed by (1) transesophageal echocardiography in the operating room (incidence: 0/25, 0%, 70% CL 0% to 7.3%); (2) discharge auscultation (incidence: 1/30, 3%, 70% CL 0.5% to 10.8%); and (3) follow-up Doppler echocardiography (incidence: 3/25, 12%, 70% CL 5.4% to 22.6%). Video-assisted thoracoscopic techniques can be safely applied to pediatric patients with patent ductus arteriosus and vascular rings and may become an effective addition to the staged management of more complex forms of congenital heart disease.

Umbrella occlusion of persistent arterial duct in children under two years

OBJECTIVE

To assess the use of trans-catheter occlusion of a persistent arterial duct in symptomatic children < 2 years of age.

DESIGN

Descriptive study of selected, non-randomised infants with persistent arterial duct who underwent attempted umbrella occlusion.

SETTING

Tertiary referral centre.

PATIENTS

Between June 1990 and April 1993, 29 young children with a symptomatic persistent arterial duct underwent attempted transcatheter occlusion. Their age ranged from 1.5 to 23 months, with the youngest infant weighing 2.9 kg. The diagnosis was established before operation in all patients by cross sectional echocardiography.

INTERVENTION

Transcatheter occlusion of a haemodynamically important persistent arterial duct was performed with the Rashkind ductal umbrella. In the past year the front loading technique has been used to place the 12 mm umbrella through a 6 F (French) sheath and the 17 mm device through a 8 F sheath so extending the indications for their use.

RESULTS

Umbrellas were successfully placed in 25 (86.2%) infants and there was symptomatic improvement in all. There were no deaths or severe complications. The four failures occurred early in the series. They were caused by kinking of the 11 F sheath in two cases and embolisation into the left pulmonary artery in one case. The procedure was abandoned in the fourth case because of a large duct. Only three of the 25 patients had small residual shunts at one year follow up (all with 17 mm devices) but no stenosis or turbulence was noted in any of the patients.

CONCLUSION

The transcatheter occlusion of persistent arterial duct in young children with symptoms is a safe alternative to surgery. The new front loading umbrella technique enables successful ductal closure in even smaller infants than earlier devices.

Forty-six years of patient ductus arteriosus division at Children's Memorial Hospital of Chicago. Standards for comparison

OBJECTIVE

The authors reviewed a large surgical experience (during five decades) with ligation and division of patent ductus arteriosus (PDA) in light of previously reported historical standards and present-day alternatives.

SUMMARY BACKGROUND DATA

Ligation of PDA was first performed by Gross in 1938. Various surgical techniques used since then have included ligation and division, simple ligation, and hemaclip application. Recently introduced therapies include percutaneous transcatheter ductal closure devices (PTDC) and video-assisted thoracotomy (VAT). Percutaneous transcatheter ductal closure device protagonists cite surgical recurrence rates as high as 22% to justify continued application.

METHODS

Between 1947 and 1993, 98.2% of 1108 patients (premature babies excluded) had interruption of PDA by ligation and division. Recent improvements have included muscle-sparing thoracotomy, minimal use of tube thoracostomy, and same-day surgery.

RESULTS

Mortality was zero and morbidity (4.4%) has been low over time. Mean age at surgery has decreased from 5.9 +/- 3.3 years to 3.6 +/- 3.8 years (p < 0.001); patients requiring blood transfusion decreased from 34% to 4.6% (p < 0.001); and length of hospital stay (LOS) has decreased from 12.1 +/- 2.9 days to 3.8 +/- 2.1 days (p < 0.001). Length of stay for the last 27 patients was 2.8 +/- .8 days. Patient ductus arteriosus recurrence rate is zero with this technique.

CONCLUSIONS

Recurrence rates for PTDC are high with as yet unknown consequences of large catheter vascular access, endocarditis, or left pulmonary artery stenosis. Video-assisted thoracotomy for PDA interruption has the potential for uncontrolled exsanguinating hemorrhage. Open thoracotomy for PDA ligation and division can be performed safely and without recurrence through a muscle-sparing incision with short LOS. All other therapeutic interventions must be compared to these standards.

Interventional pediatric cardiology: state of the art and future perspective

Interventional catheter therapy has drastically changed the practice of cardiac catheterization and the treatment of congenital heart disease. In some centers, interventions amount to 30% or more of all cardiac catheterizations. For some lesions, surgery has become obsolete. For valvular pulmonary stenosis, balloon dilatation is the therapy of choice and results in permanent elimination of pressure gradients. Balloon dilatation is also indicated for valvular aortic stenosis and results in mild residual stenosis with gradients below 35 mmHg. Aortic insufficiency, mostly mild, is induced in 15%-20%. Native and post-operative coarctation can be successfully dilated. About 50% of pulmonary artery stenoses can be relieved by balloon dilatation. Stent placement increases the success rate to 75%-80%. Stent implantation is also being investigated for other lesions. Valvular pulmonary atresia can be opened by catheter technique. In the majority of patients over 6 kg, the patent ductus arteriosus is transvenously closed by implantation of the Rashkind occluder. Secundum or similar atrial septal defects and muscular ventricular septal defects can also be closed by catheter technique, but suitable specific occluders are not generally available at present. Therapeutic vascular occlusions, radiofrequency ablation of aberrant conduction pathways and arrhythmia foci are examples of other catheter interventions.

Transoesophageal echocardiography detects residual ductal flow during video-assisted thoracoscopic patent ductus arteriosus interruption

This report describes transoesophageal echocardiographic (TEE) monitoring in a one-year-old boy undergoing patent ductus arteriosus (PDA) interruption. After application of a first vascular clip, echocardiographic monitoring detected incomplete interruption of ductal flow, prompting the surgeon to add a second clip to the ductus. The procedure was performed via a new surgical technique: video-assisted thoracoscopic surgery (VATS). This innovative approach offers many advantages to patient care including reduced postoperative pain and better preservation of pulmonary function. We conclude that the use of TEE monitoring during PDA interruption via the VATS procedure may improve the surgical result, and eliminate reintervention and the complications associated with residual ductal flow.

Medium-term follow up of residual shunting and potential complications after transcatheter occlusion of the ductus arteriosus

OBJECTIVES

To determine the causes and outcome of residual shunting after transcatheter occlusion of persistent ductus arteriosus with the Rashkind double umbrella occluder, and to determine the potential of the device to produce obstruction to flow in the aorta and left pulmonary artery.

DESIGN

Angiographic examination of morphology of ductus followed by prospective clinical and ultrasound evaluation (including cross sectional imaging, colour flow mapping, and pulse wave Doppler) of all patients undergoing occlusion of persistent ductus arteriosus between October 1987 and July 1992.

PATIENTS

140 patients with ages between 0.5 and 78 (median 3.8) years and weights between 6.8 and 74 (median 13.8) kg.

INTERVENTIONS

Attempted implantation of the Rashkind double umbrella ductus occluder under angiographic control through a transvenous (n = 136) or transarterial (n = 4) approach.

MAIN OUTCOME MEASURES

Successful occlusion of ductus; frequency, pattern, and prognosis of residual shunts; Doppler velocities in left pulmonary artery and aorta; volume loading of the left heart.

RESULTS

Including reocclusions the overall rate of successful occlusion was 96%. A total of six devices embolised at the time of operation (4.3%) with no sequelae. There were no anatomical factors that predicted a poor outcome, but suboptimal positioning of the device led to a significantly higher incidence of residual shunts (p < 0.001). Colour flow mapping correctly identified shunts that were unlikely to close spontaneously (n = 9) and to date seven have undergone successful closure with a second device. Encroachment of device legs produced statistically (p < 0.001) but not clinically significant increases in left pulmonary artery Doppler velocities that diminished with time.

CONCLUSIONS

Transcatheter occlusion provides a safe and effective means of closing a persistent ductus arteriosus. Doppler colour flow mapping is necessary for follow up and shows those ducts requiring reocclusion. The device did not produce significant disturbance to flow in the pulmonary arteries or aorta.

Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. The Patient Ductus Arteriosus Closure Comparative Study Group

BACKGROUND

Transcatheter implantation of the Rashkind PDA occluder is an alternative to conventional surgical closure of isolated patent ductus arteriosus. Neither the clinical outcomes nor the costs of these procedures have been formally compared.

METHODS

We performed a retrospective cohort study to evaluate the clinical outcomes within a seven-month period for comparable patients with patent ductus arteriosus who underwent either placement of an occluder or surgical closure. The patients were treated between 1982 and 1987 at 14 major North American centers where patent ductus arteriosus was closed predominantly by a surgical procedure or by the occluder technique. To estimate inpatient and follow-up costs, we multiplied the observed use of resources by 1989 unit costs based on hospital-accounting and physician-reimbursement data.

RESULTS

On the basis of cardiac auscultation at follow-up, the initial procedure resulted in closure of the ductus arteriosus in 77.3 percent of 185 patients in whom the occluder was implanted (95 percent confidence interval, 70.6 to 83.1 percent) and 99.8 percent of 446 surgical patients (95 percent confidence interval, 98.8 to 100.0 percent). Second procedures increased the percentage of successful closures to 87.6 percent (95 percent confidence interval, 81.9 to 92.0 percent) and 100.0 percent (95 percent confidence interval, 99.3 to 100.0 percent) for patients in the occluder and surgical groups, respectively. There were no deaths. Major complications occurred in 2.7 percent of the patients in whom the occluder was implanted (95 percent confidence interval, 0.9 to 6.2 percent) and 0.2 percent of the patients who underwent surgery (95 percent confidence interval, 0.0 to 1.2 percent); moderate complications in 16.8 percent (95 percent confidence interval, 11.7 to 22.9 percent) and 15.0 percent (95 percent confidence interval, 11.8 to 18.7 percent), respectively; and minor complications in 11.4 percent (95 percent confidence interval, 7.2 to 16.8 percent) and 24.9 percent (95 percent confidence interval, 20.9 to 29.2 percent). Including the cost of follow-up care, the mean estimated cost per case treated surgically was $8,838 (in 1989 U.S. dollars), as compared with $11,466 per case treated with the occluder technique. Sensitivity analyses based on our data identified no plausible situations in which the costs of surgery and of implantation of the occluder would be equal.

CONCLUSIONS

The more effective and less costly surgical procedure was superior to transcatheter placement of the occluder for closure of isolated patent ductus arteriosus. Consequently, our results do not support the wide-spread dissemination of the occluder procedure for the management of this common congenital lesion.

Transcatheter occlusion of patent ductus arteriosus with Gianturco coils

BACKGROUND

Transcatheter occlusion with Gianturco coils has been attempted in a small number of patients with tiny (< or = 1.5-mm diameter) patent ductus arteriosus, and preliminary results have been encouraging. The present study extends this method to larger ductus sizes and makes recommendations for proper coil size selection.

METHODS AND RESULTS

Coil occlusion was attempted in 24 consecutive patients with patent ductus arteriosus who did not require other cardiac surgery. Median patient age was 4.2 years (8 months to 30 years), and mean ductus diameter was 1.7 +/- 0.8 mm. Two instances of coil embolization occurred in the first 4 patients, with successful coil retrieval. Based on this experience, we proposed that the coil helical diameter should be twice or more the minimum ductus diameter, with coil length sufficient for three or more loops. With these recommendations, coils were successfully implanted in the subsequent 20 consecutive patients. Of the 22 patients with successful coil implantation, 15 (68%) had no residual shunting, and 7 had trace residual shunting by angiography. The continuous murmur was abolished in all 22 patients. No significant complications occurred, and all patients were discharged within 24 hours of successful coil implantation. No change in the systolic pressure gradient between main and left pulmonary artery or ascending and descending aorta was observed.

CONCLUSIONS

Transcatheter occlusion of patent ductus arteriosus can be safely and effectively achieved in patients with ductus diameters up to 3.3 mm. Coil occlusion does not cause obstruction to flow in the left pulmonary artery or descending aorta. Coils should be selected to provide a helical diameter twice or more the minimum ductus diameter and a length sufficient for three or more loops.

Transcatheter occlusion of patent ductus arteriosus in adults

This study examines whether transcatheter closure of a patent ductus arteriosus (PDA) using a Rashkind PDA occluder device is safe and effective in adults, or if adults have complications not sited in children owing to prolonged aorticopulmonary communication, high surgical risks or calcified PDAs. Fifteen patients aged 22 to 76 years (mean 42 +/- 14) were referred for transcatheter PDA occlusion. Exercise intolerance was the most frequent clinical manifestation. Eleven of 15 patients had surgical risk factors that included left ventricular failure (n = 10), biventricular failure (n = 1), elevated pulmonary pressures (n = 1), and a calcified PDA (n = 5). Twelve millimeter devices were placed in 4 PDAs < or = 3 mm in diameter; 17 mm devices were placed in 11 PDAs 3 to 6 mm in diameter. Seven (47%) were occluded angiographically shortly after device placement; another 5 PDAs (33%) were occluded echocardiographically within 24 hours of the procedure. Completed occlusion in this time interval was more likely to occur in PDAs < 5 mm in diameter (p = 0.0009). Of the 3 remaining PDAs with follow-up ranging from 9 to 38 months, 2 have demonstrated gradual diminution of shunting and have trivial leaks by color/Doppler flow. The other patient with a residual PDA has no ductal flow after placement of a second device. No complications related to device implantation or closure of the PDA occurred in any patient. No complications were reported in the follow-up patients who received evaluation (14 of 15 patients; range 1 to 38 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of a second transcatheter Rashkind arterial duct occluder for persistent flow after implantation of the first device: indications and results

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.

Transfemoral closure of patent ductus arteriosus in adult patients

Patent ductus arteriosus is an uncommon anomaly in adult patients. Surgical closure of patent ductus arteriosus in this age group presents difficult problems to the surgeon. We report our experience of 21 adult patients (19-62 years of age, mean 40 years) who underwent closure of the ductus by transfemoral implantation of a Rashkind double umbrella device. The patients came to light because of atrial fibrillation, congestive heart failure, residual flow after surgical ligation of the duct or because of incidental diagnosis made during physical examination or chest X-ray. In ten patients the pulmonary arterial pressure was normal (systolic pressure < 30 mmHg), in eleven it was elevated (systolic pressure from 30 to 100 mmHg, mean 50 mmHg). In seven patients the duct was clearly calcified and the size of the duct varied from 3 to 9 mm (mean 4.3 mm). In 16 patients the ductus resulted perfectly closed after implantation of the first double umbrella device, two patients had minimal residual aortopulmonary flow, whereas in three patients the residual shunt was significant; two of these also developed haemolysis and went to surgery, in the latter the shunt was completely abolished after implantation of a second 17-mm device 16 months later. In conclusion transcatheter closure of patent ductus arteriosus in adults is feasible, even in the presence of calcifications and/or pulmonary hypertension; taking into account the significant surgical risk, PDA umbrella closure should be considered the first choice procedure in this group of patients.

Effect of low intravaginal doses of prostaglandin E2 on the closure time of the ductus arteriosus in term newborn infants

Seventeen term newborn infants (control subjects) and 17 whose mothers had been given intravaginal doses of prostaglandin E2 (PGE2) were examined serially by color Doppler echocardiography to determine whether maternal PGE2 prolonged ductal patency. No clinically relevant differences in closure times were found. Low-dose intravaginal PGE2 therapy was not associated with prolonged ductal patency in term infants.

Transcatheter occlusion of the persistently patent ductus arteriosus. Forty-month follow-up and prevalence of residual shunting

BACKGROUND

Percutaneous closure of the persistently patent ductus arteriosus with the Rashkind prosthesis is an established effective therapeutic modality, although some patients are left with residual shunting. To evaluate this, a retrospective study of the prevalence of persistent shunting over a 40-month period in the first 190 patients was undertaken.

METHODS AND RESULTS

All patients (male 45, female 145; mean age, 3.9 +/- 3.6 years; range, 5 months to 20 years) had serial clinical and color-flow echocardiographic follow-up at 6-12-month intervals (range, 6-40 months). Four patients required surgical removal of an embolized device, leaving a cohort of 186 patients in whom 196 procedures were performed, resulting in successful placement of 195 devices (43 17-mm [22%] and 152 12-mm [78%]). Complications occurred in seven of 195 procedures (3.6%). Nine of 10 attempted reocclusions (all with 12-mm devices) were successful. The prevalence of residual shunting was 38% at 1 year, 18% at 2 years, and 8% at 40 months. Patients with ductus measuring less than 4 mm had a higher success of initial occlusion. Thirty-four patients were left with residual shunting determined by color-flow Doppler study, but no anatomic or echocardiographic features were found predictive for residual shunting. All remain asymptomatic with 26 (76%) having no detectable murmur, two (6%) a continuous murmur, and six (18%) a systolic murmur.

CONCLUSIONS

Catheter occlusion will obviate the need for surgery in the majority of patients presenting with persistently patent ductus arteriosus. Reocclusion has been found feasible in those with continuous murmurs (nine of nine) and should be offered early because it is unlikely for spontaneous closure to occur in this group. It appears prudent to follow those with small residual shunting because further spontaneous closure can occur.