Effect of multiple coil closure of patent ductus arteriosus on blood flow to the left lung as determined by lung perfusion scans

[Lung perfusion studies after percutaneous closure of patent ductus arteriosus using the Amplatzer Duct Occluder in children]

OBJECTIVE

The closure of patent ductus arteriosus with multiple devices has been associated with a reduction in lung perfusion. We evaluated the pulmonary perfusion after percutaneous closure of patent ductus arteriosus with the Amplatzer Duct Occluder device using perfusion lung scan.

METHODS

Thirty patients underwent successful percutaneous patent ductus arteriosus occlusions using the Amplatzer Duct Occluder device were included in this study. Lung perfusion scans were preformed 6 months after the procedure. Peak flow velocities and protrusion of the device were analyzed by Doppler echocardiography. A left lung perfusion<40% was considered abnormal.

RESULTS

The device implantation was successful in all patients. Average perfusion of left lung was 44.7±4.9% (37.8-61.4). Five patients (16.6%) showed decreased perfusion of the left lung. Age, low weight, the length of the ductus arteriosus and the minimum and maximum diameter/length of the ductus arteriosus ratio were statistically significant in patients with abnormalities of lung perfusion. It was observed protrusion the device in 6 patients with a higher maximum flow rate in the left pulmonary artery.

CONCLUSION

The left lung perfusion may be compromised after percutaneous closure of patent ductus arteriosus with the Amplatzer Duct Occluder. The increased flow velocity in the origin of the left pulmonary artery can be a poor indicator of reduction in pulmonary perfusion and can occur in the absence of protrusion of the device.

Long-term follow-up results of lung perfusion studies after transcatheter closure of patent ductus arteriosus

OBJECTIVE

This study presents the long-term follow-up of patients who developed left lung perfusion (LLP) abnormalities following patent ductus arteriosus (PDA) closure with various device types.

DESIGN

The study includes 23 adult and pediatric patients who had undergone transcatheter PDA closure and were shown to have decreased LLP (<40%) by the first scintigraphy performed within the average follow-up period of 14.0 ± 8.12 months (2.0-30 months). For PDA closure, the Amplatzer duct occluder was used in 12 patients, and coils were used in 11. Within the average period of 58.91 ± 12.93 months (37-85 months) after transcatheter PDA closure, a second lung perfusion scintigraphy was performed.

RESULTS

In 13 out of 23 patients (56.5%), LLP improved by the time of the second scintigraphy. Improved and unimproved patients did not differ with regard to age, weight, body surface area, PDA diameter, ampulla diameter, and PDA length at the time of PDA closure and the second scintigraphy. There was no significant difference with regard to the percent of improved patients between the different device types (P =.88). The left pulmonary artery indexes were also insignificantly different (P =.446). Patients with persistent LLP abnormality had significantly higher average Doppler velocity index [(LPA blood flow velocity--RPA blood flow velocity) / MPA blood flow velocity] × 100 (P =.007) and PDA diameter/length. If Doppler velocity index ≥50% is taken as the cutoff value, it is possible to predict persisting LLP abnormality with 80% sensitivity and 76% specificity. Left lung perfusion abnormality was found to persist in patients with PDA diameter/length ≥0.5 with 80% sensitivity and 92.3% specificity.

CONCLUSIONS

The LLP abnormalities seen after PDA closure with various devices eventually improve to normal in the majority of patients during long-term follow-up. Patients whose PDA length is shorter than its diameter are at risk of developing LLP abnormalities that persist long-term.

Consideration of the Pathological Features of Pediatric Congenital Heart Diseases Which Are Ideally Suitable for Diagnosing With Multidetector-row CT

Background

A lots of articles published regarding the usefulness of multidetector-row computed tomography (MDCT) in children with congenital heart disease (CHD) mostly describe that it can be an alternative to the invasive catheterization and angiography. The unique diagnostic features of this imaging modality have been largely ignored or disregarded. We described the pathological conditions that cannot be diagnosed by conventional angiography with cardiac catheterization but can be accurately diagnosed by MDCT.

Methods

We retrospectively reviewed non-ECG-gated MDCT images acquired from 452 children and young adults with CHD between 2005 and 2010 in our institute. In this article, we focused on the diagnostic advantages of MDCT, and indicated five pathological conditions. (1) When Blalock-Taussig shunt total occlusion prevents catheter insertion into the artificial vessel and angiography is ruled out, the peripheral pulmonary artery during the peripheral pulmonary artery can be imaged and diagnosed using MDCT based on blood flow supplied from many small collateral vessels originating from the aorta. (2) The location and protrusion of the device in the vessel after coil embolization to treat patent ductus arteriosus can be accurately visualized by virtual endoscopy using MDCT. (3) Calcification of patches, synthetic blood vessels, and other prostheses that is indistinct on conventional angiograms is clear on MDCT. (4) Simultaneous MDCT observations of the anatomical relationships between arterial and venous systems on the same image can clarify the detail diagnosis for surgical treatment. (5) Compression of the airways by the great vessels and pulmonary segmental emphysematous change can be diagnosed by MDCT.

Results and Conclusions

Among patients with CHD, MDCT is useful not only as a non-invasive alternative to conventional angiography, but also as a tool for specific morphological diagnoses. In the future, it will be necessary to accumulate experience in the recognition of cardiovascular conditions under which MDCT is necessary and to perform as the appropriate examination.

Pulmonary perfusion scans following transcatheter patent ductus arteriosus closure using the Amplatzer devices

INTRODUCTION

Obstruction to flow in the left pulmonary artery (LPA) is a well-known complication after transcatheter device closure of patent ductus arteriosus (PDA). This complication has been studied for different devices using lung perfusion radionuclide scintigraphy (LPRS), but not for Amplatzer devices. This study was performed to evaluate the effect of such devices on lung perfusion using LPRS.

METHODS

This is a retrospective study that looked at all patients who had PDA closure using different Amplatzer devices at our center between July 1999 and January 2007. All patients underwent LPRS within 24 hr of the procedure. We compared LPRS with other hemodynamic data obtained by cardiac catheterization and echocardiography. Results are presented as mean ± SD or median and ranges.

RESULTS

A total of 70 patients had PDA closure using an Amplatzer device; median age was 1.8 years (4 months to 75 years) and median weight was 12 kg (5-112 Kg). Nine patients had associated cardiac anomalies. Sixty eight patients had available LPRS. The mean percent of left lung perfusion (LLP) was 42.7% (± 6.7%). Excluding patients with pre-existing LPA stenosis, 17% had abnormally decreased LLP. On hemodynamic measurements, 62 patients had available direct pressure measurements following PDA closure. None had significant increase. No correlation was found with echocardiographic data.

CONCLUSION

PDA closure with Amplatzer family of devices is associated with a relatively significant risk of decreased perfusion to the left lung, mostly mild abnormalities. Comparison with catheterization and echocardiographic measurements showed lack of correlation with LPRS findings.

Differential pulmonary perfusion scan after percutaneous occlusion of the patent ductus arteriosus: one-decade consecutive longitudinal study from a single institution

Reduced left lung perfusion has been described following percutaneous occlusion of the patent ductus arteriosus (PDA). We aimed to identify the incidence of lung perfusion abnormalities and the associated risk factors in our consecutive series. Between November 1994 and December 2003, 150 procedures were performed on 145 patients, age 4.6 +/- 4 years. Gianturco coil was used in 88.2%, Amplatzer duct occluder in 6.7%, and Rashkind Umbrella in 5.5%. Lung perfusion scan was scheduled within 48 h (LPS-1), at 6-12 months (LPS-2) and later (LPS-3) in the case of persistent abnormalities. Left lung perfusion <40% was considered abnormal. LPS-1 was obtained in 95.8% and was abnormal in 31%. LPS-2, available in 48.2%, returned to normal in 65.7% (p < 0.001). LPS-3, required in 6.2%, was normal in 55.6% (p = 0.07). Identifiable risk factors were low age and height (p < 0.01), higher Q(p)/Q(s) ratio (p < 0.05), and larger PDA size indexed for height (p < 0.001) or body surface area (p < 0.01). The number of coils or loops deployed in the pulmonary end of the PDA did not influence lung perfusion. In conclusion, we describe a high incidence of left lung perfusion reduction following percutaneous PDA occlusion, more likely in the young with large PDA. However, spontaneous recovery usually occurs within a few months.

Transcatheter closure of moderate to large patent ductus arteriosus with the Amplatzer duct occluder

OBJECTIVES

To investigate the acute and follow-up results of transcatheter closure of moderate to large patent ductus arteriosus (PDA) with the Amplatzer duct occluder.

METHODS

Between April 2000 and June 2005, 237 patients underwent attempted transcatheter closure of PDA, of whom Amplatzer duct occluder was used in 68 patients with moderate-to-large-sized PDA (45 females, with ages ranging from 56 days to 75 years, median 3.3 years). Moderate to large PDA is defined as ductus diameter > or =2.5 mm (> or =3 mm in early phase of this study) in infants and young children, or > or =4 mm in adolescents and adults. The size of device selected was generally at least 1-2 mm larger than ductus diameter.

RESULTS

The ductus diameter ranged from 2.5 to 8.5 mm (4.1 +/- 1.3 mm). Amplatzer duct occluder was successfully deployed in 66 out of 68 patients. The size of device deployed ranged from 4 to 12 mm (6.3 +/- 1.6 mm). The causes of failure in the 2 patients included calcification of ductus resulting, in failure in advancing a sheath to descending aorta in 1 and kinking of a Cook sheath in the other. Distal embolization of the device occurred several hours later in one. After the device was retrieved percutaneously, the patient was sent to surgery. No other significant complications occurred. In the 3-month follow-up, complete occlusion was achieved in all patients. No patient had left pulmonary artery stenosis.

CONCLUSIONS

Transcatheter closure of moderate-to-large-sized ductus with Amplatzer ductus occluder is effective and safe.

Virtual endoscopy using multidetector-row CT for coil occlusion of patent ductus arteriosus

The objective of this study was to report the clinical value of virtual endoscopy using multidetector-row CT (MDCT) for coil occlusion of patent ductus arteriosus (PDA). We studied 10 consecutive patients with PDA undergoing cardiac catheterization and coil occlusion. All patients had previously undergone MDCT, and subsequently underwent transcatheter closure of ductus. MDCT evaluations were performed again in 1-3 months after occlusion. Virtual endoscopy showed the anatomy of the orifice of the ductus and spatial relations of adjacent structures from both the aortic and pulmonary sides in all patients. We were able to observe the inner space, and fly through the PDA. This approach is the virtual view of the catheter advancing during coil occlusion. Following occlusion, visualization of the coil can also be established by viewing from inside. Coil protrusion into the aortic and pulmonary sides was clearly observed. Virtual endoscopy provides unique information regarding the ductal lumen that is of use for the coil occlusion of PDA.

A strategic approach to transcatheter closure of patent ductus: Gianturco coils for small-to-moderate ductus and Amplatzer duct occluder for large ductus

OBJECTIVE

To investigate the effectiveness of the strategy of transcatheter occlusion with the Gianturco coil for small-to-moderate sized ductus and with Amplatzer duct occluder (ADO) for large ductus.

PATIENT AND METHODS

For ductus closure, the following strategy was applied: ADO was used in large ductus: infants and young children weighing < 15 kg with a ductus diameter > or = 3 mm and in older children or adults with a ductus diameter > or = 4 mm and coils were employed in patients with small-to-moderate sized ductus. During a 3-year period, this strategy was applied in 136 patients. The results were compared between 214 patients (group I) undergoing ductus closure using only coil before application of this strategy and strategic closure in 136 patients (group II). Each group was divided into 2 subgroups: subgroup A with large ductus and subgroup B with small-to-moderate ductus. There were 54 patients in subgroup IA, 160 in subgroup IB, 33 in subgroup IIA and 103 in subgroup IIB, respectively.

RESULTS

In group I, PDA occlusion was successful in 207 (96.7%) and failed in 7 (6 of group IA and 1 of group IB). In group II, ductus closure was successful in 134 patients (98.5%) (32/33 with ADO and 102/103 with coils). There was no significant difference in success rate between group I and II. Distal embolization occurred in 19 patients of group I and in 2 of group II, respectively (19/214 vs. 2/136, P < 0.01). There was no significant difference in success rate between group IA and IIA but the distal embolization rate was higher in group IA than IIA (13/54 vs. 1/33, P=0.014). Left pulmonary artery stenosis was found exclusively in 9 patients of group I at the 6-month follow-up (P < 0.05). Nine patients in group I required second intervention to achieve complete occlusion.

CONCLUSIONS

The strategy of ductus closure worked well by reducing embolization rate, incidence of left pulmonary artery stenosis and the need of second intervention.

Transcatheter occlusion of the patent ductus arteriosus: a comparison of two devices

BACKGROUND

Transcatheter occlusion of the arterial duct is a safe and effective alternative to surgical closure. The Rashkind umbrella occluder and the Cook coil are two established devices, although the former is no longer manufactured.

AIMS

To assess any difference in outcomes between the use of the Cook detachable coil and the Rashkind double umbrella in patent ductus arteriosus (PDA) occlusion.

METHODS

A retrospective study of 77 patients in whom PDA occlusion was attempted using the Cook detachable PDA coil from March 1996 to March 2000. A comparison was carried out with patients in whom occlusion was attempted using the Rashkind double umbrella between 1989 and 1996.

RESULTS

The rate of immediate complete occlusion was 24% compared with 29.9% for the Rashkind device. The figure for complete occlusion after 24 hours with the PDA coil was 63% compared with 61.5% in the Rashkind group (p > 0.1). The overall closure rate in the coil group was 72% versus 74.6% for umbrellas.

CONCLUSION

The outcome in terms of complete duct closure using the Cook coil is comparable with figures obtained using the Rashkind umbrella. Both devices have a good safety profile in the short and medium-terms.

Transcatheter closure of patent ductus arteriosus using Gianturco coils in adolescents and adults

We present the short- and intermediate-term results of transcatheter closure of patent ductus arteriosus with Gianturco coils in adolescents and adults. During a 5-year period, 55 patients (44 females, 11 males) with ages ranging from 14 to 72 years (median, 23) underwent attempted transcatheter closure of patent ductus with the Gianturco coils. The diameter of the narrowest segment of the ductus ranged from 0.8 to 7.6 mm (3.9 +/- 1.3 mm). The 55 patients were divided into three groups. Group I consisted of nine patients with a ductal diameter < or = 3 mm, group II consisted of 27 patients with a ductal diameter > 3 mm but < or = 4 mm, and group III consisted of 19 patients with a ductal diameter > 4 mm. Four- to five-loop Gianturco coils were used, which were deployed via retrograde aortic route. Multiple-coil technique was generally applied in group II patients. Balloon occlusion technique in combination with multiple-coil technique was generally used in group III patients. Deployment of coil was successful in 51 patients (93%) but failed in 4. The success rate of coil deployment in group I, II, and III were 100% (9/9), 96% (26/27), and 84% (16/19), respectively. A mean of 1.9 +/- 0.7 coils was deployed per patient. Of the four patients with unsuccessful coil deployment, three underwent surgery and one received implantation with Amplatzer duct occluder. Distal embolization of 21 coils occurred in 10 patients (3 in group II and 7 in group III), from whom 20 coils were retrieved with a gooseneck snare and 1 coil was removed during surgery. The mean diameter of ductus in the 10 patients with distal embolization was significantly larger than that in those without (5.2 +/- 1.4 vs. 3.7 +/- 1.1 mm; P < 0.01). Among the 51 patients with successful coil deployment, immediate complete closure was achieved in 20 (39%), while trivial to mild leak was present in 31 (61%). No significant complications were encountered. After a follow-up period ranging from 5 to 42 months, four patients had a small residual shunt and three underwent a second intervention with complete occlusion. None had left pulmonary artery stenosis documented with Doppler echocardiography. Transcatheter closure of ductus with the Gianturco coils is safe and feasible in the majority of adolescents and adults. Taking high embolization rate in patients with a ductus diameter > 4 mm into consideration, controlled-release coils, Buttoned device, or Amplatzer duct occluder can be a better choice.

Transcatheter closure of the patent ductus arteriosus using an Amplatzer duct occluder in adults

Patent ductus arteriosus (PDA) is a congenital heart disease that frequently escapes detection until the patient reaches adulthood. Percutaneous closure of the PDA has been established as a safe alternative to surgery, the Amplatzer duct occluder (ADO) is a new device that has been recently reported in paediatric patients. Our initial experience with an of ADO in an adult population appears to be encouraging and as good as in paediatric patients.

Comparison of two transcatheter closure methods of persistently patent arterial duct

A randomized trial of arterial duct occlusion with a double umbrella (DU) or wire coil (WC) was undertaken for patients <18 years of age, weighing >10 kg with isolated ducts < or = 3 mm in diameter. Baseline, procedural, and outcome characteristics were compared in an intention-to-treat analysis according to randomization group. From 40 consecutively screened patients, 2 were not enrolled due to a ductal diameter of >3 mm on initial aortography, 38 patients were randomized to either the DU (n = 20) or WC (n = 18) groups. The groups did not differ significantly with respect to age, weight, gender, duct size, type, or branch pulmonary artery diameters. Crossover occurred only in the DU group, where 4 patients (20%) had a ductal diameter of < or = 1 mm and could not be entered for umbrella placement. All remaining DU group patients had ductal diameters of > or = 1.3 mm (p <0.0001). There were no embolizations or secondary implants in the DU group, but in the WC group there was 1 early and 1 late embolization, with 6 patients (33%) with > or = 2 coils. Mean times for the procedure (DU 68+/-19 minutes; WC 65+/-27 minutes; p = 0.70) and fluoroscopy (DU 14+/-4 minutes; WC 11+/-6 minutes; p = 0.22) did not differ significantly. Angiographic duct closure was documented in 4 of 13 patients (31%) of the DU group and 4 of 18 patients (22%) of the WC group (p = 0.69). Combined with an echocardiogram, closure in 11 of 17 patients with DU (65%) and 13 of 18 patients with WC (72%) (p = 0.64) was documented before hospital discharge. One WC group patient received thrombolytic therapy for a femoral artery thrombus. Follow-up at a median of 6.5 months (range 3.2 to 37) showed closure by Doppler echocardiography in 15 of 19 patients with DU (79%) versus 14 of 18 patients with WC (78%) (p = 1.0). Thus, with a tendency toward similar procedural characteristics and outcomes, the higher cost of the DU system compared with coil implants favors the use of coils for closure of the small arterial duct.

Transcatheter closure of patent ductus arteriosus with the use of Rashkind occluders and/or Gianturco coils: long-term follow-up in 123 patients and special reference to comparison, residual shunts, complications, and technique

BACKGROUND

This report describes the long-term follow-up of transcatheter closure of patent ductus arteriosus (PDA) with 2 different modalities in 123 patients of diverse ages.

METHODS AND RESULTS

Between October 1990 and August 1997, 123 patients underwent transcatheter PDA (1.9 to 7.5 mm) closure at a mean age of 6.8 +/- 8.9 years (range 0.06 to 52) and mean weight of 20.9 +/- 17. 6 kg (range 2.7 to 83). In the initial procedure, the Rashkind device was used in 60, the Gianturco coil(s) in 60, and the Rashkind device with a coil in 3 patients. Six-month closure rate for the Rashkind group was 77% versus 90% for the coil group. The second procedure was carried out for residual shunt in 19 (14 in the Rashkind group and 5 in the coil group) and a third procedure in 1 patient from the Rashkind group. A balloon wedge catheter was used in 50 of 78 coil procedures to prevent coil embolization. One device and 11 coils (8 without balloon aid) embolized to the pulmonary arteries. The device and all coils except 2 were retrieved successfully. Overall, 122 (99%) patients showed complete PDA closure. The mean uneventful follow-up period was 44.11 +/- 23.77 months (range 8.7 to 90.28).

CONCLUSIONS

Transcatheter closure of PDA is feasible in infants as well as in patients >50 years of age without significant complications. The coils are easy to implant, less expensive, and multiple coils may be used in moderately large (>3.5 mm) ducts more effectively than with the Rashkind device. The use of a balloon wedge catheter prevents immediate coil embolization. Multiple procedures are feasible and safe to achieve complete closure.

Long-term outcome of transcatheter coil closure of small to large patent ductus arteriosus

Coil closure of patent ductus arteriosus (PDA) has become an accepted alternative to surgical closure in most pediatric cardiac centers. However, little is known about the mid-to long-term outcome of this procedure. Therefore, we evaluated the immediate, short-, and long-term outcome of transcatheter coil closure (TCC) of PDA using single or multiple Gianturco coils or the Gianturco-Grifka Vascular Occlusive Device (GGVOD). One hundred forty-nine patients underwent an attempt at TCC of their PDAs at a median age of 2.4 years (2 weeks to 55 years) and median weight of 13.5 kg (2.3-87 kg). There were 33 patients < 1 year of age. The median PDA minimal diameter was 2 mm (0.4-7 mm) with 26 patients whose PDA minimal diameter was > 4 mm. A 4 Fr catheter was used for coil deployment in 136 patients, a 3 Fr in 4, and an 8 Fr in 4 patients who received the GGVOD. A single coil was used in 77 patients and multiple coils (2-6) were used in 66 patients. One hundred forty-six patients had successful closure (142 had immediate complete closure and 4 had residual shunt), 3 patients failed the initial attempt (2 underwent surgical ligation and 1 had a successful second attempt a year later). Of the four patients with residual shunt, three underwent a second procedure with implantation of 1-3 coils resulting in complete closure in all and one patient had spontaneous resolution of the residual shunt. Complications were encountered in nine patients: six had coil migration with successful retrieval in four; two had left pulmonary artery stenosis (2.4 kg and 6.3 kg infants), and one patient had loss of femoral arterial pulse. The median fluoroscopy time was 16 min (2-152 min). One hundred forty-two patients had the procedure as an outpatient, five patients stayed greater than 24 hr, and two of these patients were in hospital for 1 month for noncardiac reasons. At a median follow-up interval of 3.0 years (1 month to 5.1 years), there were no episodes of delayed coil migration, delayed recanalization, thromboembolic episodes, or bacterial endocarditis. Lung perfusion scans performed at a median follow-up interval of 1.6 years in 31 patients who received multiple coils revealed 45% +/- 5% blood flow to the left lung. Long-term follow-up of coil closure of PDA indicates that the technique is safe and effective for most patients with PDA up to a diameter of 7 mm.

Lung perfusion studies after detachable coil occlusion of persistent arterial duct

OBJECTIVE

To evaluate relative lung perfusion following complete occlusion of persistent arterial duct with detachable Cook coils.

METHODS

Ductal occlusion using detachable coils was performed in 35 patients (median age 3.9 years, range 0.5 to 16; 32 native ducts, three patients with previous devices). If the duct could be crossed with a 0.035 inch guidewire and a 4 F catheter after coil implantation, a further coil was implanted. Between one and seven coils were used (median two).

RESULTS

Complete ductal occlusion was confirmed by echocardiography 24 hours after the procedure in all patients. Lung perfusion scans were performed three months after the procedure in 33 of 35 patients (two older patients with a single coil each did not attend). Decreased perfusion to the left lung (defined as < 40% of total lung flow) was observed in only one patient, who had previously had a 17 mm Rashkind umbrella implanted. There was no correlation between left lung perfusion and peak left pulmonary artery Doppler velocities (r = 0.27 and p = 0.125 for the entire group; r = 0.29 and p = 0.124 after excluding patients with previous devices).

CONCLUSIONS

Coil occlusion is effective in achieving complete closure of the duct. An aggressive approach using multiple coils did not compromise perfusion to the left lung.