Safety and Feasibility of Transcatheter Closure of Large Patent Ductus Arteriosus Measuring ≥4 mm in Patients Weighing ≤6 kg

A Challenging Interventional Procedure: Transcatheter Closure of Tubular Patent Ductus Arteriosus in Patients with Pulmonary Hypertension

Transcatheter closure of the tubular ducts remains the most challenging procedure, with higher complication rates than other types. This study evaluates the characteristics of transcatheter closure of tubular ducts with pulmonary hypertension. 73 patients with tubular ducts who underwent cardiac catheterization for transcatheter PDA closure were analyzed. The mean age and weight were 1.93 ± 2.68 years and 8.83 ± 6.14 kg, respectively. Transcatheter closure was attempted in 72 patients. Four cases (5.5%) were referred to surgery, while the procedure was completed in the remaining (94.5%). Amplatzer duct occluder (ADO) I or Cardiofix duct occluder (CDO) was the most commonly used devices. However, the use of Amplatzer vascular plug (AVP) II raised in recent years. The most common concern was aortic protrusion/stenosis in ADO I/CDO devices, but most regressed during follow-up. Iatrogenic coarctation of the aorta was observed in two with ADO I/CDO. Embolization of the device to the pulmonary artery was observed in three with CDO, AVP II, and AVP I. Significant left pulmonary artery stenosis requiring stenting developed in one after closure with an MVSDO device. Tubular ducts are highly associated with pulmonary arterial hypertension, and transcatheter closure of them is still challenging despite the developing device armamentarium. Although ADO I or similar devices are widely used, off-label devices are usually needed at increasing rates. The AVP II device is unsuitable for short tubular ducts but seems the best option for long ones.

Risk factors associated with device embolisation or malposition during transcatheter closure of patent ductus arteriosus

BACKGROUND

Device embolisation is a serious adverse event during transcatheter duct closure. This study analyses risk factors for embolisation.

METHODS

Demographic parameters, echocardiographic anatomy, haemodynamics, and procedural characteristics of consecutive duct closures in a tertiary centre over 8 years were analysed. Procedures complicated by embolisation were compared to uncomplicated procedures.

RESULTS

Fifteen embolisations occurred during 376 procedures. All except one embolisation were in infants. The pulmonary artery: aortic pressure ratio was 0.78 ± 0.22. Embolisation was seen significantly more commonly in Type C tubular ducts. Vascular plugs were more significantly associated with embolisations. Logistic regression analysis showed device embolisation was significantly higher in age group of < 6 months compared to 6-12 months (p = 0.02), higher in those with tubular ducts versus conical ducts (p = 0.003), use of vascular plugs compared to conventional duct occluders (p = 0.05), and in duct closure with undersized devices (p = 0.001). There was no in-hospital mortality. Three patients needed surgical retrieval while others were successfully managed in catheterisation laboratory.

CONCLUSIONS

Device embolisation complicates 4% of transcatheter duct closures, with need for surgery in one-fifth of them. Larger ducts with high pulmonary artery pressures in younger and smaller infants are more often associated with device embolisation. Tubular ducts are more prone for embolisation compared to usual conical ducts. Softer vascular plugs are often associated with embolisations. Intentional device undersizing to avoid vascular obstruction in small patients is a frequent risk factor for embolisation. Precise echocardiographic measurements, correct occluder choice, proper technique and additional care in patients with high pulmonary artery pressures are mandatory to minimise embolisations.

Off-label use of Lifetech KONAR-MF™ ventricular septal defect occluder for large patent ductus arteriosus closure in <6 ​kg infants

Background

Device PDA closure is increasingly used in smaller patients. Major safety concerns remain when applied to <6 ​kg infants with large PDA and challenging anatomy. We aimed to report our experience with the new Konar-MF™ ventricular septal defect (VSD) occluder for transcatheter closure of large patent ductus arteriosus (PDA) in infants <6 ​kg.

Methods

Infants <6 ​kg in whom PDA occlusion was attempted using the Konar-MF™ VSD occluder were analyzed to review procedural characteristics and outcomes. Prospective follow-up was achieved until August 2021.

Results

A total of 9 implantations were performed in 7 infants [age: 5.3 ​± ​3.4 (1.7-10.1) months, weight: 4.1 ​± ​0.8 (2.9-5.8) kg]. All PDAs were large and short [minimal ductal diameter: 5.6 ​± ​1.0 (4.5-7.0) mm, ductal length: 4.3 ​± ​0.6 (3.5-5) mm]. Successful device implantation was achieved in all cases without major complication. Early device embolization occurred in 1 case with safe percutaneous device removal. Late percutaneous device retrieval was achieved 5 weeks after implantation because of symptomatic residual shunt. In both cases a second Konar-MF™ VSD occluder was implanted with excellent outcome. Over a median follow-up of 12 (6-25) months, 1 patient died from a device-unrelated cause; all remaining patients are asymptomatic, with complete occlusion and no delayed device-related complication.

Conclusions

Transcatheter closure of large PDA using the Konar-MF™ VSD occluder appears to be feasible, effective and safe in <6 ​kg infants. This approach might be an alternative to surgical ligation in carefully selected infants, although that remains to be confirmed by extensive experience and long-term outcomes data.

Percutaneous patent ductus arteriosus closure: Twelve years of experience

INTRODUCTION

Patent ductus arteriosus, a persistent communication between the descending thoracic aorta and the pulmonary artery, is one of the most common congenital heart defects. Transcatheter occlusion is an effective alternative to surgery and is currently standard of care for most patients. The authors present the results from a single center after twelve years of experience using this technique.

METHODS

Retrospective analysis of medical records from all patients referred to a tertiary center for percutaneous ductus closure between January 2006 and September 2018.

RESULTS

A total of 221 patients were referred, with a mean age of 5.5 years-old (16 patients were infants, with the youngest aged four months). A Nit-Occlud® coil was used 139 times (62.9%), an Amplatzer™ duct occluder 79 times (35.7%), and vascular plugs were used three times. Percutaneous closure was achieved in every treated patient, with 1.4% maintaining residual shunting. Although higher overall coil device implantation was noted, duct occluder usage has been greater since 2011. Of all the coils, 55% were either 4x4 or 5x4 mm, and 73% of all Amplatzer duct occluders were either 6x4 or 8x6 mm, which correlates to the majority of patients having a small to moderately sized ductus. No complications were noted during the procedure, with a 1.8% post-procedure complication rate (one device embolization after 48 hours and three cases of loss of arterial pulse).

CONCLUSIONS

Percutaneous patent ductus arteriosus closure was safe and effective in this setting, with a low global complication rate and similar outcomes to most equivalent centers.

Percutaneous patent ductus arteriosus closure: Twelve years of experience

INTRODUCTION

Patent ductus arteriosus, a persistent communication between the descending thoracic aorta and the pulmonary artery, is one of the most common congenital heart defects. Transcatheter occlusion is an effective alternative to surgery and is currently standard of care for most patients. The authors present the results from a single center after twelve years of experience using this technique.

METHODS

Retrospective analysis of medical records from all patients referred to a tertiary center for percutaneous ductus closure between January 2006 and September 2018.

RESULTS

A total of 221 patients were referred, with a mean age of 5.5 years-old (16 patients were infants, with the youngest aged four months). A Nit-Occlud® coil was used 139 times (62.9%), an Amplatzer™ duct occluder 79 times (35.7%), and vascular plugs were used three times. Percutaneous closure was achieved in every treated patient, with 1.4% maintaining residual shunting. Although higher overall coil device implantation was noted, duct occluder usage has been greater since 2011. Of all the coils, 55% were either 4x4 or 5x4 mm, and 73% of all Amplatzer duct occluders were either 6x4 or 8x6 mm, which correlates to the majority of patients having a small to moderately sized ductus. No complications were noted during the procedure, with a 1.8% post-procedure complication rate (one device embolization after 48 hours and three cases of loss of arterial pulse).

CONCLUSIONS

Percutaneous patent ductus arteriosus closure was safe and effective in this setting, with a low global complication rate and similar outcomes to most equivalent centers.

Percutaneous Closure of Patent Ductus Arteriosus in Infants 1.5 kg or Less: A Meta-Analysis

OBJECTIVE

To investigate technical success and safety of percutaneous patent ductus arteriosus closure in infants ≤1.5 kg.

STUDY DESIGN

A systematic review and meta-analysis was performed. Data sources included Scopus, Web of Science, Embase, CINAHL, Cochrane, and PubMed from inception to April 2020. Publications were included if they had a clear definition of the intervention as percutaneous patent ductus arteriosus closure in infants ≤1.5 kg. Data extraction was independently performed by multiple observers. Primary outcome was technical success and secondary outcomes were adverse events (AEs). Subgroup analysis was performed in infants ≤6.0 kg. Data were pooled by using a random-effects model.

RESULTS

We included 28 studies, including 373 infants ≤1.5 kg and 69 studies enrolling 1794 infants ≤6.0 kg. In patients ≤1.5 kg, technical success was 96% (95% CI, 93%-98%; P = .16; I² = 23%). The overall incidence of AE was 27% (95% CI, 17%-38%; P < .001; I² = 70%) and major AEs was 8% (95% CI, 5%-10%; P = .63; I² = 0%). There were 5 deaths related to the procedure (2%; 95% CI, 1%-4%; P = .99; I² = 0%); 4 of these deaths occurred in infants <0.8 kg. The probability of technical failure was inversely related to age at the time of the procedure (OR, 0.9; 95% CI, 0.830-0.974; P = .009). Weight at intervention has decreased over time and procedural success has increased.

CONCLUSIONS

Percutaneous patent ductus arteriosus closure is feasible in infants ≤1.5 kg with few major AEs. The procedural success rate is high, despite performing the intervention in smaller patients.

PROSPERO REGISTRATION

CRD42020145230.

Outcomes of transcatheter closure of ductus arteriosus in infants less than 6 months of age: a single-center experience

PURPOSE

Transcatheter device closure of patent ductus arteriosus (PDA) is challenging in early infancy. We evaluated PDA closure in infants less than 6 months old.

METHODS

We performed a retrospective review of infants less than 6 months of age who underwent attempted transcatheter device closure in our institution since 2004. To compare clinical outcomes between age groups, infants aged 6-12 months in the same study period were reviewed.

RESULTS

A total of 22 patients underwent transcatheter PDA closure during the study period. Patient mean age was 3.3±1.5 months, and weight was 5.7±1.3 kg. The duct diameter at the narrowest point was 3.0±0.8 mm as measured by angiography. The most common duct type was C in the Krichenko classification. Procedural success was achieved in 19 patients (86.3%). Major complications occurred in 5 patients (22.7%), including device embolization (n=1), acquired aortic coarctation (n=2), access-related vascular injury requiring surgery (n=1), and acute deterioration requiring intubation during the procedure (n=1). Two patients had minor complications (9.1%). Twenty-four infants aged 6-12 months received transcatheter device closure. The procedural success rate was 100%, and there were no major complications. The major complication rate was significantly higher in the group less than 6 months of age (P=0.045). There was a trend toward increased major complication and procedural failure rates in the younger age group (P<0.01).

CONCLUSION

A relatively higher incidence of major complications was observed in infants less than 6 months of age. The decision regarding treatment modality should be individualized.

Outcome after transcatheter occlusion of patent ductus arteriosus in infants less than 6 kg: A national study from United Kingdom and Ireland

OBJECTIVES

This study aimed to report our national experience with transcatheter patent ductus arteriosus (PDA) occlusion in infants weighing <6 kg.

BACKGROUND

The technique of transcatheter PDA closure has evolved in the past two decades and is increasingly used in smaller patients but data on safety and efficacy are limited.

METHODS

Patients weighing < 6 kg in whom transcatheter PDA occlusion was attempted in 13 tertiary paediatric cardiology units in the United Kingdom and Ireland were retrospectively analyzed to review the outcome and complications.

RESULTS

A total of 408 patients underwent attempted transcatheter PDA closure between January 2004 and December 2014. The mean weight at catheterization was 4.9 ± 1.0 kg and mean age was 5.7 ± 3.0 months. Successful device implantation was achieved in 374 (92%) patients without major complication and of these, complete occlusion was achieved in 356 (95%) patients at last available follow-up. Device embolization occurred in 20 cases (5%). The incidence of device related obstruction to the left pulmonary artery or aorta and access related peripheral vascular injury were low. There were no deaths related to the procedure.

CONCLUSIONS

Transcatheter closure of PDA can be accomplished in selected infants weighing <6 kg despite the manufacturer's recommended weight limit of 6 kg for most ductal occluders. The embolization rate is higher than previously reported in larger patients. Retrievability of the occluder and duct morphology needs careful consideration before deciding whether surgical ligation or transcatheter therapy is the better treatment option.

Percutaneous Patent Ductus Arteriosus (PDA) Closure During Infancy: A Meta-analysis

CONTEXT

Patent ductus arteriosus (PDA) is a precursor to morbidity and mortality. Percutaneous (catheter-based) closure is the procedure of choice for adults and older children with a PDA, but use during infancy (<1 year) is not well characterized.

OBJECTIVE

Investigate the technical success and safety of percutaneous PDA closure during infancy.

DATA SOURCES

Scopus, Web of Science, Embase, PubMed, and Ovid (Medline) were searched through December 2015 with no language restrictions.

STUDY SELECTION

Publications needed to clearly define the intervention as percutaneous PDA closure during infancy (<1 year of age at intervention) and must have reported adverse events (AEs).

DATA EXTRACTION

The study was performed according to the Systematic Reviews and Meta-Analysis checklist and registered prospectively. The quality of the selected studies was critically examined. Data extraction and assignment of AE attributability and severity were independently performed by multiple observers. Outcomes were agreed on a priori. Data were pooled by using a random-effects model.

RESULTS

Thirty-eight studies were included; no randomized controlled trials were found. Technical success of percutaneous PDA closure was 92.2% (95% confidence interval [CI] 88.8-95.0). Overall AE and clinically significant AE incidence was 23.3% (95% CI 16.5-30.8) and 10.1% (95% CI 7.8-12.5), respectively. Significant heterogeneity and publication bias were observed.

LIMITATIONS

Limitations include lack of comparative studies, lack of standardized AE reporting strategy, and significant heterogeneity in reporting.

CONCLUSIONS

Percutaneous PDA closure during infancy is feasible and associated with few catastrophic AEs; however, the limitations constrain the interpretability and generalizability of the current findings.

Follow-Up Results of Device Occlusion of Patent Ductus Arteriosus

BACKGROUND

Transcatheter patent ductus arteriosus (PDA) closure is an established procedure.

OBJECTIVES

The aim of the study was to assess midterm follow up of the Nit-Occlud coil and the amplatzer ductal occluder (ADO) closure of PDA.

PATIENTS AND METHODS

In this cohort study, we collected the longitudinal data of patients who underwent percutaneous closure using coil or ADO from November 2005 to November 2013. A total of 404 patients with PDA closure by devices were included during the study period. Coil occlusion was performed in 220 patients and 184 patients underwent catheterization using ADO. Follow-up evaluations were performed with echocardiography at two weeks, two months, six months, and during the study period (in average 4.8 ± 3.8 years).

RESULTS

The patients' mean age was 24 months (range: 1 - 312). The catheterization was successful in 393 (97.2%) patients and unsuccessful in 11 (2.7%). Immediate complete occlusion was seen in 290 (73.7 %) patients. The occlusion rates at two weeks, two months, six months, and during the study period were 73.7%, 84%, 93.6%, 98.7%, and 99.5%, respectively. Complications occurred in 23 (5.8%) patients during or immediately after the catheterization, and device embolization with 2.7% was the most common complication. Most complications occurred in a patient with pulmonary hypertension who was less than one year old and was undergoing the first year of experience with devices.

CONCLUSIONS

Our findings showed that transcatheter occlusion of the PDA is an effective and safe intervention by coil or Amplatzer with excellent early and one-year outcomes. Pulmonary hypertension, age of less than 12 months and experience of less than one year may increase the complications of device closure.

Transcatheter closure of patent ductus arteriosus in under 6 kg and premature infants

BACKGROUND

Transcatheter closure of a patent ductus arteriosus (PDA) has always been considered risky for infants weighing <6 kg and preterms. We present our findings regarding transcatheter closures of PDA.

METHODS

The inclusion criteria were a weight of <6 kg and the presence of PDA symptoms. The study subjects were divided into two groups: <6 kg and premature infants.

RESULTS

A total of 69 infants were included. The mean ages and weights of the <6 kg and the preterms were 5.4 ± 2.7 months and 30.3 ± 19.9 days, and 4.6 ± 0.8 and 1.7 ± 0.3 kg, respectively. Type C PDAs were most frequently observed in the premature group, and type A was in <6 kg. Sixteen of the patients were premature infants, and 81.2% of them had an extremely low birth weight. All of the premature infants had comorbidities, and had been receiving respiratory support therapy. Transcatheter closure was successfully completed in 81.2% of the premature infants and 94.3% of the <6-kg infants. Major complications occurred in 4 patients (one death and three device embolizations). The patient's age was found to be the main risk factor. The most frequently used device was the Amplatzer duct occluder II in additional sizes (84.6%) in the preterms and the Amplatzer duct occluder I (34%) and II (34%) in the <6-kg group.

CONCLUSION

The transcatheter closure of PDA is relatively safe and effective in preterms and in infants <6 kg. The selection of a suitable device based on the type of PDA is critical to the success of the procedure.

Transcatheter closure of symptomatic arterial duct in infants younger than 1 year old

Transcatheter closure is currently considered the first-choice therapeutic option in patent arterial duct (AD), although this approach remains challenging in younger patients. To evaluate feasibility, safety, and mid-term efficacy of percutaneous AD closure using different devices in symptomatic infants <12 months old. Among the 483 patients who underwent transcatheter AD closure at our institution from April 2000 to January 2012, 69 were <12 months old. All patients showed cardiac overload at echocardiography, and 72 % of them were on anticongestive therapy. Based on ductal morphology and local anatomy, AD closure was attempted using detachable coils in 24 cases (group A) or the Amplatzer Duct Occluder (AGA Medical, Golden Valley, MN) device in 45 cases (group B). Procedural feasibility was 95.7 % without any difference between groups (95.8 % vs. 95.6 %, p = NS) as were fluoroscopy and procedural times. AD size was 2.5 ± 0.9 mm, and QP/QS ratio was 2.2 ± 1.1, with both being significantly higher in group B [2.1 ± 0.9 vs. 2.6 ± 0.9 mm (p = 0.04) and 1.7 ± 0.8 vs. 2.5 ± 1.2 (p = 0.009), respectively]. Overall complication rate was 1.5 %, without any difference between groups, as was the occlusion rate at hospital discharge (86 %) and over midterm follow-up (55 ± 36 months) (98.5 %). Percutaneous closure of symptomatic AD might be considered effective and safe in very young infants by tailoring the device choice to ductal morphology and local anatomy. In this setting, the controlled-release coil option was shown to be as effective as the ADO device during midterm follow-up.

Clinical outcome of transcatheter closure of patent ductus arteriosus in small children weighing 10 kg or less

PURPOSE

Transcatheter closure has become an effective therapy in most patients with patent ductus arteriosus (PDA). However, there are difficulties in transcatheter closure of PDA in small children. We reviewed clinical outcomes of transcatheter closure of PDA in children weighing less than 10 kg in a single center.

METHODS

Between January 2003 and December 2009, 314 patients with PDA underwent transcatheter closure in our institute. Among them, 115 weighed less than 10 kg. All of these patients underwent transcatheter closure of PDA using either COOK Detachable Coil®, PFM Nit-Occlud®, or Amplatzer duct occluder®. A retrospective review of the treatment results and complications was performed.

RESULTS

The mean age of patients was 9.1±5.9 months (median, 8 months), and mean weight was 7.6±1.8 kg (median, 7.8 kg). The mean diameter of PDA was 3.2±1.4 mm (median, 3 mm). Complete occlusion occurred in 113 patients (98%). One patient was sent to surgery because of a failed attempt at device closure, and another patient had a small residual shunt after device placement. The average mean length of hospital stay was 3.0±3.3 days, and mean follow-up duration was 21.0±19.6 months. There were no major complications in any of the patients.

CONCLUSION

Transcatheter closure of PDA is considered safe and efficacious in infants weighing less than 10 kg. With sufficient experience and further effort, transcatheter closure of PDA can be accepted as the gold standard of treatment for this group of patients.

Closure of large patent ductus arteriosus in renal failure under echocardiographic guidance without use of radiographic contrast media

Large patent ductus arteriosus with large left-to-right shunt results in heart failure, and if untreated, leads to multiorgan dysfunction. Use of radiographic iodinated contrast media for angiogram during transcatheter duct closure may aggravate preexistent renal dysfunction. Aortogram with contrast media was avoided in a patient with renal failure, and echocardiogram guided deployment of duct occluder device in the cardiac catheterization laboratory for closure of a large duct. This article highlights use of a nitinol-based occluder that employs nonporous polytetrafluoroethylene fabric to aid in instantaneous duct closure.

Closure of large patent ductus arteriosus in infants

The purpose of this study was to evaluate the feasibility, clinical outcome, and resource utilization of transcatheter closure of large, symptomatic patent ductus arteriosus (PDA) in young infants, and compare the results with those of surgery. From January 2003 to December 2006, successful transcatheter implantation of the Amplatzer duct occluder was performed in 20 young infants (< or = 3 months of age) with large PDA who suffered from severe congestive heart failure despite medical treatment. The data was compared with a historical control of 18 young infants who underwent surgical ligation of PDA. Patient ages ranged from 18 to 89 days (mean 51.8) in the study group and 13 to 82 days (mean 39.9) in the control group. Patient weight ranged from 2.7 to 7.1 kg (mean 4.24) in study group and 2.5 to 5.7 kg (mean 3.79) in the control group. Between the 2 groups, there was no significant difference in the rate of complications. Patients who underwent transcatheter closure utilized significantly fewer resources (length of hospital stay and total cost) than those who underwent surgery. In conclusion, percutaneous device occlusion with Amplatzer duct occluder in small, symptomatic infants is feasible and more cost-effective compared with surgery. In experienced hands with careful preprocedural evaluation and delicate manipulation, the safety of transcatheter closure with Amplatzer ductus occluder in this age group can be assured and major complication avoided. Revision of the delivery sheath, making it kink-resistant, and PDA shape-tailored devices should further optimize the procedure.