Long-term outcome comparison between rashkind umbrella and gianturco coils occlusion in native patent ductus arteriosus

Background: The Rashkind Umbrella device has proven effective in closing small to moderate size patent ductus arteriosus. A comparable early occlusion rate was also seen in PDA occlusion using Gianturco coils. This study addresses the long-term outcome of both techniques in a single centre. Methods: Review was undertaken of 522 patients with PDA who underwent transcatheter occlusion before January 1997; 244 patients (mean: age 8.0±6.7 years, weight 21.8±12.9 kg, PDA size 3.2±1.0 mm) were intended to receive the Rashkind Umbrella device and the remaining 278 patients (mean: age 6.4±5.6 years, weight 18.6±11.2 kg, PDA size 2.5±1.0 mm) would receive Gianturco coils. Deployment failure occurred in 8 patients (3%) and 6 (2%) during the initial learning curve of the Rashkind Umbrella and Gianturco coil, respectively. In the Rashkind Umbrella group, haemolysis occurred in 6, device embolisation in 3, and 1 patient died from anaesthetic sequelae. Peripheral pulmonary embolisation of coils occurred in 7 patients and all were successfully retrieved. Results: Results were analysed from 228 and 258 patients who had successful Rashkind Umbrella device and Gianturco coil deployment respectively. All had completed at least 1 year follow-up. They were evaluated clinically for residual ductal murmur and echocardiographically for a residual ductal shunt and presence of pulmonary artery or aortic obstruction. The Rashkind Umbrella group had significantly higher residual shunt compared to the Gianturco coil group at various stages of follow-up (p<0.05), 40% v 22% at 24 hours, 29% v 7% at 3 months, 25% v 4% at 6 months and 22% v 3% at 1 year. In 57 patients, a reocclusion procedure during the study period was undertaken to effect immediate complete occlusion. Mild left pulmonary artery stenosis (velocity<2 m/s) was noted in 6 patients who had multiple coils and one who had a 17 mm Rashkind Umbrella device. Conclusions: Transcatheter occlusion of PDA using the Gianturco coil is safer and more effective than the Rashkind Umbrella device. It has become the first choice for treating small to moderate size native PDA at our institution.     

Indications, technique, results and clinical impact of reocclusion procedures for residual shunts after transcatheter closure of the patent ductus arteriosus.

PURPOSE: To assess the results of reocclusion procedures for late residual shunts after transcatheter closure of the patent ductus arteriosus. MATERIAL AND METHODS: Nineteen patients underwent reocclusion procedures either with Rashkind technique (2 patients) or with coils. Mean age was 96.5 months and mean interval between the initial and the additional procedure was 15.7 months. In 5 patients, the duct was balloon-dilated prior to occlusion. RESULTS: In 3 patients the procedure was unsuccessful because it was impossible to cross the duct using either a guide wire or a catheter. Immediate or late complete occlusion occurred in 13 patients. Two patients required a third procedure for complete closure. One patient developed severe intravascular hemolysis after coil implantation and was sent to surgery. The rate of final late residual shunting decreased from 17.1% to 6.6% (5/76) in the umbrella group and from 15.8% to 1.8% (1/56) in the coil group. CONCLUSIONS: Reocclusion procedures are indicated after one year of persistent shunting following the primary procedure. They are generally effective and reduce significantly the rate of late residual shunting. In patients with tiny shunts, the duct may need to be dilated. Coils are preferred because of their low cost.     

经导管封堵动脉导管未闭介入治疗后残余分流

目的探讨经导管封堵动脉导管未闭(PDA)介入治疗后残余分流的可行性和临床疗效。方法自1997年3月至2001年8月16例PDA介入治疗后残余分流的患者,其中男4例,女12例,平均年龄5.9±2.4岁(2～9岁),平均体重17.7±5.4kg(9～28kg),应用不同介入方法经动脉或静脉途径封堵残余分流,首次介入治疗与再次介入治疗的时间间隔平均为1.5±1.1年(1天～3.5年)。结果残余分流直径平均为2.7±0.9mm(1.2～5.0mm)。15例成功完成残余分流封堵术,1例失败,技术成功率为94%(15/16)。单纯应用Cook可控弹簧圈9例(其中双弹簧圈2例),Rashkind双面伞2例,Sidris纽扣式补片1例,Amplatzer蘑菇伞2例,同时应用Cook可控弹簧圈和Sidris纽扣式补片1例。封堵术后即刻造影,3例仍有少量残余分流,完全闭合率为80%(12/15)。平均手术时间为75.0±22.8min(45～120min),平均X线透视时间为10.4±3.9min(5～20min)。股动脉并发症1例,其余无并发症出现。封堵术后24h复查超声心动图,所有残余分流均完全闭合(100%),在平均2年随访中未出现残余分流再通、封堵器移位和左右肺动脉狭窄。结论经导管封堵PDA介入治疗后残余分流安全、疗效确切、创伤小,可作为外科手术治疗PDA介入治疗后残余分流的一种替代方法。     

Follow-up results of transvenous occlusion of patent ductus arteriosus with the buttoned device

OBJECTIVES: The purpose of this presentation is to document results of buttoned device (BD) occlusion of patent ductus arteriosus (PDA) in a large number of patients with particular emphasis on long-term follow-up in an attempt to provide evidence for feasibility, safety and effectiveness of this method of PDA closure. BACKGROUND: Immediate and short-term results of BD occlusion of PDA have been documented in a limited number of children. METHODS: During a six-year period ending August 1996, transcatheter BD closure of PDA was attempted in 284 patients, ages 0.3 to 92 years (median 7) under a protocol approved by the local institutional review boards and FDA with an investigational device exemption in U.S. cases. RESULTS: The PDAs measured 1 to 15 mm (median 4) at the narrowest diameter; 20 were larger than 8 mm and 10 larger than 10 mm. They were occluded with devices measuring from 15 to 35 mm delivered via 7F (N = 140) or 8F (N = 144) sheaths. Successful implantation of the device was accomplished in 278 (98%) of 284 patients. The Qp:Qs decreased from 1.8+/-0.6 (mean+/-SD) to 1.09+/-0.19 (p < 0.001). Effective occlusion defined as no (N = 167 [60%]) or trivial (N = 79 [28%]) residual shunt was achieved in 246 (88%) patients. All types of PDAs, irrespective of the shape (conical, tubular or short), size (small or large) or length (short or long) of the PDA and previously implanted Rashkind devices, could be occluded. Follow-up data, 1 to 60 months (median 24) after device implantation, were available in 234 (84%) patients. Seven (3%) patients required reintervention to treat residual shunt with (N = 2) or without (N = 5) hemolysis. Actuarial reintervention-free rates were 95% at 1 and 5 years. There was gradual reduction of actuarial residual shunts and were 40%, 28%, 21%, 14%, 11%, 10%, 6% and 0% respectively at 1 day, 1, 6, 12, 24, 36, 48 and 60 months after device implantation. Incorporation of folding plug over the button loop in 10 additional patients produced immediate and complete occlusion of PDA. CONCLUSIONS: This large multiinstitutional experience confirms the feasibility, safety and effectiveness of buttoned device closure of PDAs. All types of PDAs irrespective of the shape, length and diameter can be effectively occluded. Incorporation of folding plug over the button loop produces complete PDA occlusion at the time of device implantation.     

Stenting small coronary arteries using two second-generation slotted tube stents: acute and six-month clinical and angiographic results.

We report our experience with transcatheter occlusion of the small PDA using Gianturco coils comparing a single coil strategy to a "multiple coil-no residual shunt strategy". Fifteen patients (Group I) had a single coil only placed irrespective of residual shunting and 20 (Group II) were treated using the no residual shunt strategy. Age, minimal PDA diameter, PDA length and PDA types were similar between groups. Closure rates in Group I patients were 60%, 80% and 87% at <1 month, 6 months and 1 year, respectively. In Group II, the <1 month and 6 month closure rates were 100%. The costs and hospital charges for coil closure were comparable to a concurrent surgical group; the total charges (hospital plus physician) were less for Group I, but similar between Group II and the surgical group. The complication rate for coil closure was significantly less than surgical closure. From these data, transcatheter closure with multiple coils can achieve the same closure rate as surgery at similar hospital charges with fewer complications.     

Follow-up of coil occlusion of patent ductus arteriosus

Objective. We sought to determine the prevalence and fate of residual ductal shunting following coil occlusion of patent ductus arteriosus.Background. Although transcatheter coil occlusion of patent ductus arteriosus has gained popularity, few follow-up data have been reported.Methods. A review of 75 patients who underwent coil occlusion was performed. Residual shunting was investigated by Doppler echocardiography in follow-up. Angiograms were reviewed to obtain minimal ductal diameter and ductal angiographic type.Results. Residual shunts were found in 31 patients (41%) on the day of the procedure, and of these, spontaneous closure was noted in 17 (55%) at 2 weeks to 20 months of follow-up. Of the 75 patients studied, 5 (7%) required a second coil procedure, and 10 (13%) remained with persistent residual shunts at most recent follow-up. Actuarial analysis estimated a 6 ± 5% prevalence of residual shunts 20 months after a single coil procedure and 3 ± 3% after all coil procedures. Minimal ductal diameter was associated with immediate complete ductal occlusion by a single coil. These patients had significantly smaller (p = 0.003) minimal ductal diameters (1.2 ± 0.7 mm) than those who required two coils during their initial procedure to achieve immediate occlusion (1.9 ± 0.7 mm), those who required a second coil procedure (2.0 ± 0.9 mm), those who had spontaneous closure of residual shunts (1.9 ± 0.7 mm) and those with persistent residual shunts (2.0 ± 0.9 mm). No association was identified between ductal angiographic type and outcome of coil occlusion. No late adverse clinical events of coil occlusion or evidence of recanalization was found.Conclusions. Small residual shunts are common after coil embolization of patent ductus arteriosus, but most close spontaneously. Actuarial analysis estimates complete closure in 94% at 20 months, and reintervention was required in only 7% of patients.     

A comparative study of Rashkind, Grifka and coil devices in percutaneous closing of patent ductus arteriosus

This study was performed to evaluate the efficacy of transcatheter Coil and Grifka closure of the patent ductus arteriosus in comparison to our experience with the Rashkind umbrella device. Ninety seven patients (36 male and 61 females) underwent occlusion of the PDA. The following variables were compared: age, sex, ductus diameter, morphology, device, occlusion time, residual shunt, multiple device and complications. Data obtained were compared using the Student's test and Chi 2. Median patient age was 7.82 +/- 6.89, forty five patients underwent transcatheter Rashkind-17 closure, 19 patients with Rashkind-12, 18 patients with Coil and 13 patients with Grifka device, in two patients the closure could not be performed. There were differences between the morphology and device used (p = 0.008), between the ductus diameter and device used (p < 0.001). There was immediate closure in 26.7% in the Rashkind-17 group compared with, 57.9% for the Rashkind-12 group, 83.3% for Coil group and of 91.7% for Grifka group. The occlusion within 24 hrs of implantation was 60% with Rashkind-17, 78.9% with Rashkind-12, 94.4% with Coil and 100% with Grifka. Residual shunt persisted for more than a year in 7 patients with Rashkind-17 and 1 with Rashkind 12, (p = 0.001), in 4 patients two devices wore placed. The complications were, 15.5% for Rashkind-17, 26.3% for Rashkind-12, 5.2% for Coil and 30% for Grifka, (p = 0.004), one coil and one Grifka embolized. Transcatheter Coil and Grifka occlusion are more effective in achieving immediate closure than the Rashkind device. The indication to use each device is made according to the morphology and size of the ductus.     

Device Closure of Patent Ductus Arteriosus in Marfan Patients: Safety and Effect on the Aortic Root Diameter

Objectives. There is little evidence in the medical literature about safety of PDA device closure and its effects on aortic root diameter in Marfan patients. We reported on nine Marfan patients whose ducts were occluded by coil or Amplatzer Duct Occluder. Patients and Interventions. Two patients had aneurismal type E ducts which were closed by a single coil, respectively. The others had conical ducts for which even Amplatzer occluder, stiff, or double coils were used. Results. No untoward consequence was found during a median follow up period of 18.5 months (range 3 months to 6.33 years). Two patients had small residual shunts. The observed change in the mean ratio of aortic root diameter to its estimated value was statistically insignificant in seven patients who had complete data on their aortic root diameter before PDA closure and during the follow up. Conclusions. We concluded that PDA device closure in Marfan patients is safe. Risk of residual shunt is higher even after closure of small ducts.     

Mild or subclinical intravascular haemolysis subsequent to transcatheter occlusion of the patent arterial duct.

One of the important complications of transcatheter occlusion of the patent duct by insertion of either the Rashkind double umbrella or coil devices is intravascular haemolysis, particularly the severe form which occurs in 0.5-0.6% of cases. The incidence of subclinical or mild intravascular haemolysis including morphologic changes in the red cells, however, is not known, especially in the group of patients with residual shunt. We studied laboratory and haematologic changes in 37 patients subsequent to transcatheter occlusion. Their ages ranged from 2 years 2 months to 11 years 8 months (6.2 + 2.7 years), and the duration of occlusion had ranged from 1 month to 2 years 11 months (1.24 + 0.89 years). In 30 cases we had used the Rashkind double umbrella device, and nine of these patients (30%) had a residual shunt. The other seven ducts were closed with detachable coils, and five of these cases (71%) had residual shunting. There was evidence of mild or subclinical intravascular haemolysis in almost half the cases, although no patient developed acute intravascular haemolysis. Fragmented red cells, blur cells and spherocytes from blood smears were found in up to one-third of the overall series, with no differences found according to persistence of shunting. Haemosiderin was found in the urine of the group with residual shunting and in 13-23% of those with complete occlusion. Serum hypohaptoglobin was found in 9-13% of the patients with a residual shunt, and in 9-23% of those with complete occlusion. Four of the patients had haptoglobin levels < 50 mg/dl. There were no patients with reticulocytes counts > 2% in the blood smears. We conclude that subclinical or mild intravascular haemolysis, along with morphologic changes in the red blood cells, are significant findings subsequent to occlusion of the patent arterial duct with either the Rashkind double umbrella or detachable coils.     

Patent ductus arteriosus

Opinion statement In the absence of irreversible pulmonary hypertension, closure of clinically detectable patent ductus arteriosus (PDA) is usually recommended in adults. Device closure obviates the need for general anesthesia and a surgical incision and eliminates postoperative pain, long convalescence, and lifelong scarring. Over the past 20 years, the efficacy and safety of transcatheter device closure of PDA in adults has been established [1–5]. Even though the immediate success rate is lower with transcatheter device closure than with surgical closure, transcatheter reintervention for residual clinical shunts is very effective at abolishing residual leaks. The late complete closure rate, as determined by echocardiography, is very similar with surgical closure and with device closure. The clinical significance of silent residual shunts is unknown. In patients with silent residual shunts, the use of prophylactic antibiotics is as of yet recommended. Occlusion devices should be used whenever possible in adults, and surgical closure of patent ducts should be reserved for patients with larger ducts. The method of ductal closure should be selected on the basis of the quality of and experience with available interventional and surgical resources. Emerging minimally invasive surgical treatments seem promising, but further experience and follow-up are needed before widespread application of these techniques can be recommended.     

Transcatheter closure of the patent ductus arteriosus: A comparative study between occluding coils and the Rashkind umbrella device

This study was performed to evaluate the efficacy of transcatheter coil closure of the patent ductus arteriosus in comparison to our experience with the Rashkind umbrella device. Transcatheter coil closure of the patent ductus arteriosus has been reported with encouraging results. We present our experience with ducti up to 5.0 mm in diameter and report the short-term follow-up. We compare the results with our previous experience with the Rashkind umbrella device. Seventy-one patients underwent transcatheter coil closure. Median age was 3.1 years, and median weight was 13.6 kg. Mean ductus diameter was 2.0 ± 1.1 mm. These were compared with 105 patients who underwent transcatheter closure using a single Rashkind umbrella device. The median age was 3.2 years and the median weight was 14.0 kg. The mean ductus diameter for this group was 2.1 ± 0.6 mm. The ductus murmur in the coil group disappeared in all patients. Immediate (≤24 h), complete closure was achieved in 89% of the coil group as compared to 71% for the Rashkind umbrella device group (P < 0.005). Closure rate for the coil group was 97% at the 6-month follow-up, vs. 82% for the Rashkind umbrella device group at the 6–12-month follow-up (P ≤ 0.05). In almost all patients requiring more than one coil, the ductus was crossed serially from the aortic end. All patients with ductus diameter ≥3.0 mm required two or more coils. Eleven coils in six patients embolized to the pulmonary arteries. All coils except one were retrieved with subsequent successful coil placement. Sixty-seven patients (94%) in the coil group were discharged in ≤24 h. Transcatheter closure of the patent ductus arteriosus using multiple coils is a more effective technique than the Rashkind umbrella closure and has excellent short-term results. This can be performed safely as an outpatient procedure. © 1996 Wiley-Liss, Inc.     

Gianturco-Grifka device in the percutaneous closure of patent ductus arteriosus

We present our early experience with the Gianturco-Grifka device for transcatheter closure of patent ductus arteriosus. Grifka occlusion was attempted in 13 patients (7 female, 6 male), median patient age was 6.5 years. Echocardiographic evaluation showed a mean ductal diameter of 5.47 +/- 1.09 mm, and the morphology was type C in 7 patients, type A in 5 and type E in 1 patient. The angiographic ductal morphology was 6 type A, 5 type C and 2 type E. Mean PDA diameter was 5.69 +/- 1.15 mm. Three patients had pulmonary hypertension. They were given supplemental oxygen (100%), decreasing their pulmonary pressures. A total of 13 devices were implanted, 5 of 7 mm and 8 of 9 mm. Twelve patients had complete ductal occlusion documented by aortic angiography (92%), one patient presented residual shunt (8%). Color echocardiography at 24 hrs documented complete occlusion in 12 cases. One device embolized to the descending aorta 2 hours after closure, and it was successfully retrieved in the catheterization lab. We conclude that the Gianturco-Grifka device is an appropriate alternative for transcatheter closure of the PDA. This technique can be performed in ductus arteriosus type C, D and E, with diameter < 9 mm. More clinical trials are needed to establish the long-term results of this technique.     

Severe intravascular hemolysis after transcatheter coil occlusion of patent ductus arteriosus

Severe intravascular hemolysis is a rare complication of transcatheter closure of patent ductus arteriosus (PDA). It is thought to be secondary to red blood cell damage from a high-velocity jet from a residual shunt. However, only a small minority of patients with a residual shunt develop this complication. We report a case of intravascular hemolysis after partial coil occlusion of a PDA in which the Dacron strands were stripped off the coils during bioptome-assisted deployment. The exposure of the blood flow jet to bare metallic coils may have contributed to the occurrence of the severe hemolysis.     

Transcatheter occlusion of moderate to large patent arterial ducts, having a diameter above 2.5 mm, with the Amplatzer Duct Occluder. Comparisons with the Rashkind, buttoned devices, and coils in 116 consecutive patients

AIM: To report results of transcatheter occlusion of moderate to large patent arterial ducts, having a minimum diameter above 2.5 mm, with the Amplatzer duct occluder, and to compare these with results achieved using Rashkind or Sideris devices and Cook detachable coils. DESIGN AND SETTING: Retrospective study conducted on intention-to-treat data from a tertiary referral centre. PATIENTS: Since 1989, 116 consecutive patients, 77 females and 39 males, underwent percutaneous closure with several devices. We used the Rashkind double umbrella in 23 patients, the Sideris buttoned device in 39 patients, coils in 17 patients, and the Amplatzer duct occluder in 37 patients. The median age of the patients was 37 months, and the median weight 13 kg. The mean minimum diameter of the duct was 3.8 +/- 1.22 mm, with a median of 3.5 mm, and range from 2.5 to 10 mm. RESULTS: Implantation succeeded in all but 9 of the children (92%). The time of fluoroscopy was shorter, and full occlusion was better as judged on angiography, in patients closed using the Amplatzer device, despite closure of larger ducts, than in patients closed using other devices (p < 0.0001, p = 0.0003, and p = 0.0015 for the Rashkind, Sideris, and coils, respectively). Complications included embolisation in 2 patients, and haemolysis in 3 patients. In 12 patients, a second device was inserted because of residual shunting noted during follow-up. Complete occlusion was achieved earlier after implantation (p = 0.0002), and the rate of complete occlusion was better in patients receiving an Amplatzer device (97%, p = 0.024) than in patients undergoing closure with other devices. CONCLUSION: Transcatheter closure of moderate to large patent arterial ducts using the Amplatzer duct occluder is an effective and safe procedure, providing better results than those achieved using other occluders.     

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.     

Safety and efficacy of using 0.052-inch Gianturco coil for closure of large ( > or = 4mm) patent ductus arteriosus

Transcatheter closure of patent ductus arteriosus (PDA) is now a well-established treatment alternative to surgery in many cardiology centers. Of all the methods used, transcatheter coil occlusion is the preferred therapy. For small PDA, the method using 0.038" Gianturco coils has proven safe and effective. However, this therapeutic strategy has encountered some difficulties with large PDA. This study provides an alternative strategy, using 0.052" Gianturco coil and complete closure of residual shunt with multiple coils to close large PDA. Fifteen patients underwent transcatheter coil occlusion of large ( > or = 4mm) patent ductus arteriosus. The intermediate success rate was 86.7%. There were four complications and only two patients had to be referred for surgery.     

Comparison of two transcatheter device strategies for occlusion of the patent ductus arteriosus

Objectives: The present study evaluates two transcatheter closure strategies utilized at a single center and makes recommendations for device selection when occluding the patent ductus arteriosus. Background: A variety of devices are available for transcatheter closure of the patent ductus arteriosus (PDA) but no guidelines exist to guide operator device choice. Methods: A total of 132 patients underwent attempted transcatheter PDA closure utilizing one of two consecutive closure strategies between January 2000 and June 2005. Strategy A (n = 64; January 2000–May 2003) utilized Gianturco coils only. Strategy B (n = 68; June 2003–June 2005) utilized a single Gianturco coil for the PDA with a minimal diameter ≤1 mm (n = 28) or an Amplatzer Duct Occluder (ADO) if the PDA diameter exceeded 1 mm (n = 40). Success was defined as complete occlusion on a follow up echocardiogram. Results: 58 of 64 (90.6%) patients treated utilizing strategy A had successful coil implantation. 68 of 68 (100%) patients treated utilizing strategy B had successful coil/device implantation. At follow up echocardiography, 32 of 44 (72.7%) strategy A patients had complete ductal closure, as compared with 57 of 58 (98.3%) strategy B patients (P < 0.0001). Stepwise logistic regression analysis identified closure strategy as the most powerful predictor of procedural success (OR = 85.9; CI 5.6–9.99). Conclusions: A transcatheter PDA closure strategy consisting of a single Gianturco coil for PDA ≤ 1 mm or an ADO for larger sized PDA (strategy B) achieves superior outcomes compared to the use of coils alone. © 2008 Wiley‐Liss, Inc.     

Transesophageal echocardiographic predictors for successful transcatheter closure of defects within the oval fossa using the CardioSEAL septal occlusion device

OBJECTIVES: To define the utility of transesophageal echocardiography in predicting the likelihood of a successful procedure and residual shunting in patients undergoing transcatheter closure of defects within the oval fossa using the CardioSEAL device. BACKGROUND: Transesophageal echocardiography is used to monitor transcatheter closure of interatrial defects within the the oval fossa, but predictors of successful closure and residual shunting have yet to be determined. METHODS: We reviewed transesophageal echocardiograms obtained from 26 consecutive patients undergoing attempted transcatheter closure of interatrial defects within the oval fossa between January, 1997 and May, 1998. Assessment of the atrial septum, the septal defect, and the rims of the oval fossa bordering the defect was performed in 3 planes: longitudinal, 4-chamber, and basal short-axis. RESULTS: Closure proved successful in 24 patients (92%). The defect was significantly larger, and the anterosuperior rim of the defect smaller, in the 2 patients in whom occlusion was not successful. Residual shunting 24 hrs after closure was detected in 14 patients. Significant predictors of leakage included smaller posterior and superior rims, a larger shunt prior to closure, and herniation of a one left atrial arm of the device into the right atrium. In all cases, the sites of leakage were the superior rim of the defect at the superior cavo-atrial junction, and the anterosuperior rim behind the aortic root. Herniation of a left atrial arm into the right atrium was seen in 7 patients (29%). In all, it was the anterosuperior arm which herniated Doppler color flow was suboptimal in detecting residual leaks, and was enhanced substantially with the use of contrast echocardiography. CONCLUSIONS: Transesophageal echocardiography allows excellent assessment of the oval fossa and deficiencies of its floor in all of their dimensions. It is an important tool for guiding the deployment of the occlusion device in patients undergoing attempted transcatheter closure of defects within the fossa. Contrast echocardiography should be used for optimal detection of residual shunting.     

Advantages and disadvantages of coils for transcatheter closure of patent ductus arteriosus

Different coils have been used to close the patient ductus arteriosus (PDA). In small- and moderate-sized PDA, coils are an adequate alternative to surgery and/or to other devices. The aim of the study is to review and discuss the advantages and disadvantages of using coils (excluding PFM coils PFM Medical, Germany) to close PDA. Cambier was the first to successfully close a PDA using a Gianturco coil. To date, thousands of patients worldwide have undergone transcatheter closure of PDA using this or other types of coils. The use of coils is analyzed with regard to costs in comparison with other therapeutic modalities; techniques--anterograde, retrograde approach, selection of coil size--in relation to the size of the PDA and the available sizes of coils; efficacy of the rate of complete occlusion and the need for reocclusion; and safety in relation to embolization rate, other complications including hemolysis, left pulmonary artery LPA stenosis and coarctation. It is concluded that coils are a cheap alternative for the occlusion of PDA in the small-to-moderate PDA. The technique can be learned quite quickly, it has a high rate of complete occlusion, and has an acceptable rate of safety. The disadvantages include a moderate rate of coil embolization and of hemolysis in patients with residual shunt after coil occlusion in large PDAs. When more than one coil is used, the potential for developing LPA stenosis is high.