Management of patent ductus arteriosus in preterm infants.

OBJECTIVE: To evaluate the incidence of symptomatic patent ductus arteriosus (PDA) in preterm infants, and the results of the intravenous indomethacine treatment and surgery. METHODS: Among 394 preterm infants (<37 weeks), symptomatic PDA was diagnosed by echocardiography in 51 babies and they were examined retrospectively. All infants were managed conservatively and then IV indomethacine was given to non-responders (n=30). Surgical closure was performed in 12 babies. RESULTS: The incidence of symptomatic PDA in preterm infants was 12.9%: median age: 3 days, mean birth weight: 1434+/-540 g (540-2900g) and mean gestational age (GA) 30.9+/-3.3 weeks (23-37 weeks). With indomethacine, ductal closure was achieved in 70% infants. Early clinical improvement was observed in all cases that underwent surgery and most of them had a low birth weight (<1500 g) and an early gestational age (<32 weeks). None of them died due to operation. CONCLUSION: The incidence of symptomatic PDA is high in preterm infants. Treatment with indomethacine improves ductal closure and is associated with few reversible adverse effects. In the other hand, early clinical improvement and high success rate were achieved after surgery. If indomethacine fails to achieve ductal closure, decision of surgery must be made immediately.     

Surgical Closure of Patent Ductus Arteriosus in Preterm Low Birth Weight Infants

Background and Aim of the Study. In many preterm low‐birth‐weight infants, ductus arteriosus fails to close spontaneously. This study evaluates the results of surgical ligation of symptomatic patent ductus arteriosus (PDA) in preterm low birth weight infants. Methods. We reviewed the medical records of all infants undergoing surgical closure of PDA from January 1987 to December 2005. Demographic data, age and weight at operation, surgical technique to close PDA and outcome were analyzed. Results. One hundred and forty‐five infants underwent surgical closure of PDA in which either indomethacin treatment had failed or was contraindicated. The mean gestational age was 25.5 ± 2.3 (range 24–36 weeks) and the mean birth weight was 837.7 ± 277.2 g (450–1000 g). The average age and weight at operation were 14.1 (±1.8) days and 881.7 g (±338.1), respectively. PDA was surgically closed by left thoracotomy using either nonabsorbable suture (73%) or hemoclips (27%). Postoperative complications occurred in 10 patients, which included intraoperative bleeding (6), pneumothorax (1), left vocal cord paralysis (1), lymphatic leak (1), and injury to left phrenic nerve (1). There was no mortality related to surgical closure of PDA. Conclusion. We conclude that surgical closure of hemodynamically significant PDA is safe and effective in preterm low birth weight infants when pharmacological treatment is ineffective or contraindicated. The associated morbidity is minimal and no surgery‐related mortality was observed.     

Noninvasive assessment of indomethacin therapy in patent ductus arteriosus in preterm infants

We performed 138 serial two-dimensional (2-D), M-mode, and Doppler echocardiographic studies to assess the efficacy of intravenous indomethacin (INDO) therapy for patent ductus arteriosus (PDA) in 41 preterm infants. Nine infants expired without sufficient echo data to warrant inclusion in the study. Of the remaining 32 infants, 12 (Group 1) required ligation despite INDO therapy, 18 (Group 2) responded to INDO or spontaneously closed their PDAs, and 2 were transferred to other hospitals with their PDAs still open and were lost to follow-up. The presence of PDA was verified by 2-D echo visualization of the ductus (high parasternal short-axis views) and Doppler demonstration of high velocity ductal flow toward the main pulmonary artery. The ratio of PDA lumen to aortic root inner diameter (Ao) was measured as well. Indication for surgical ligation was failure of the PDA to close after 3 or more courses of INDO. In Group 1, the PDA/Ao ratio was 0.45 +/- 0.10 standard error of the mean (SEM) pre-INDO, and 0.40 +/- 0.12 SEM post-INDO (immediately before ligation). In Group 2, the PDA/Ao ratio was 0.42 +/- 0.11 SEM pre-INDO, and 0.19 +/- 0.14 SEM at the end of INDO course (p less than 0.001), with 12 infants showing no ductal flow by Doppler. Follow-up six months after INDO therapy has shown no residual murmurs or other evidence of PDA in any INDO-closed infant. Five of the 18 infants have undergone repeated echocardiographic studies, all of which were negative for PDA patency or flow.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lung perfusion studies after transcatheter closure of persistent ductus arteriosus with the Amplatzer duct occluder

Background : Reduced left lung perfusion has been described after transcatheter closure of the patent ductus arteriosus (PDA) with several prostheses. Although the Amplatzer ductal occluder (ADO) device is currently the most widely used occluder for closure of large‐sized PDAs, the potential consequences of flow distribution to the lungs of this device have not been completely clarified. We evaluated lung perfusion following occlusion of PDA with the ADO device. Methods : Forty‐seven patients underwent successful transcatheter PDA occlusion using the ADO device were included in this study. Lung perfusion scans were performed 6 months after the procedure. Results : Decreased perfusion to the left lung (defined as < 40% of total lung flow) was observed in 17 patients (36%), 5 of whom were low‐weight symptomatic infants. Ductal ampulla length was significantly shorter and minimal ductal diameter to ampulla diameter ratio was significantly higher in patients with decreased left lung perfusion and correlated well with left lung perfusion values (r = 0.516 and r = ?0.501, respectively). A cut‐off value of ≤5.8 mm for the ductal ampulla length and ≥1.9 for ampulla diameter to ampulla length ratio showed high sensitivity and specificity for reduced lung perfusion. Conclusions : The incidence of abnormal left lung perfusion is high 6 months after transcatheter closure of PDA with the ADO, more likely in the low weight symptomatic infants and in patients with a short duct or a relatively shallow duct having abrupt narrowing of a large ampulla. © 2010 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.     

Patent ductus arteriosus in premature infants

An analysis of the course and complications in the ligation of patent ductus arteriosus (PDA) in 30 very low birth-weight preterm neonates was carried out. The mean gestational stage at birth was 26.97 weeks, and median weight was 811 gm. Attempted closures of the ductus with indomethacin in 19 infants failed, although there was temporary closure in nine. Congestive heart failure was present in 29 and respiratory distress syndrome in 22 patients. Endotracheal intubation with ventilation assistance was necessary in the entire series. The mean age at operation was 13.5 days, and ductal ligation was performed in the intensive care unit under local anesthesia, supplemented with pancuronium and pethidine. There were no intraoperative deaths, but five infants died during their hospitalization from unremittent respiratory distress syndrome. There were seven additional late deaths. Eighteen survivors were followed for a mean of 26.5 months. Early ligation of PDA in very low birth-weight prematures improved the cardiorespiratory status, and long-term follow-up revealed good clinical progress in two-thirds of the surviving group.     

Left ventricular dysfunction after closure of large patent ductus arteriosus

Changes in left ventricular dimensions and performance were studied in 43 patients after transcatheter occlusion or surgical ligation of patent ductus arteriosus. The patients were assigned to 2 groups based on their ductal diameter: >/= 3.1 mm to group A (n = 27) and 相似文献   

经导管介入治疗婴幼儿大型动脉导管未闭临床疗效

目的探讨应用导管介入治疗直径≥5mm婴幼儿大型动脉导管未闭（patent ductus arteriosus．PDA）的临床疗效。方法回顾性分析60例大型PDA（直径≥5mm）患儿的临床资料,着重分析手术方法、临床疗效和随访结果。结果56例PDA采用Amplatzer或国产先健动脉导管封堵器．3例采用膜部室间隔缺损封堵器,1例采用肌部室间隔缺损封堵器。封堵成功率为98．3％（59／60）,术后1d超声心动图显示15％（9／60）微量至少量残余分流,术后3月超声心动图复查未见残余分流：3例采用室间隔缺损封堵器患儿术后12月超声心动图示左肺动脉血流速度增快。结论应用导管介入治疗直径≥5mm婴幼儿大型PDA是安全、有效的方法。     

Amplatzer蘑菇伞器治疗儿小动脉导管未闭的临床应用

目的：探讨应用Amplatzer蘑菇伞器治疗小儿动脉导管未闭（PDA）的临床疗效及价值。方法：本组共68例,年龄8个月－12岁（平均6．4岁）,体重6．5－30（平均18．2）kg,PDA直径为3－8mm,术中行右心导管检查取血,测压,术后5－15min行隆主动脉造影,测肺动脉压,主动脉压。术后1月,3月,6月分别行X线及超声心动图检查,了解有无残余分流及封堵器位置。结果：本组68例均应用AmplatzerPDA蘑菇伞器治疗,成功率100％,疗效满意,无并发症,术后3d行超声心动图检查显示无1例分流。结论：应用Amplatzer蘑菇伞器治疗PDA创伤小,操作简单,使用广泛,成功率高,临床疗效满意。     

Comparison between the safety profile and clinical results of the Cook detachable and Gianturco coils for transcatheter closure of patent ductus arteriosus in 272 patients

OBJECTIVES: We evaluated the occlusion rate and safety of Cook detachable coils versus Gianturco coils in transcatheter closure of patent ductus arteriosus (PDA). BACKGROUND: The Cook detachable coil recently was introduced in an attempt to improve the safety of transcatheter closure of PDA. METHODS: Between January 1994 and September 1998, 272 patients underwent transcatheter PDA closure. Cook detachable coils were used in 137 patients, with a mean age of 43.9 months and weight of 13.8 kg. In 135 patients, Gianturco coils were used, with a mean age of 56.8 months and weight of 17.8 kg. The mean narrowest diameter of the PDA in the Cook detachable coil group was 2.85 mm versus 2.32 mm for the Gianturco coil group. RESULTS: The Cook detachable coil group was younger and weighed less than the Gianturco group (P < 0.05 and 0.02, respectively). Their narrowest PDA diameter was larger (P < 0.01). Embolization rate was significantly lower in the Cook coil group (9[6.5%] of 137 vs 22 (16.3%) of 135; P = < 0.013). The mean follow-up for the Cook coil group was significantly shorter (0.55 years) than for the Gianturco coil group (1.18 years; P < 0.001). On an intention-to-treat basis, complete occlusion by echocardiography was achieved in 99 (72.3%) of 137 patients in the Cook detachable coil group, which was significantly less than the Gianturco coil group (114 [84.4%] of 135; P = 0.008). CONCLUSION: Cook detachable coils for transcatheter closures of the PDA are safer than Gianturco coils. Hence, children with large ductal can be treated earlier in life. Short-term complete occlusion rate was lower in the Cook detachable coil group. This rate can be explained by a shorter follow-up time, larger ductal diameter, and the different materials used for the detachable coils.     

The Amplatzer duct occluder: experience in 209 patients

OBJECTIVES: The aim of the study was to assess the safety and efficacy of the Amplatzer ductal occluder (ADO) in transcatheter occlusion of patent ductus arteriosus (PDA). BACKGROUND: Transcatheter closure of small to moderate sized PDAs is an established procedure. The ADO is a self-expandable device with a number of salutary features, notably its retrievability, ease of delivery via small 5F to 7F catheters and a range of sizes suitable even for the larger PDAs. METHODS: Between November 1997 and August 1999, the ADO was successfully implanted in 205 of 209 patients with PDA. The inclusion criteria for this device occlusion method were patients with clinical and echocardiographic features of moderate to large PDA, weighing > or =3.5 kg as well as asymptomatic adolescents and adults with PDA measuring > or =5.0 mm on two-dimensional (2D) echocardiogram. Occlusion was achieved via the antegrade venous approach. Follow-up evaluations were performed with 2D echocardiogram, color-flow mapping and Doppler measurement of the descending aorta and left pulmonary artery velocity at 24 h and 1, 3, 6 and 12 months after implantation. RESULTS: Two hundred and five patients had successful PDA occlusion using this device. The patients were between two months and 50 years (median 1.9) and weighed between 3.4 kg and 63.2 (median 8.4). Infants made up 26% of the total patients. The PDA measured from 1.8 to 12.5 mm (mean 4.9) at the narrowest diameter. Forty-four percent of patients achieved immediate complete occlusion. On color Doppler the closure rates at 24 h and 1 month after implant were 66% and 97%, respectively. At 6 and 12 months all except one patient attained complete occlusion. Device embolization occurred in three patients; in two this was spontaneous, and in the other it was due to catheter manipulation during postimplant hemodynamic measurement. Mild aortic narrowing was seen in an infant. CONCLUSIONS: Patent ductus arteriosus occlusion using ADO is safe and efficacious. It is particularly useful in symptomatic infants and small children with relatively large PDA. Embolization can be minimized by selection of appropriate sized devices, and caution should be exercised in infants <5 kg.     

Challenges in Device Closure of a Large Patent Ductus Arteriosus in Infants Weighing Less Than 6 Kg

Introduction

Transcatheter closure of patent ductus arteriosus (PDA) has replaced surgery in most institutions. Despite improvements in techniques and the devices available, closure of large PDA in very small infants remains a challenge.

Aim

To assess the challenges, feasibility, and efficacy of device closure of large PDA, in infants weighing ≤6 kg.

Materials and Methods

Analysis of device closure of a PDA was done in 61 infants ≤6 kg. Their ages, ranged from 9 days–12 months (mean 8.9 months), weight ranged from 2.2 to 6 kg (mean 5.3 kg), and PDA measured 3.2–8.7 mm (mean 4.8 mm). The fluoroscopy time was 3–18 minutes. The largest device used was 12 × 10 mm.

Results

Successful device placement was achieved in 60/61 infants (98.4%). Mild aortic obstruction occurred in 2 cases (3.3%), as the device got displaced towards the aorta after release. The device embolized in 2 cases (3.3%). In one it was retrieved by a novel method like fastening the screw in the aorta and was closed with a 4 × 6 ADO II. In the other infant, with a single kidney, died of uremia after device retrieval. Mild left pulmonary artery (LPA) obstruction occurred in one case (1.6%). Four cases (6.6%) had minor vascular complications. The postprocedure weight gain after 3 months was between 2.5 kg ± 250 mg.

Conclusions

Device closure of large PDA in infants weighing ≤6 kg with left ventricular failure is challenging but possible, safe and effective. Retrieval of embolized device could be tricky. (J Interven Cardiol 2013;26:69–76)

     

Transcatheter occlusion of the patent ductus arteriosus in infants: Experimental testing of a new Amplatzer device

Objectives: This study assessed the feasibility and efficacy of implanting a new miniaturized nitinol device to occlude the patent ductus arteriosus (PDA) in a newborn porcine model. Background: Transcatheter device closure is the standard of care for PDA in older children and adults. Currently available technology is not designed for the newborn infant. Methods: The Amplatzer Duct Occluder II 0.5 is a new transcatheter Nitinol device without fabric designed to close the PDA with small aortic and pulmonary artery structures. The device was implanted in 8 infant pigs (average weight 2,400 g) after balloon dilation of PDA (average diameter 2.7 mm, average length 5.8 mm) with immediate, ～ 7, ～ 30, and ～ 90 day follow‐up by echocardiography, angiography, and final pathological examination. Half were implanted arterial, and half venous. Results: The device was successfully implanted in all animals. There was complete occlusion of the PDA in all cases without obstruction of the pulmonary arteries or aorta. There was complete late endothelialization without thrombus. The only complication was transection of a femoral artery accessed by cutdown. Conclusions: The success of this animal study confirms safety and feasibility of the Amplatzer Duct Occluder II 0.5 (now known as the ADO II AS) for use when the aorta and pulmonary arteries are small. Consideration can be given to transcatheter closure of the PDA in preterm and other small infants with this device. © 2011 Wiley Periodicals, Inc.     

Transcatheter closure of the patent ductus arteriosus in adults using the gianturco coil

Background and hypothesis: Although results of surgical ligation of the patent ductus arteriosus (PDA) in the pediatric age group are excellent, surgical management of the adult with a PDA may be more problematic. The PDA that presents in adulthood may be calcified and friable, rendering simple ligation via a thoracotomy difficult, inadequate, and hazardous. Patch closure of the ductus arteriosus from either the aortic or pulmonary artery orifice using cardiopulmonary bypass or transient aortic cross-clamping is necessary but increases surgical risks. Furthermore, older patients with diseases unrelated to their PDA and patients with Down's syndrome may have higher risks with intubation, general anesthesia, and surgery. Early results of percutaneous transcatheter occlusion of the PDA with Gianturco coils performed under sedation and local anesthesia are promising. Methods: Six adults with mean age of 39.1 years (range 23.1–62.0 years) were found to have an isolated PDA with mean minimum diameter of 2.7 mm (range 1.0–5.0 mm) at cardiac catheterization. All underwent percutaneous transcatheter occulsion of the PDA using Gianturco coils. Results: Coil implantation was successful in all patients. There were no complications and all were discharged home within 24 hours. Complete ductal occlusion was seen immediately in 4 of 6 patients (67%) while 2 of 6 (33%) had small residual leaks. However, complete occlusion was achieved in all patients by 6 months following the procedure. Conclusion: Transcatheter occlusion of the PDA using coils is safe and efficacious in adults.     

Outcomes of Early Ligation of Patent Ductus Arteriosus in Preterms,Multicenter Experience

Persistent ductal patency may have serious effects in preterm infants. Analysis of the results of different trials were inconclusive in determining whether medical or surgical closure of the ductus is preferable and what is the best timing for surgical intervention.The aim of this study was to evaluate the effect of timing of surgical closure of patent ductus arteriosus (PDA) on ventilatory, hemodynamic, and nutritional status of preterm infants.The authors retrospectively looked at the outcomes of surgical ligation of PDA from January 2010 to June 2014 at 2 Saudi neonatal intensive units at 2 tertiary care centers and the authors compared the results of early ligation (before 3 weeks) to the late ligation (after 3 weeks) regarding different hemodynamic, ventilatory, and nutritional parameters.A total of 120 preemies were included (75 preemies with early ligation and 45 with late ligation of PDA). The early ligation group had shorter duration of assisted ventilation of 10 (8–37) days as compared with 37 (26–90) days in the late ligation group (P < 0.05). The median fraction of inspired oxygen, needed to maintain good oxygen saturation in patients, was higher in the late ligation group [0.29 (0.21–0.70)] than in the early group [0.23 (0.21–0.55)] at 24 hours postoperatively. Full oral feeding was achieved earlier in the early ligation group than in the late group, 29 (15–73) days of life versus 53 (34–118) days of life, respectively (P < 0.05). Body weight at 36 weeks postconceptional age was higher in the early group—2100 (1350–2800) g—than in the late group—1790 (1270–2300) g—(P < 0.05).Our study demonstrated that earlier surgical ligation of the PDA in preterm infants has a more favorable nutritional and ventilatory outcome.     

Bacillus Calmette-Guerin vaccination in preterm infants.

OBJECTIVE: To evaluate the tuberculin response after bacille Calmette-Guérin (BCG) vaccination in preterm infants. METHODS: Thirty-five infants born at <35 weeks gestation were included in the study. An intradermal injection of 0.05 ml BCG vaccine was given to each infant at postnatal months 2-3. Tuberculin skin tests (TSTs) were done 8-12 weeks after vaccination using 0.1 ml of 5 TU purified protein derivative (PPD). The diameter of induration was measured 72 h later and > or =5 mm induration was taken as a positive response. RESULTS: The babies had a mean birth weight (SD) of 1650 (424) g, and a gestational age of 32.4 (2.1) weeks. The TST was positive in 20 (57%) of the infants. The mean body weight of the tuberculin-positive babies was significantly higher than the others at both vaccination and TST. No difference was found between groups concerning sex, birth weight, gestational age, intrauterine growth and postnatal age at BCG vaccination and TST. CONCLUSION: BCG vaccination in preterm infants at months 2-3 of postnatal life results in a high percentage of BCG scarring and 57% TST conversion. A positive tuberculin response was significantly related to the postnatal weight gain of the preterm infants.     

Systematic review and meta-analysis of preterm birth and later systolic blood pressure

Lower birth weight because of fetal growth restriction is associated with higher blood pressure later in life, but the extent to which preterm birth (<37 completed weeks' gestation) or very low birth weight (<1500 g) predicts higher blood pressure is less clear. We performed a systematic review of 27 observational studies that compared the resting or ambulatory systolic blood pressure or diagnosis of hypertension among children, adolescents, and adults born preterm or very low birth weight with those born at term. We performed a meta-analysis with the subset of 10 studies that reported the resting systolic blood pressure difference in millimeters of mercury with 95% CIs or SEs. We assessed methodologic quality with a modified Newcastle-Ottawa Scale. The 10 studies were composed of 1342 preterm or very low birth weight and 1738 term participants from 8 countries. The mean gestational age at birth of the preterm participants was 30.2 weeks (range: 28.8-34.1 weeks), birth weight was 1280 g (range: 1098-1958 g), and age at systolic blood pressure measurement was 17.8 years (range: 6.3-22.4 years). Former preterm or very low birth weight infants had higher systolic blood pressure than term infants (pooled estimate: 2.5 mm Hg [95% CI: 1.7-3.3 mm Hg]). For the 5 highest quality studies, the systolic blood pressure difference was slightly greater, at 3.8 mm Hg (95% CI: 2.6-5.0 mm Hg). We conclude that infants who are born preterm or very low birth weight have modestly higher systolic blood pressure later in life and may be at increased risk for developing hypertension and its sequelae.     

Transcatheter occlusion of patent ductus arteriosus using a new angled Amplatzer duct occluder: initial clinical experience.

In the present study, we report the initial clinical experience with the new angled Amplatzer duct occluder (ADO) for the percutaneous closure of patent ductus arteriosus (PDA). Percutaneous closure of PDA using standard ADO in infants and in patients with small PDA ampulla is difficult, or even impossible, due to protrusion of the aortic disk into the descending thoracic aorta. The aortic disk of an angled ADO is angled at 32 degrees to the body of the device and concave toward the aorta to prevent protrusion of the disk into the aorta. Percutaneous closure of PDA was attempted in nine patients with a median age of 5.2 years (range, 0.5-12.7) and median weight of 20 kg (range, 4.9-55). Selection of the occluder and the implantation technique were similar to the standard ADO. The minimal PDA diameter ranged from 2.1 to 3.7 mm (median, 2.5 mm). Occluders were successfully implanted in all patients. Immediate complete PDA closure was achieved in all patients. There were no complications. The new angled ADO is a safe and effective device for PDA closure, particularly suitable for infants and patients with small PDA ampulla. Further studies and long-term follow-up are necessary to confirm our initial experience.     

Dilatation of the entire thoracic aorta in patients with bicuspid aortic valve: a magnetic resonance angiography study

BACKGROUND: The presence of a bicuspid aortic valve (BAV) might be associated with a progressive dilatation of the aortic root and ascending aorta. However, involvement of the aortic arch and descending aorta has not yet been elucidated. PATIENTS AND METHODS: Magnetic resonance angiography (MRA) was used to assess the diameter of the ascending aorta, aortic arch, and descending aorta in 28 patients with bicuspid aortic valves (mean age 30 +/- 9 years). RESULTS: Patients with BAV, but without significant aortic stenosis or regurgitation (n = 10, mean age 27 +/- 8 years, n.s. versus control) were compared with controls (n = 13, mean age 33 +/- 10 years). In the BAV-patients, aortic root diameter was 35.1 +/- 4.9 mm versus 28.9 +/- 4.8 mm in the control group (p < 0.01). The diameter of the ascending aorta was also significantly increased at the level of the pulmonary artery (35.5 +/-5.6 mm versus 27.0 +/- 4.8 mm, p < 0.001). BAV-patients with moderate or severe aortic regurgitation (n = 18, mean age 32 +/- 9 years, n.s. versus control) had a significant dilatation of the aortic root, ascending aorta at the level of the pulmonary artery (41.7 +/- 4.8 mm versus 27.0 +/- 4.8 mm in control patients, p < 0.001) and, furthermore, significantly increased diameters of the aortic arch (27.1 +/- 5.6 mm versus 21.5 +/- 1.8 mm, p < 0.01) and descending aorta (21.8 +/- 5.6 mm versus 17.0 +/- 5.6 mm, p < 0.01). CONCLUSIONS: The whole thoracic aorta is abnormally dilated in patients with BAV, particularly in patients with moderate/severe aortic regurgitation. The maximum dilatation occurs in the ascending aorta at the level of the pulmonary artery. Thus, we suggest evaluation of the entire thoracic aorta in patients with BAV.     

Perpulmonary Device Closure of Patent Ductus Arteriosus with Minimum Diameter More Than 4 mm in Infants

Background: Closure of large patent ductus arteriosus (PDA) in older children has been accomplished using surgical and percutaneous techniques with remarkable outcomes. However, outcomes amongst infants have been variable with several drawbacks. Here we describe a novel minimally invasive technique, a product of mini-thoracotomy and traditional percutaneous technique skills, accomplished exclusively under echocardiography guidance. Methods: Symptomatic infants with a significant left-to-right shunt from PDA measuring more than 4 mm were selected. The symptoms were varying degrees of tachypnea, tachycardia, heart failure, failure to thrive, recurrent respiratory tract infections, or intensive care unit treatment for a longer duration. Through a left parasternal mini-thoracotomy, two parallel purse-string sutures were placed on the pulmonary trunk. After purse-string circle puncture, under exclusively transesophageal echocardiography guidance, a device secured to the safety-suture was implanted on the ascending aorta via pulmonary trunk using a specially designed set. The safety-suture prevented device migration in case of dislocation. The basic demographics, PDA size, device size and type, intrapulmonary manipulation time, operation time, PDA parameters (length, diameter, type of duct), redeployment of the device, residual shunt, and retention of safety-suture were all recorded and analyzed. The follow-up was done with transthoracic echocardiography on the 2^nd postoperative day, 1, 3, 6, and 12 months, and yearly thereafter. Results: Fifty-two infants with a mean age of 8 months ± 2.8 months (Interquartile range = 0) underwent Perpulmonary device closure of PDA. Successful PDA occlusion was accomplished event-free in all subjects. The mean PDA, mean device, and mean operation time were 5.6 mm ± 1.4 mm, 7.9 mm ± 1.7 mm, and 61.2 min ± 12.9 min, respectively. The immediate acceptable residual shunt was noted among 3 subjects and disappeared at a 1-month follow-up. Eighteen infants had retained safety-suture for added safety. There were no reports of the device or procedure-related complications. Conclusion: Perpulmonary device closure is an effective and safe approach to PDA with a diameter measuring > 4 mm among infants. The safety-suture, in case of dislocation, prevents migration and associated complications.