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.     

Nonsurgical closure of patent ductus arteriosus: clinical application of the Rashkind PDA Occluder System

The first successful application of a transcatheter closure technique for patent ductus arteriosus (PDA) suitable for use in infants and children was performed by us in 1977. Since that time, there has been continued improvement and simplification of the equipment as well as in the implantation technique. Following a Food and Drug Administration protocol, a multicenter study was conducted to test the safety and effectiveness of this interventional method. The clinical results from three major regional test centers (Philadelphia, Houston, and New Haven) are presented. One hundred forty-six patients from a test population of 156 were treated for PDA with use of the Rashkind PDA Occluder Systems. Successful closure was accomplished in 94 (66%) of the total cases. Ten patients (7%) retained residual ductal murmurs despite correct placement of the occlusion devices; five additional patients (3%) were considered failures due to the presence of abnormal Doppler flow patterns after the procedure. Postrelease embolizations occurred in 19 (15%) instances. One patient required emergency surgical intervention after attempted retrieval of an embolized occluder. With the improvements in the manufacturing of the double-disk occluder systems as well as the perfection of the transvenous delivery technique, the incidences of closure failure and postrelease complications have decreased. Since January 1984, 78% of all transcatheter closure attempts were successful, with 10% embolization.     

Advances in interventional occlusion of persistent ductus arteriosus: comparison of results using different occlusion devices

This report describes our results with transcatheter closure of patent ductus arteriosus between March 1993 and May 2000 including our early experience with the Amplatzer duct occluder. One hundred and sixty-six consecutive procedures were performed in 160 patients. The mean age was 6.8 years (range 0.8 to 26.2), mean weight 24.3 kg (range 7.7 to 84.0). Single or multiple coils were implanted successfully in 114 cases, a Rashind double umbrella in 35 patients, and an Amplatzer duct occluder in 16 patients. After failure to implant coils in one patient, a second attempt with a Rashkind double umbrella was successful. Complete closure of the patent ductus arteriosus was achieved in a total of 148 patients (92.5%), mean fluoroscopy time was 13.7 min (range 3.1 to 126 min). In 144 patients (90.0%), occlusion without residual shunting was achieved by the first interventional approach. Angiography showed immediate closure in 44%, echocardiography within 48 h revealed complete closure in additional 28%. In a further 18%, a residual shunt disappeared spontaneously in the following months. In five patients a second procedure was performed to terminate residual shunting after placement of a Rashkind occluder system by coils. In three patients, the residual shunt resolved. In 12 patients (7.5%) echocardiography showed a residual shunt 2-1259 days after interventional approach. Occlusion rates of the different devices were 83% for the Rashkind occluder, 92% for detachable coils, and 100% for the Amplatzer duct occluder. Coil embolisation into the pulmonary artery occurred in two patients, interventional removal was successful in one of them. There were no further complications. According to our experience interventional occlusion of patent ductus arteriosus is highly effective and associated with a low complication rate. Transcatheter closure using the Amplatzer duct occluder seems to be safe and effective also in small children with a body weight of 8 kg and a large ductus diameter. Compared to the total group of patients, the occlusion rate of the Amplatzer duct occluder was significantly higher (p = 0.005), and of the Rashkind occluder system significantly lower (p = 0.026). Therefore, we recommend the use of detachable coils in patients with small ductus (diameter < or = 2 mm) and the Amplatzer duct occluder in those with a larger ductus. Transcatheter closure of the patent ductus arteriosus according to this regimen should achieve occlusion rates above 95%.     

Technique for closure of the small patent ductus arteriosus using the Rashkind occluder

Percutaneous transcatheter closure of the patent ductus arteriosus has become a clinically viable procedure in childhood due to the pioneering work of Rashkind and Mullins. Presented is a modification of the technique to accomplish catheter closure in the small ductus arteriosus.     

Percutaneous closure of patent ductus arteriosus with the Amplatzer duct occluder

BACKGROUND AND METHODS: Percutaneous closure of a moderate-to-large sized patent ductus arteriosus using multiple coils or a Rashkind double-umbrella may be technically demanding and raises a significant rate of embolization and residual shunting. This is why we tried a new self-expandable device called Amplatzer Duct Occluder to close transvenously large ductuses in eighteen patients at a median age of 2.8 years (range: 0.7 to 34). They had a patent ductus arteriosus with a minimal diameter > 3 mm (mean: 5 +/- 2 mm). The device had a mean diameter of 9 +/- 2 mm and was delivered through a 6F venous sheath. Aortography was done 5 to 10 minutes after the release and follow-up evaluation was performed with color Doppler echocardiography within 24 h, 1 and 3 to 6 months after the procedure. RESULTS: Placement was successful in all but the first patient (95%). Complete closure was achieved immediately in 4/17 patients (24%) and in 13/17 (76%) 24 h later. Two patients were lost for follow-up. Complete closure was confirmed in 14 of the 15 (93%) reviewed patients at 1 and 3 months. In all patients with a ductal diameter < or = 7.5 mm the closure was complete at 1 month. Embolization occurred in one patient with a 9.7 mm duct and surgery was undertaken. A mild and transient hematuria was observed in one patient. No pulmonary artery stenosis nor aortic obstruction were observed on follow-up. CONCLUSION: The Amplatzer Duct Occluder device offers a safe and effective option to treat patients with a ductus arteriosus which minimal diameter is up to 7.5 mm.     

Transfemoral vein catheter occlusion of patent ductus arteriosus

Between February 1988 and September 1989, 15 patients underwent closure of patent ductus arteriosus by the Rashkind technique modified by Mullins. The insertion of the occluder was achieved in all cases; however, in one patient, the prosthesis migrated to the abdominal aorta several hours after implantation. No other complications were observed. All patients were discharged from hospital under 24 hours after the procedure. The follow-up period ranges from 3 to 12 months. The rate of complete closure of the ductus was 50% 24 hours after implantation, 57% at 3 months, 66% at 6 months and 82% 12 months after the procedure. Our results suggest that the Rashkind technique for the closure of patent ductus arteriosus by the transvenous femoral approach is an effective and low risk procedure.     

Outpatient closure of the patent ductus arteriosus

We have modified and applied to selected outpatients the transvenous approach to correction of patent ductus arteriosus (PDA) with the Rashkind PDA Occluder. Modifications included establishing the diagnosis and PDA anatomy before catheterization with echocardiography. The sedation/anesthetic regimen was altered to meet the needs with respect to transcatheter PDA closure rather than diagnostic cardiac catheterization. Anticoagulation was avoided. A strategy for management of pin entrapment in the foam was devised. Residual trans-PDA flow after umbrella placement was temporarily occluded with balloon-tipped catheters. These modifications were used in 23 consecutive patients with uncomplicated PDA. Closure was successful in each child. Nineteen of 23 patients were discharged on the day of the procedure. No serious complications were encountered.     

Transcatheter closure of a large patent ductus arteriosus with the clamshell septal umbrella

In 14 patients undergoing transcatheter closure of a large (greater than 4 mm diameter) patent ductus arteriosus, occlusion was attempted with use of the Bard Clamshell septal umbrella. Patient age ranged from 0.7 to 30.4 years. Isolated patent ductus arteriosus was present in 11 patients; 3 had additional congenital heart lesions. Moderate or severe pulmonary hypertension was present in four patients. The diameter of the patent ductus arteriosus ranged from 4.5 to 14 mm, as determined by contrast injection through an 11F sheath or by balloon sizing; it appeared larger by this method than by the standard angiographic method. All 14 patent ductus arteriosi were successfully closed. Prior embolization of a Rashkind umbrella was the reason for using a Clamshell device in three patients; one additional embolization of a Clamshell device occurred. All errant devices were retrieved at cardiac catheterization, without associated hemodynamic instability. No other complications occurred. Among the 14 patients, 11 had complete ductal closure by Doppler color flow mapping at last follow-up and 3 had trivial residual flow. All four patients having associated complex lesions or pulmonary hypertension, or both, had symptomatic improvement after the procedure, although one child (with Shone's anomaly) died 3 months later. The Clamshell device provides stable and effective closure of a large patent ductus arteriosus, and allows transcatheter closure to be offered to some patients who were previously considered unsuitable for this procedure.     

Percutaneous closure of the small patent ductus arteriosus using occluding spring coils

Objectives. This report summarizes our experience with the use of occluding spring coils to close the small patent ductus arteriosus.Background. Several patent ductus arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent ductus arteriosus in a small group of patients. This report describes our series of patients having patent ductus arteriosus closure with occluding spring coils.Methods. Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent ductus arteriosus closure by occluding spring coils. Selection criteria were age >6 months and narrowest patent ductus arteriosus internal dimension ⪯3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent ductus arteriosus and into the aortic diverticulum. Patent ductus arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging.Results. Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent ductus arteriosus. Average ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent ductus arteriosus noted on color flow imaging. One patient did not have successful implantation. This patient had a 3.2-mm ductus, and two coils migrated to the distal left pulmonary artery and could not be retrieved. There were no deaths or any significant complications noted during early or late follow-up in these patients.Conclusions. Occluding spring coils may have additional application in closing the small patent ductus arteriosus.     

Endoluminal occlusion, using a catheter, of patent ductus arteriosus in an adult

The risk of surgical closure of the ductus arteriosus in the adult is greater than in children. The ductus arteriosus can now be occluded by venous catheterisation using a Rashkind umbrella. This procedure vas performed in a 63 year old woman. The diagnosis was confirmed and the anatomy of the lesion defined by catheterisation with aortography. The patent ductus was then occluded with a balloon catheter to assess the reversibility of the pulmonary hypertension. A 17 mm Rashkind umbrella was then used to completely occlude the ductus. The advantages of the method over surgical closure are: absence of morbidity related to thoracotomy, to general anaesthesia, to blood transfusion and the reduction of hospital stay to 3 days.     

Initial results and medium-term follow-up of stent implantation of patent ductus arteriosus in duct-dependent pulmonary circulation

OBJECTIVES: This study was designed to assess the safety, efficacy, medium-term outcome, and complications of patent ductus arteriosus (PDA) stenting in duct-dependent pulmonary circulation. BACKGROUND: Patent ductus arteriosus stenting has been proposed as an alternative to surgical shunt on account of postoperative morbidity and complications of surgical shunting. METHODS: Between April 2000 and February 2003, 69 patients with duct-dependent pulmonary circulation underwent cardiac catheterization with the intent of PDA stenting as first palliative procedure. Patients with critical pulmonary stenosis and pulmonary atresia with intact ventricular septum post-radiofrequency valvotomy who had PDA stenting were excluded. Thirteen more patients were excluded because of branch pulmonary artery (PA) stenosis. The follow-up was by clinical examination, echocardiography, and repeat cardiac catheterization at six to nine months following the procedure. RESULTS: Patent ductus arteriosus stenting was successful in 51 patients (91.1%) and failed in 5 patients (8.9%). The mean narrowest PDA diameter was 1.9 +/- 0.6 mm. The mean procedure and fluoroscopy time were 95.7 min and 29.4 min, respectively. In one patient the stent dislodged and migrated to the left femoral artery and another patient developed transient intravascular hemolysis. There was no procedure-related mortality. Three patients (5.9%) died one day to two months after the procedure. At follow-up (3.2 months to 2.4 years), 8 patients developed significant stent stenosis requiring reintervention. Seven patients developed worsening of preexisting branch PA stenosis. The freedom from reintervention was 89% and 55% at 6 months and 1 year, respectively. CONCLUSIONS: Patent ductus arteriosus stenting is an attractive alternative to surgical shunt in a majority of patients with duct-dependent circulation. An absolute contraindication to this technique is the presence of branch pulmonary stenosis.     

Amplatzer封堵器介入治疗动脉导管未闭疗效分析

目的 评价Amplatzer封堵器介入治疗动脉导管未闭(PDA)的临床疗效。方法 对10例管型PDA患儿用Amplatzer PDA封堵器进行堵闭，2例窗型PDA用Amplatzer房间隔双伞封堵器堵闭。在透视下经6F输送器置入封堵器，术后10分钟，行右心导管检查及主动脉弓降部造影，术后24小时、1、3个月分别行彩色多普勒超声心动图、血常规及肝肾功能检查，评价治疗效果。结果 本组技术成功率为100％，患儿心脏双期连续性杂音均消失，术后10分钟主动脉弓降部造影显示少量残余分流2例，均为窗型PDA。术后24小时超声心动图示上述2例仍有微量分流。术后24小时、1、3个月行彩色多普勒超声心动图检查，均未发现残余分流、PDA再通及封堵器移位，血常规及肝肾功能检查均正常。2例有分流的患儿术后均出现急性溶血，经积极内科治疗后好转。其余10例无并发症发生。结论 应用Amplatzer封堵器介入治疗PDA安全有效，近中期疗效满意，远期疗效尚待进一步观察。对窗型PDA可试用Amplatzer房间隔封堵器堵闭。对术后发生急性溶血者可采用内科治疗。     

经导管堵塞婴幼儿动脉导管未闭89例体会

目的探讨经导管堵塞婴儿动脉导管未闭的疗效。方法对８９例动脉导管未闭患儿采用了４种不同堵塞装置治疗。结果总成功率９８．８８％（８８／８９），失败１例，严重并发症２例，术后２４小时内残余分流１９例（２１．３％），经１个月～３．５年随访，微量残余分流７流（７．０８％）。结论经心导管堵婴幼儿动脉导未闭安全、有效、操作简单、适应证广，可作为治疗婴幼儿动脉导管未闭的首选方法。     

浅低温心脏不停跳体外循环下动脉导管缝闭术

为探讨重症动脉导管未闭（PDA）的手术方法，在浅低温心脏不停跳体外循环下，经主肺动脉切口行动脉导管缝闭术12例，手术效果满意。此祛适用于成人粗大型PDA、PDA并重度肺动脉高压、PDA并感染性心内膜炎、PDA结扎后再通及PDA并存心内畸形。     

应用Cook可控弹簧栓子封堵动脉导管未闭

目的 :应用 Cook可控弹簧栓子封堵动脉导管未闭 （PDA）并对其疗效进行评价。方法 :全组共 10例 ,年龄 2～ 35 （平均 11.6 ）岁 ,体重 8～ 6 4（平均 30 .6 ） kg,PDA最窄处直径 1.4～ 3.2 （平均 2 .6 ） m m。经导管置入 Cook可控弹簧栓子封堵 PDA。封堵后 10 min行胸主动脉造影评价疗效。术后 3天、1月、6月及 12月行超声心动图检查观察有无残余分流及 PDA再通。结果 :全组技术成功率为 10 0 % ,术后 10 m in胸主动脉造影及术后 3d超声心动图未见残余分流。随访 12个月 ,均未发现 PDA再通及弹簧栓子移位。结论 :应用 Cook可控弹簧栓子封堵小型 PDA是一种安全、有效的非手术方法     

Percutaneous treatment of multiple heart defects

We describe our experience in 6 cases with multiple congenital heart defects treated by percutaneous intervention. Their age ranged from 2.3 to 10 years (mean 6.1), with follow-up from 1 to 84 months (mean 28.8). Two cases had coarctation of the aorta (AC) and persistent ductus arteriosus (PDA). Two patients had pulmonary valve stenosis (PVS) and PDA, one case with aortic stenosis (AE) and PDA and one case with AC, mitral stenosis and subaortic stenosis (Shone's Syndrome). Ductus arteriosus was occluded in all patients with Gianturco coils or Rashkind occluder. The valvular gradient post balloon decreased in cases with AC from 46 to 9 mmHg, with PVS from 110 to 10 mmHg and with AE from 40 to 14 mmHg. In a 8 year old boy with Shone's syndrome, we performed angioplasty of aortic coarctation, mitral valvuloplasty with Inoue catheter. He was referred to surgery for subaortic repair stenosis. All are asymptomatic at follow-up. In conclusion; percutaneous intervention is possible in patients with multiple congenital heart defects.     

Transcatheter closure of a 22 mm patent ductus arteriosus with an Amplatzer atrial septal occluder.

Transcatheter techniques for closure of patent ductus arteriosus (PDA) have been used for almost 40 years. We report a case of a 24-year-old female with a 22 mm PDA, congestive heart failure, and atrial fibrillation. She underwent transcatheter PDA closure with an Amplatzer atrial septal occluder (ASO). Following the procedure, she developed hemolysis due to a large residual shunt. However, the shunt gradually resolved until complete closure was achieved within 8 months. An attempt to restore sinus rhythm with electrical cardioversion was successful and the patient is now, 2 years after procedure, in New York Heart Association functional class I. Off-label use of an ASO for closure of a very large PDA yielded an excellent clinical result.     

The use of transesophageal echocardiography monitoring of transcatheter closure of a persistent ductus arteriosus

We performed transesophageal echocardiography (TEE) with pediatric biplane probes throughout the procedure of transcatheter closure of the ductus arteriosus in 42 out of 46 patients who were scheduled for this intervention. Patient ages ranged from 15 months to 14 years and body weight from 9-53 kg. Both Rashkind double umbrella devices and coils were used. The described approach resulted in fewer contrast injections and was helpful in monitoring the procedure and in deciding when to release the device. To the best of our knowledge this is the first report describing a large series where continuous monitoring of transcatheter ductus closure was combined with x-ray fluoroscopy and TEE.     

Transcatheter umbrella closure of congenital heart defects

Between October 1984 and September 1986, we attempted transcatheter umbrella closure, using the Rashkind PDA occluder, of 12 congenital or postoperative cardiovascular defects (other than patent ductus arteriosus [PDA]) in 11 patients. In each, we used the umbrella for closure because the defect was too short and/or too large to close with conventional transcatheter methods. The defects included three post-Glenn venous communications (superior vena cava-right atrium, n = 2; azygos vein to inferior vena cava), four congenital "interatrial defects" producing cyanosis ("coronary sinus" septal defect, left superior vena cava to left atrium, patent foramen ovale, left inferior vena cava to left atrium), and five non-PDA systemic-to-pulmonary arterial communications (two congenital and three postoperative). Ten of 12 defects were embolized successfully; nine had complete or subtotal closure, and one was partially closed. The first attempted closure resulted in embolization of a 12 mm device to a lower-lobe pulmonary artery, without clinical sequelae. No other complications occurred. Clinical improvement was most dramatic in those patients whose cyanosis was relieved and less obvious when pulmonary blood flow was reduced. The Rashkind umbrella device, originally designed for closure of PDA, considerably expands the list of congenital or operative defects that can be closed nonsurgically.     

Transcatheter closure of patent ductus arteriosus in adults using the Amplatzer duct occluder: initial results and follow-up

BACKGROUND: Surgical closure of patent ductus arteriosus in adult patients may be problematic. Transcatheter closure of patent ductus arteriosus is an established procedure. Recently, transcatheter closure of patent ductus arteriosus using the Amplatzer duct occluder has been shown to be safe and efficacious. We present our experience with this device in adults. METHODS AND RESULTS: Between January 2000 and January 2002,41 adult patients (31 females and 10 males) with a patent ductus arteriosus were referred for closure with the Amplatzer duct occluder. The median age was 35.6 years (range 18-70.7 years) and the median weight was 65.8 kg (range 32.7-164.5 kg). Of these 41 patients, 37 underwent attempted closure of the patent ductus arteriosus using the Amplatzer duct occluder. The device was successfully deployed in all patients except 1. Complete angiographic closure was seen Immediately after device deployment in 29 out of 36 patients (81%). Complete echocardiographic closure was demonstrated within 24 hours post-procedure in 34 out of 36 patients (94%), and at 6-month follow-up in 35 out of 36 patients (97%). No complications related to device implantation occurred in any patient. CONCLUSIONS: Closure of patent ductus arteriosus using the Amplatzer duct occluder is safe and effective in adults.