Heart Views

ORIGINAL ARTICLE
Year
: 2006  |  Volume : 7  |  Issue : 3  |  Page : 101--104

Percutaneous transcatheter closure of patent ductus arteriosus using amplatzer duct occluder: First yemeni experience


Ahmed Al-Motarreb1, Mohammed Al-Hammadi1, Mohammed Shamsan1, Hala Kherbash1, Fakhri Al-Hakeem2,  
1 Cardiac Centre, Al-Thawrah Teaching Hospital, Sana'a, Yemen
2 Qween Alia Heart Institute, K.H.M.C. Amman, Jordan

Correspondence Address:
Ahmed Al-Motarreb
Cardiac Centre, Al-Thawrah hospital, P.O. Box 89, Sana«SQ»a, Yemen

Abstract

Background: Results of transcatheter closure of Patent Ductus Arteriosus (PDA) using Amplatzer duct occluder are excellent and have replaced the conventional surgical closure of the PDA in the majority of the cases. Objectives : To assess the immediate and short term results of Transcatheter closure of patent ductus Arteriosus < 6.5mm, using the Amplatzer Duct Occluder (ADO) for the first time in Yemen. Patients & Methods: Seventeen patients (11 females & 6 males) were diagnosed to have Patent Ductus Arteriosus between May 2003 to May 2005. They underwent an attempt of Transcatheter closure of the PDA with ADO. The median age was 5.1 years (range 7 months to 11 years ), and weight ranged from 4kg to 30kg (median 5. 6 kg). A 6F sheath was used for delivery of the ADO. Results: The median PDA diameter at the narrowest segment was 4.1mm (range 2.5 to 6.5mm) and the mean pulmonary / systemic flow ratio (QP/QS) was 1.7:1 (range 1.2:1 to 3:1). There was immediate & complete closure in 10/17 by angiography results. At 24 hrs, 16/17 patients had complete closure of PDAs on colour Doppler echocardiography. Ten patients out of seventeen have completed the 6 & 12 months follow-up and all had complete closure without any complications. Conclusion: Our initial results show that Amplatzer duct occluder is safe and effective in closing PDA in most patients with a PDA < 6.5mm in diameter.



How to cite this article:
Al-Motarreb A, Al-Hammadi M, Shamsan M, Kherbash H, Al-Hakeem F. Percutaneous transcatheter closure of patent ductus arteriosus using amplatzer duct occluder: First yemeni experience.Heart Views 2006;7:101-104


How to cite this URL:
Al-Motarreb A, Al-Hammadi M, Shamsan M, Kherbash H, Al-Hakeem F. Percutaneous transcatheter closure of patent ductus arteriosus using amplatzer duct occluder: First yemeni experience. Heart Views [serial online] 2006 [cited 2023 Feb 4 ];7:101-104
Available from: https://www.heartviews.org/text.asp?2006/7/3/101/63921


Full Text

 Introduction



Patent Ductus Arteriosus (PDA) is a common form of congenital heart disease. It has been estimated to occur in 1 in 2500-5000 live births. As an isolated lesion, it represents 9-12% of all congenital heart diseases [1] . The presence of volume overload of the left atrium and left ventricle is an indication for closure of the defect. Closure eliminates left to right shunt, volume overload of the left-sided circulation, the risk for pulmonary hypertension and the risk of infective endocarditis. Gross et al (1939) [2] began the era of Congenital Heart Surgery when they reported the first successful ligation of a Patent Ductus Arteriosus (PDA). Porstman et.al [3] were the first to use a new method by which a PDA was closed successfully by Ivalon foam plug via combined femoral artery and vein approach. The Rashkind device [4] the buttoned device [5] , the Botallocluder device [6] and coils [7] have been used extensively for transcatheter closure of PDA with variable degrees of success. Masura et.al (1998) [8] had reported the use of the new Amplatzer Duct Occluder (ADO) in humans to close the PDA by the Transcatheter approach.

In this report, we describe our initial experience using the ADO to close PDAs less than 6.5mm in diameter.

 Patients & Methods



Seventeen patients (11 female, 6 male) were diagnosed to have patency of the arterial duct between May 2003 to May 2005. Using the classification adopted by Krichenko et al [9] , sixteen patients had type A (well- defined ampulla at the aortic end) and one patient had type C (Tubular ductus). All patients underwent an attempt of PDA Transcatheter closure at our cardiac center as an alternative to surgical ligation. Informed consents were obtained from all patients. All patients had clinical and echocardiographic findings of PDA. The patients median age was 5.1 years (range 7m to 11y) and their weights ranged from 4kg to 30kg (median 15.6kg). Eight patients were symptomatic in the form of failure to thrive, recurrent chest infection and pulmonary hypertension.

 Amplatzer Duct Occluder Device (ADO)



The amplatzer Duct Occluder (AGA Medical Corporation, Golden Valley, MN) is a self expandable, mushroom shaped device made from a 0.004- inch thick nitinol wire mesh ( a thin retention disk 4mm larger in size than diameter of the device ensures secure positioning in the mouth of the PDA) [Figure 1]. The PDA is closed by the induction of thrombosis which is accomplished by polyester fibers sewn securely into the device with platinum marker bands applied to the wire ends and laser welded. The shape is then formed by heat treatment. After cooling a stainless steel sleeve with a female thread it is welded to the marker band using advanced laser technology.

All devices are cone-shaped and 7mm in length with a screw and available in five sizes (6/4, 8/6, 10/8, 12/10, 14/12). The delivery system consists of a delivery cable, long Mullins type sheath loader and pin vise. The ADO device was designed to provide the most desirable characteristics for a percutaneous closure device that can be used in most patients with PDA.

 Closure Protocol



All patients underwent routine right and left heart catheterization using a 5F-sheath in the femoral vein. A monoplane anteroposterior and lateral descending aortogram was performed to evaluate the size, position and shape of the ductus [Figure 2]. A 5F or 6F multipurpose catheter was advanced from the venous side into the PDA and placed in the descending aorta. This catheter was exchanged for the delivery sheath (6F) over a 0.035 inch exchange guide wire and the dilator was removed, leaving the sheath in the descending aorta. The loader was introduced into the delivery sheath and without rotation the device was advanced into thedescending aorta. The sheath was retracted until the retention disk was opened in the proximal descending aorta. While maintaining tension on the delivery cable, the introducing sheath was withdrawn into the pulmonary artery to deploy the tubular frame of the prosthesis into the PDA [Figure 3]. With the device still attached to the cable, a descending aortogram was performed in the lateral projection to confirm device position. Once the proper device position was confirmed, the device was released by turning the cable counter clockwise using the pin vise [Figure 4].

 Results



The clinical and haemodynamic data and results of PDA closure are shown in [Table 1]. The mean PDA diameter was 4.1mm (range 2.5mm to 6.5mm) by angiography. The mean pulmonary to systematic flow ratio. (Qp/Qs) was 1.7:1 (range 1.2:1 to 3:1). The closure was achieved from the venous side and the procedure was successful in all the PDAs. Seven patients had trace angiographic residual shunt with foaming through the device with contrast jet.

The mean fluoroscopy time was 13.7 min range (4.5 min. to 30 min.) and the mean total procedure time was 33.6min. (range 20 min to 50 min.)

There was no evidence of obstruction of left pulmonary artery or the descending aorta, as confirmed by 2D-Doppler in the following day follow- up.

No patient required blood transfusion. There were no femoral arterial or venous complications. All patients were discharged home one day after the closure and one patient had residual shunt on Colour Doppler Echocardiography after 24 hours.

Ten out of seventeen patients had completed 6- months and 12-months follow- up and all patients were found to have complete closure with no evidence of device migration, recanalization, thromboembolic episodes, wire fracture, hemolysis or endocarditis.

 Discussion



Transcatheter closure technique using various devices including the Rashkind device, the buttoned device, Gianturco coils and the Botallocluder have been reported with variable success rates. These devices require large sheaths (7F to 16F) which preclude their use in small pediatric patients, except for coiocclusion for which 4F sheath is needed. In this study, we report our initial experience using a new device to close PDA [10] . Transcatheter closure of 10.5 mm and 12 mm PDA with ADO device had been reported and shown to be effective and safe [11],[12] . Immediate and short-term results of PDA closure using ADO are excellent and long-term outcome in these Patients with completely closed PDA have been reported [13] . In our cardiac centre, we implanted two devices after incomplete surgical PDA ligation and the shunt was successfully closed. This saved the patients from another thoracotomy, general anaethesia and the overall hospital stay.

Although some patients had a residual shunt at the end of the procedure. Only one patient had detectable shunt by colour flow mapping after 24 hours of implantation, indicating the advantage of the plug type design of the device for closing PDAs.

 Conclusion



Our initial results reinforce the published initial results by Masura et.al [8] , Hakim et al [15] , confirming that the ADO is safe and effective in closing PDAs. There were no complications during the first 12 months of follow-up.

Acknowledgement:

The authors wish to thank Dr. F. Hakim for teaching us the technique of the PDA closure using the new Amplatzer Duct Occluder.

References

1A. congenital heart disease: a surgical-historical perspective. Ann Thorac Surg 2005 June 79 (6): S 2217-2220.
2Gross RE, Hubbard JP. Surgical Ligation of a patent ductus Arteriosus: report of the first successful case, JAMA 1939;112:729.
3Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of a patent ductus Arteriosus:62 cases treated without thoracotomy. Radiol Clin North Am 1971; 9: 203-18.
4Rashkind WJ, Mullins CE, Hellenbrand WE, et al. Non-surgical closure of patent ductus arteriosus: clinical application of thee Rashkind PDA occluder. Circulation 1987; 75: 583 -92.
5Rao PS, Sideris EB, Hadad J et al. Transcatheter occlusion of patent ductus arteriosus with adjustable buttoned device: initial clinical experience. Circulation 1993;88:1119-26.
6Verin VE, Saveliev VS, Kolody SM, Prokubovski VI. Results of transcatheter closure of the patent ductus arteriosus with Batello occluder. J AM Coll Cardiol 1993;22: 1509-1514.
7Moore JW, George L, Kirkpatrick SE et al. Percutaneous closure of the small patent ductus arteriosus using occluding spring coils. J AM Coll Cardiol 1994; 23: 759-765.
8Masura J, Walsh KP, Thanopoulous B, Chan C, Bass J, Goussou Y, et al. Catheter closure of
9moderate to large sized patent ductus arteriosus using the new Amplatzer duct Occluder: Immediate and short-term results. J Am Coll Cardiol 1998; 31: 878-882.
10Krichenko MD,Lee N,Benson MD. Angiographic Classification of the isolated persistently Patent Ductus Arteriosus and implications for percutaneous Catheter Occlusion. Am J Cardiol 1989 April 1,877-879.
11Vazquez-Anona CA, Vallejo M, Becerra RB, Gonzaler A., Hernandez AB, Barron JV.Treatment of patent ductus arteriosus. Comparison of costs between surgical and trans-catheter closure in a public institution. Arch Cardiol Mex.2004 Oct-Dec;74(4):276-282.
12Jan SL, Hwang B, Fu YC, Chi CS. Transcatheter closure of a large patent ductus arteriosus in a young child using the Amplatzer duct occluder. Pediatr Cardiol 2005 Sep-Oct;26(5):703-706.
13Pass RH,Hijazi Z,Hsu DT, Lewis V, Hellenbrand WE. Multicenter USA Amplatzer patent ductus arteriosus occlusion device trial: initial and one-year results. J AM Coll Cardiol 2004 Aug 4:44(3):513-519.
14Masura J, Tittel P, Gavora P, Podnar T. Long-term outcome of transcathter patent ductus arteriosus closure using Amplatzer duct occluder. Am Heart J. 2006 Mar;151(3):755.e7-755.e10.
15Al-Hakim FA, Harahsheh AS & Hijazi IS. Transcatheter Closure of Persistent Ductus Arteriosus using the Amplatzer Duct Occluder in infants. Pak J Med Sci 2005;21(2):138-142.