TRANSCATHETER PDA CLOSURE USING THE AMPLATZER DUCT OCCLUDER

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TRANSCATHETER PDA CLOSURE USING THE AMPLATZER
DUCT OCCLUDER

• BY
• JAMEEL AL-ATA, MD
• ASSISTANT PROFESSOR and CONSULTANT PEDIATRIC
  CARDIOLOGIST

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INTRO

• Transcatheter closure of the small to moderate
  patent ductus arteriosus utilizing coils is an
  accepted treatment (Hijazi, Galal Int card).
  

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• Addressing the larger PDA using multiple coils
  was shown to be feasible, but not without
  problems (Hizji, gt 4mm PDA, Galal Zeitschrift
  kardiologie).

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INTRO

• The large PDA remained the domain of surgery for
  a while. Only recently the Amplatzer duct occlude
  (ADO) has been introduced as an alternative
  (Masura) ( Saliba)

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• Especially in the younger age and weight group
  there are still relatively few reports describing
  the experience with this device (Alwi JACC 2001)

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The aim of this study

• To present our experience with the ADO to close
  large PDA in a relatively young patients
  population.

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• Special attention was taken to focus on the
  selection of the optimum sized device as well as
  the problems and complications which can be
  encountered while using this device.

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METHODS

• In a clinical study, all 43 patients (29/43
  females, 14/43 males) who underwent attempt of
  transcatheter closure of their patent ductus
  arteriosus using an Amplatzer duct occlud between
  July 2001 and October 2003 were reviewed.

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Inclusion criteria

• All patients who had a PDA, which was judged
  angiographically to be too large for a single
  coil implantation ( gt 3 mm narrowest diameter)
  were included in this study.

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Exclusion criteria

• Patients who underwent transcatheter closure in
  which coils were utilized.
• Had other cardiac anomelies.

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Clinical Examination and Echocardiographic
Evaluation

• All patients underwent complete cardiac
  evaluation including physical examination,
  twelve lead ECG, and a radiogram of the chest.

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Cont.

• Detailed echocardiograms were performed at
  baseline using Hewlett Packard Sonos 5500.

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CONT

• The narrowest diameter of the PDA was measured in
  the ductal view using color Doppler and
  electronic calipers.

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Cont.

• Routine M-mode echo tracings were obtained in the
  parasternal long axis view as recommended by the
  American Association for ECHO.

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Cont.

• Follow-up echocardiograms were performed in most
  before discharge, one month and then 6 months
  after closing the ductus arteriosus.

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Cardiac Catheterization procedure

• In all patients signed consent was obtained from
  their parents. Patients were sedated with
  ketamine and midazolam during the procedure.

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Cont.

• None of the patients received general anesthesia
  or intubation.
• Heparin in a dose of 100 IU/kg was administered

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CONT

• Aortograms performed in straight lateral position
  were reviewed to determine the PDA diameter and
  the type of the ductus was described according to
  the classification of Krichenko.

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Cont.

• The narrowest diameter of the PDA, the aortic
  diameter of the ampulla, the length of the
  ampulla and the mid diameter of the ampulla were
  measured.

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CONT.

• Amplatzer duct occlud of the PDA was performed
  through anterograde approach

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Study group

• The procedure proved successful in 42 patients
  (97.5).
• We used a device of size 6/4 in 21 of the
  patients (50), using the 8/6 device in 10 (24),
  the 10/8 device in 7 (16.5), and the 12/10
  device in 4 (9.5) of the patients.

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Cont.

• In all patients who underwent implantation of
  devices, cefuroxime (30 mg/kg) was administered
  intravenously during the procedure.
• Two more doses were given with the next 24 hours.

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Selection criteria of the ADO

• The duct occluder is offered in five different
  sizes. The first number mentioned on the package
  of the device belongs to the larger diameter of
  the device, which is 2 mm larger than the smaller
  diameter given on the package.

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Cont.

• The larger diameter is usually positioned in the
  aortic end of the ductul ampulla, while the
  smaller diameter is positioned at the pulmonary
  end.

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Cont.

• In the first two patients, we followed the
  recommendation suggesting to use a duct occluder
  in which its smaller diameter (pulmonary end) is
  1-2 mm larger than the narrowest diameter of the
  specific duct.

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Cont.

• In view of the problems we encountered with
  positioning of the second device, we tried to put
  all the measurements of the PDA into
  consideration, while selecting adequate ADO.

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Cont.

• In this specific case,though the Recommendation
  was followed, because of a mismatch between the
  skirt of the device and aortic end of the duct,
  the skirt of the device protruded into the
  descending aorta.

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Cont.

• We therefore measured the narrowest diameter of
  the duct, its length, the largest diameter for
  the aortic end,

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Cont.

• Since it has to accommodate the skirt of the
  device, which is 4 mm larger than the number
  given for the larger (aortic) end of the ADO.

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Cont.

• The mid ductul diameter was also measured, so to
  make sure in case the duct is too long, that the
  larger part of the ADO will fit.

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Results
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Cont.

• All patients were done as a day case.
• None had to be admitted over night.

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• Rate of occlusion
• Immediate occlusion, confirmed angiographically,
  was achieved in 25 (60) patients.
• In another 8 (19), complete occlusion occurred
  some hours after the procedure, as confirmed by
  echocardiography.
• In 33 (79) of the patients, therefore, complete
  occlusion was achieved on the day of the
  procedure.

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• At a further follow-up, of between one week and 6
  months, complete occlusion had occurred in 6 more
  patients.
• At that time, 2 patients had trivial residual
  shunting, while one had a significant residual
  leak.

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Issues pertinent to Procedure

• Mean number of angiographies to visualize the PDA
  before implantation was 1.8 injection (range
  1-7).

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PROBLEMS COMPLICATIONS

• There was no device embolization.
• There was no loss of pulse.
• There was no mortality.

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Cont.

• Waist of coils 3 coils in one
• patient
• Waiste of Amplatzer in two patients
• Pull through of device in three patients

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Cont.

• Kinking of sheath and inability to retrieve a too
  large device.
• Excessive bleeding needing transfusion in one.
• Difficulty in visualizing the large PDA.

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Conclusions

• Transcatheter occlusion of PDA by the ADO has a
  high complete occlusion rate and is effective in
  PDA up to a narrowest diameter of 10 mm and
  probably larger PDAs.

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Cont.

• Especially in the young age group, problems
  complication rate of 30 can be encountered in
  the learning phase.
• The ADO diameter should not exceed the largest
  ampulla diameter of the PDA in order to avoid
  descending aortic obstruction.