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Presentation on theme: "TRANSCATHETER PDA CLOSURE USING THE AMPLATZER DUCT OCCLUDER"— Presentation transcript:


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

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

4 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)

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

6 The aim of this study: To present our experience with the ADO to close large PDA in a relatively young patients population.

7 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.

8 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.

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

10 Exclusion criteria: Patients who underwent transcatheter closure in which coils were utilized. Had other cardiac anomelies.

11 Clinical Examination and Echocardiographic Evaluation:
All patients underwent complete cardiac evaluation; including physical examination, twelve lead ECG, and a radiogram of the chest.

12 Cont.: Detailed echocardiograms were performed at baseline using Hewlett Packard Sonos 5500.

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

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

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

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

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

18 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.

19 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.

20 CONT.: Amplatzer duct occlud of the PDA was performed through anterograde approach

21 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.

22 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.






28 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.

29 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.

30 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.

31 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.

32 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.

33 Cont.: We therefore measured the narrowest diameter of the duct, its length, & the largest diameter for the aortic end,

34 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.

35 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.


37 Results:

38 Age (years) 3.79 ± 3.82 (0.45 - 13) Sex Weight (kilograms)
29 females, 14 males Weight (kilograms) 11.9 ± 8.91 (4.5 – 44) Height (centimeters) 83.6 ± (59 – 154)

39 Systolic pulmonary arterial pressure (millimeters of mercury)
± (17-87) Systolic aortic pressure  (millimetres of mercury) 88 ± (59-115) Ratio of pulmonary to systemic flows 2.43 ± (1-7.6) Index of pulmonary arteriolar resistance (Wood units) 3.29 ± ( )

40 Time required for fluoroscopy (minutes) 16.9 ± 7.8 (5.6-36.7)
± ( ) Overall procedural time ± (46-169) Contrast used (milligrams per kilogram) ± ( ) Narrowest diameter of duct (millimetres) ± ( ) Largest diameter at the aortic ampulla ± (8-21) Diameter at the mid-ampulla ± (5.9-15) Total length of the duct ± (6-21.8)

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

42 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.

43 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.

44 Issues pertinent to Procedure:
Mean number of angiographies to visualize the PDA before implantation was 1.8 injection (range 1-7).

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

46 Cont.: Waist of coils 3 coils in one patient
Waiste of Amplatzer in two patients Pull through of device in three patients

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

48 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.

49 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.


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