Author + information
- Robert N. Vincent, MD, CM∗ ( and )
- Holly Bauser-Heaton, MD, PhD
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- ↵∗Reprint requests and correspondence:
Dr. Robert N. Vincent, Children's Healthcare of Atlanta, Emory University, 2835 Brandywine Road, Atlanta, Georgia 30341.
In this issue of JACC: Cardiovascular Interventions, Zahn et al. (1) discuss transcatheter closure of patent ductus arteriosus (actually persistent ductus arteriosus [PDA]) in extremely premature infants. This represents another step in the long history of intervention on this lesion. The first successful surgical ligation of PDA occurred August 26, 1938, by Dr. Gross at Boston Children’s Hospital (2). This was the first successful surgical treatment of any congenital heart defect and led the way to the development of techniques and cardiovascular procedures that we have today.
Having established the safety and efficacy of PDA ligation, this technique became the norm for infants and children needing ductal closure. Beginning in 1966, early cardiologists sought to apply catheter techniques to occlude the ductus in children (3). In 1979, Rashkind (4) reported the first successful transcatheter closure in a 3,500-g child. During the following decades, a number of devices were developed that could be placed with a catheter, avoiding the need for surgery and an invasive thoracotomy (5,6). However, these devices required large-size catheters and were not appropriate for small babies. In the early 90s, the use of coils to occlude PDAs became the procedure of choice in many institutions for patients with small-to-moderate PDAs and even some large PDAs (7,8). These coils were general vascular embolization coils not specifically intended for PDA occlusion, but which nonetheless were found to be very effective, and are still used today.
It was not until 2003 that a new device specifically made for PDA occlusion was developed and approved by the Food and Drug Administration (9). The Amplatzer Duct Occluder (AGA Medical Corporation, Golden Valley, Minnesota) became the preferred device for PDA occlusion for patients with moderate-to-large PDAs in most centers. However, it still required a 5- to 6-F sheath, which was fairly stiff and difficult to use, especially in babies <2.5 kg. The introduction of the Amplatzer Duct Occluder II and the Amplatzer Vascular Plugs (10,11), which use thinner wires and do not have a polyester core, allowed for smaller introducer sheaths and less stiff catheters, and opened the door to attempting ductal occlusion on smaller infants. The issue that remained was concern over femoral arterial access in order to angiographically assess and guide device position. The use of echocardiography as an alternative imaging modality was previously reported (12), but now Zahn et al. (1) have put these 2 technologies together in order to perform this procedure in the very premature and small newborns and infants.
In this report, the authors describe their experience utilizing this approach in 24 infants weighing 755 to 2,380 g. These infants were selected on the basis of ductal anatomy (only a ductus of >6 mm in length due to the length of the closure device), and no patient was excluded on the basis of body size, age, severity of illness, or ductal diameter. Although the procedures were first performed in the cardiac catheterization laboratory, the last 5 procedures transitioned to the bedside using a portable C-arm and echocardiographic guidance. There was 88% procedural success (3 patients had device removal during the procedure due to the device causing left pulmonary artery stenosis) and 96% survival to discharge with the single late death being unrelated to the catheter procedure. Of the 21 patients with device insertion and release, there were 3 instances of device malposition, 2 being treated with device repositioning during the same procedure and 1 with a stent placed in the left pulmonary artery afterwards during a second procedure. One of the patients requiring extensive device repositioning had septal dyskinesia with need for reintubation but did well following discharge. Follow-up echocardiograms demonstrated complete ductal occlusion in all patients, no new aortic or pulmonary artery stenosis and normal ventricular function.
Zahn et al. (1) are to be congratulated for these excellent results. They have shown what can be safely accomplished by a group of highly trained and skilled individuals. The manipulation of catheters in these extremely small and fragile infants by the catheterizing physician, quick response to device malposition outside of the comfort of the cardiac catheterization lab, the ability to image the exact location of the device by the imaging physician, along with the communication between these individuals is all paramount in the success of this procedure.
The performance of this procedure at the bedside is consistent with the transition from the traditional catheterization laboratory of the past to the use of multimodality imaging required for complex interventions either before or during procedures, combined with new areas where the procedures are being performed: balloon atrial septostomy at the bedside (13), bedside balloon aortic valvuloplasty in newborns with critical aortic stenosis (14), hybrid surgical labs, combined magnetic resonance imaging and fluoroscopic areas, and magnetic resonance imaging stand-alone catheterization suites.
We look forward to seeing the next advances as our patients continue to get smaller and the interventions more complex.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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