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Closure of residual patent ductus arteriosus with occluding spring coil after implant of a Rashkind occluder
Volume 127, Number 4, Part 1 American Heart Journal
5.
6.
Moore, George, and Kirkpatrick
Rao PS, Wilson AD, Levy JM, Gupta VK, Chopra PS. Role of “buttoned” double-disc device in the management of atria1 septal defects. AM HEART J 1992;123:191-200. Rao PS, Wilson AD, Chopra PS. Transcatheter closure of atria1 septal defects by “buttoned” devices. Am J Cardiol 1992;69:1056-61.
7.
a.
Sideris EB, Sideris SE, Ehly RL. Occlusion of patent ductus arteriosus in piglets by a double-disc self-adjustable device [Abstract]. J Am Co11Cardiol 1990;15:24OA. Rao PS, Wilson AD, Sideris EB, Chopra PS. Transcatheter closure of patent ductus arteriosus with “buttoned” device: first successful clinical application in a child. AM HEART J 1991;121:1799-820.
Rao PS, Sideris EB, Haddad J, Rey C, Hausdorf G. A new adjustable buttoned device for transcatheter occlusion of patent ductus arteriosus: initial clinical experience [Abstract]. Pediatr Res 1993;33:25A. 10. Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968;30:4-13. 11. Hang CL, Sullebarger JT. Patent ductus arteriosus presenting in old age. Cathet Cardiovasc Diagn 1993;2&228-30. 9.
Closure of residual patent ductus arteriosus with occluding spring coil after implant of a Rashkind occluder John W. Moore, MD, Lily George, MD, and Stanley E. Kirkpatrick, MD Sun Diego, Calif. Percutaneous closure of patent ductus arteriosus (PDA) by the Rashkind double-umbrella occlusion system has been extensively studied. 1-3Late follow-up evaluations have re-
vealed a significant occurrenceof residual device “leaks.” From
the Division
Reprint requests: Way, San Diego, Ahl HEART
of Cardiology, John W. Moore, CA 92123.
Children’s
Hospital,
MD, Children’s
San Diego.
Hospital,
3020 Children’s
J 1994;127:943-5.
Copyright 6 1994 0002~8793/94/$3.00
by Mosby-Year + 0 4/4/52086
Book,
Inc.
Fig. 1. Lateral
aortogram
showing
943
Some patients with residual PDAs eventually have spontaneousclosure, and others have undergonesuccessfulocclusionwith a secondRashkind device. However, many residual PDAs persist for years and may be too small for closure by a secondRashkind device. Becauseof our success with closure of small native PDAs,~,5 we have considered patients with residual PDAs after implantation of a Rashkind device to be candidatesfor closureby occluding spring coils. This report describesa patient who had successful closureof a post-Rashkind residual PDA by placement of an occluding spring coil. The patient wasinitially evaluated at 6 years of ageand was found to have an isolated PDA. In March 1988 at age 7 years, she had cardiac catheterization and placement of an I2 mm Rashkind PDA occluder as a participant in the Food and Drug Administration-approved protocol. Before the Rashkind device was delivered, her PDA was characterized asfollows: smallestinternal dimensionequal to 2.6 mm, normal pulmonary artery pressure,and ratio of pulmonary to systemic blood flow (&p/&s) equal to 1.5. The Rashkind device was placed without problems,and there wereno complicationsof the procedure.After implantation of the device, aortography showeda small residualleak. On follow-up outpatient evaluations the patient was noted to have a persisting continuous heart murmur; echocardiography confirmed a residual small PDA in spite of good position of the Rashkind device. The patient had no clinical problemsand subacutebacterial endocarditis prophylaxis wascontinued. In March 1993(5 years after the placement of the Rashkind device), the family requested closure of the residual PDA. Color flow imaging demonstrated a singleresidual PDA jet with width < 2.5 mm. Becausethe patient met our selectioncriteria for a native PDA, closure of the residual PDA with an occluding spring coil was recommended.The parents provided informed consent for the procedure in accordance with our institutional policy. The patient wasadmitted to Children’s Hospital on the
Rashkind
PDA occluder
with residual
PDA.
944
April
Moore, George, and Kirkpatrick
Fig. 2. Lateral
aortogram
American
showing
Cook occluding
morning of the procedure. She was taken to the catheterization laboratory and received ketamine sedation, and cefazolin prophylaxis appropriate for her weight. Sheaths (5F) were placed in the femoral artery and vein. Heparin, 100 U/kg, was administered intravenously. Routine right heart pressures and saturations were measured. An aortogram was performed via a 5F pigtail catheter in the anterior and go-degree lateral projections (Fig. 1). The size of the residual PDA was measured by using magnification correction from the known catheter dimension, and angiographic characteristics and landmarks were determined. The residual PDA was crossed from the aortic end with an 0.035-inch straight wire guided by a 5.2F Judkins right coronary catheter. The catheter was advanced over the wire into the main pulmonary artery with slight resistance as it passed across the PDA. By using the lateral aortogram as a road map and the previously implanted Rashkind device as a landmark, an occluding spring coil (Cook Inc., Bloomington, Ind., No. MCE 38-3-4) was positioned in the PDA with our previously described procedure.4, 5 Aortography was performed 10 minutes after the procedure. Subsequently the patient was taken to the recovery unit. Cefazolin prophylaxis was completed, and echocardiography with color flow study and chest radiograph were obtained 4 hours after completion of catheterization. The patient recovered uneventfully and was discharged 6 hours after catheterization. The patient’s residual PDA had smallest internal angiographic dimension of 1.2 mm. Her pulmonary artery pressure was normal, and there was no measurable increase in pulmonary blood flow by oximetry. We were able to place the embolus without difficulty with one loop in the main pulmonary artery and one loop in the aortic diverticulum. The follow-up aortogram (Fig. 2)
spring
coil closing residual
Heart
1994
Journal
PDA.
and the color flow study show complete occlusion of the residual PDA. Fluoroscopy time for this procedure was 14 minutes. Long-term studies of patients having PDA occlusion by Rashkind devices have shown an incidence of residual PDAs ranging from 21 to 34 percent 6 months to 1 year after device placement. After 30 to 40 months (and in amenable cases, placement of a second Rashkind device) the incidence of residual leaks remains significant at 5.2% to 8% .2, 3 Although some authors have argued that small residual PDAs have little risk of endarteritis and may not need closure,6 most authorities recommend closure of PDAs regardless of hemodynamic significance. Furthermore, the presence of an intravascular foreign body in association with a residual PDA arguably could increase vulnerability to endarteritis rather than decrease it. We have reported the use of occluding spring coils of small native PDAs.~, 5 In those reports, we speculated that an additional application of occluding spring coils might be closure of residual PDAs after implant of a Rashkind device. This case demonstrates that closure of post-Rashkind residual PDAs may be performed successfully and safely by occluding spring coils.
REFERENCES
1. Rashkind WJ, Mullins CE, Hellenbrand WE, Trait MA. Nonsurgical closure of patent ductus arteriosus: clinical application of Rashkind PDA occluder system. Circulation 1987; 75:583-92. 2. Hosking MC, Benson LN, Musewe N, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus: forty-month follow-up and prevalence of residual shunting. Circulation 1991;84:2313-7.
Volume 127, Number 4, Part 1 American Heart Journal
Kempler
Tynan M, Members of the European Registry Group. Transcatheter occlusion of persistent arterial duct: report of the European Registry. Lancet 1992;340:1062-6. Cambier PA, Kirby WC, Wortham DC, Moore JW. Percutaneous closure of the small patent ductus arteriosus using coil embolization. Am J Cardiol 1992;69:815-6. Moore JW, Spicer RL, Kirby WC. Percutaneous closure of very small patent ductus arteriosus (PDA) by occluding spring emboli [Abstract]. J Am Co11 Cardiol 1993;21:446A. Latson LA. Residual shunts after transcatheter closure of patent ductus arteriosus: a major concern or benign “Technomalady”? Circulation 1991;84:2591-3.
Direct current fibrillation
induction
of atrial
Pal Kempler, MD, William J. Hayes, MD, Kathy R. Dezern, RVMT, Jan R. Tuntelder, BS, Robert Splinter, MS, Robert H. Svenson, MD, and Laszlo Littmann, MD Charlotte, IV. C. From the Laser and stitute, Charlotte. Supported in part OTKA I/3-1081.
Applied
Technologies
by a grant
from
Laboratory,
the Hungarian
Reprint requests: Laszlo Littmann, MD, Laboratory, Carolinas Heart Institute, J 1994;127:945-6.
Copyright ‘J 1994 0002~8703/94/$3.00
by Mosby-Year + 0 4/4/62093
Book,
Academy
Laser and Applied P.O. Box 32861,
28232.
AM HEAW
Carolinas
Inc.
Heart
In-
of Sciences, Technologies Charlotte, NC
et at.
945
Catheter electrode induction of atria1 fibrillation (AF) is frequently used during electrophysiologic evaluation of Wolff-Parkinson-White syndrome1 and for selecting the most appropriate pacing modality in certain patients undergoing permanent pacemaker implantation.” AF induction during electrophysiologic testing is usually performed by rapid burst pacing at the right atria1 endocardium with alternate current (AC) via a multipolar catheter electrode. The purpose of this experimental study was to test the potential of direct current (DC) as opposed to AC as a simple tool to induce AF in dogs. Five healthy mongrel dogs underwent a right lateral thoracotomy while under general anesthesia. In each dog a bipolar electrode with an interelectrode distance of 3 mm was sutured to the epicardial surface of the right atria1 free wall. In addition, a 6F bipolar catheter with an interelectrode distance of 8 mm was advanced to the high right atria1 endocardial surface through a femoral vein under fluoroscopic guidance. Contact pressures were not measured with either the epicardial or endocardial method. DC was applied by means of a commercially available 9 V battery (Procell; Duracell USA, Bethel, Conn.). The current between the two tip electrodes of the pacing catheters measured 10 mA. For AF induction, the proximal plugs of the catheters were simply connected to the positive and negative poles of the battery by hand for 0.7 to 15.2 seconds (mean, 4.3 k 3.5 seconds). A total of 58 DC applications were tested, 36 epicardial and 22 endocardial. AF was instantaneously induced in all dogs (Figs. 1 and 2). After termination of DC stimulation, AF lasted for 0.5 to 90.8 seconds (mean, 13.4 + 23.9 seconds). AF was confirmed by visual inspection of atria1 activity, the typical surface ECG
Fig. 1. Endocardial catheter induction of AF by DC with a commercial 9 V battery. Arrows indicate onset and offset of DC stimulation. Solid Circle shows spontaneous termination of AF. ECG lead II, 25 mm/set, 16 mm/mV.
5.
6.
Moore, George, and Kirkpatrick
Rao PS, Wilson AD, Levy JM, Gupta VK, Chopra PS. Role of “buttoned” double-disc device in the management of atria1 septal defects. AM HEART J 1992;123:191-200. Rao PS, Wilson AD, Chopra PS. Transcatheter closure of atria1 septal defects by “buttoned” devices. Am J Cardiol 1992;69:1056-61.
7.
a.
Sideris EB, Sideris SE, Ehly RL. Occlusion of patent ductus arteriosus in piglets by a double-disc self-adjustable device [Abstract]. J Am Co11Cardiol 1990;15:24OA. Rao PS, Wilson AD, Sideris EB, Chopra PS. Transcatheter closure of patent ductus arteriosus with “buttoned” device: first successful clinical application in a child. AM HEART J 1991;121:1799-820.
Rao PS, Sideris EB, Haddad J, Rey C, Hausdorf G. A new adjustable buttoned device for transcatheter occlusion of patent ductus arteriosus: initial clinical experience [Abstract]. Pediatr Res 1993;33:25A. 10. Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968;30:4-13. 11. Hang CL, Sullebarger JT. Patent ductus arteriosus presenting in old age. Cathet Cardiovasc Diagn 1993;2&228-30. 9.
Closure of residual patent ductus arteriosus with occluding spring coil after implant of a Rashkind occluder John W. Moore, MD, Lily George, MD, and Stanley E. Kirkpatrick, MD Sun Diego, Calif. Percutaneous closure of patent ductus arteriosus (PDA) by the Rashkind double-umbrella occlusion system has been extensively studied. 1-3Late follow-up evaluations have re-
vealed a significant occurrenceof residual device “leaks.” From
the Division
Reprint requests: Way, San Diego, Ahl HEART
of Cardiology, John W. Moore, CA 92123.
Children’s
Hospital,
MD, Children’s
San Diego.
Hospital,
3020 Children’s
J 1994;127:943-5.
Copyright 6 1994 0002~8793/94/$3.00
by Mosby-Year + 0 4/4/52086
Book,
Inc.
Fig. 1. Lateral
aortogram
showing
943
Some patients with residual PDAs eventually have spontaneousclosure, and others have undergonesuccessfulocclusionwith a secondRashkind device. However, many residual PDAs persist for years and may be too small for closure by a secondRashkind device. Becauseof our success with closure of small native PDAs,~,5 we have considered patients with residual PDAs after implantation of a Rashkind device to be candidatesfor closureby occluding spring coils. This report describesa patient who had successful closureof a post-Rashkind residual PDA by placement of an occluding spring coil. The patient wasinitially evaluated at 6 years of ageand was found to have an isolated PDA. In March 1988 at age 7 years, she had cardiac catheterization and placement of an I2 mm Rashkind PDA occluder as a participant in the Food and Drug Administration-approved protocol. Before the Rashkind device was delivered, her PDA was characterized asfollows: smallestinternal dimensionequal to 2.6 mm, normal pulmonary artery pressure,and ratio of pulmonary to systemic blood flow (&p/&s) equal to 1.5. The Rashkind device was placed without problems,and there wereno complicationsof the procedure.After implantation of the device, aortography showeda small residualleak. On follow-up outpatient evaluations the patient was noted to have a persisting continuous heart murmur; echocardiography confirmed a residual small PDA in spite of good position of the Rashkind device. The patient had no clinical problemsand subacutebacterial endocarditis prophylaxis wascontinued. In March 1993(5 years after the placement of the Rashkind device), the family requested closure of the residual PDA. Color flow imaging demonstrated a singleresidual PDA jet with width < 2.5 mm. Becausethe patient met our selectioncriteria for a native PDA, closure of the residual PDA with an occluding spring coil was recommended.The parents provided informed consent for the procedure in accordance with our institutional policy. The patient wasadmitted to Children’s Hospital on the
Rashkind
PDA occluder
with residual
PDA.
944
April
Moore, George, and Kirkpatrick
Fig. 2. Lateral
aortogram
American
showing
Cook occluding
morning of the procedure. She was taken to the catheterization laboratory and received ketamine sedation, and cefazolin prophylaxis appropriate for her weight. Sheaths (5F) were placed in the femoral artery and vein. Heparin, 100 U/kg, was administered intravenously. Routine right heart pressures and saturations were measured. An aortogram was performed via a 5F pigtail catheter in the anterior and go-degree lateral projections (Fig. 1). The size of the residual PDA was measured by using magnification correction from the known catheter dimension, and angiographic characteristics and landmarks were determined. The residual PDA was crossed from the aortic end with an 0.035-inch straight wire guided by a 5.2F Judkins right coronary catheter. The catheter was advanced over the wire into the main pulmonary artery with slight resistance as it passed across the PDA. By using the lateral aortogram as a road map and the previously implanted Rashkind device as a landmark, an occluding spring coil (Cook Inc., Bloomington, Ind., No. MCE 38-3-4) was positioned in the PDA with our previously described procedure.4, 5 Aortography was performed 10 minutes after the procedure. Subsequently the patient was taken to the recovery unit. Cefazolin prophylaxis was completed, and echocardiography with color flow study and chest radiograph were obtained 4 hours after completion of catheterization. The patient recovered uneventfully and was discharged 6 hours after catheterization. The patient’s residual PDA had smallest internal angiographic dimension of 1.2 mm. Her pulmonary artery pressure was normal, and there was no measurable increase in pulmonary blood flow by oximetry. We were able to place the embolus without difficulty with one loop in the main pulmonary artery and one loop in the aortic diverticulum. The follow-up aortogram (Fig. 2)
spring
coil closing residual
Heart
1994
Journal
PDA.
and the color flow study show complete occlusion of the residual PDA. Fluoroscopy time for this procedure was 14 minutes. Long-term studies of patients having PDA occlusion by Rashkind devices have shown an incidence of residual PDAs ranging from 21 to 34 percent 6 months to 1 year after device placement. After 30 to 40 months (and in amenable cases, placement of a second Rashkind device) the incidence of residual leaks remains significant at 5.2% to 8% .2, 3 Although some authors have argued that small residual PDAs have little risk of endarteritis and may not need closure,6 most authorities recommend closure of PDAs regardless of hemodynamic significance. Furthermore, the presence of an intravascular foreign body in association with a residual PDA arguably could increase vulnerability to endarteritis rather than decrease it. We have reported the use of occluding spring coils of small native PDAs.~, 5 In those reports, we speculated that an additional application of occluding spring coils might be closure of residual PDAs after implant of a Rashkind device. This case demonstrates that closure of post-Rashkind residual PDAs may be performed successfully and safely by occluding spring coils.
REFERENCES
1. Rashkind WJ, Mullins CE, Hellenbrand WE, Trait MA. Nonsurgical closure of patent ductus arteriosus: clinical application of Rashkind PDA occluder system. Circulation 1987; 75:583-92. 2. Hosking MC, Benson LN, Musewe N, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus: forty-month follow-up and prevalence of residual shunting. Circulation 1991;84:2313-7.
Volume 127, Number 4, Part 1 American Heart Journal
Kempler
Tynan M, Members of the European Registry Group. Transcatheter occlusion of persistent arterial duct: report of the European Registry. Lancet 1992;340:1062-6. Cambier PA, Kirby WC, Wortham DC, Moore JW. Percutaneous closure of the small patent ductus arteriosus using coil embolization. Am J Cardiol 1992;69:815-6. Moore JW, Spicer RL, Kirby WC. Percutaneous closure of very small patent ductus arteriosus (PDA) by occluding spring emboli [Abstract]. J Am Co11 Cardiol 1993;21:446A. Latson LA. Residual shunts after transcatheter closure of patent ductus arteriosus: a major concern or benign “Technomalady”? Circulation 1991;84:2591-3.
Direct current fibrillation
induction
of atrial
Pal Kempler, MD, William J. Hayes, MD, Kathy R. Dezern, RVMT, Jan R. Tuntelder, BS, Robert Splinter, MS, Robert H. Svenson, MD, and Laszlo Littmann, MD Charlotte, IV. C. From the Laser and stitute, Charlotte. Supported in part OTKA I/3-1081.
Applied
Technologies
by a grant
from
Laboratory,
the Hungarian
Reprint requests: Laszlo Littmann, MD, Laboratory, Carolinas Heart Institute, J 1994;127:945-6.
Copyright ‘J 1994 0002~8703/94/$3.00
by Mosby-Year + 0 4/4/62093
Book,
Academy
Laser and Applied P.O. Box 32861,
28232.
AM HEAW
Carolinas
Inc.
Heart
In-
of Sciences, Technologies Charlotte, NC
et at.
945
Catheter electrode induction of atria1 fibrillation (AF) is frequently used during electrophysiologic evaluation of Wolff-Parkinson-White syndrome1 and for selecting the most appropriate pacing modality in certain patients undergoing permanent pacemaker implantation.” AF induction during electrophysiologic testing is usually performed by rapid burst pacing at the right atria1 endocardium with alternate current (AC) via a multipolar catheter electrode. The purpose of this experimental study was to test the potential of direct current (DC) as opposed to AC as a simple tool to induce AF in dogs. Five healthy mongrel dogs underwent a right lateral thoracotomy while under general anesthesia. In each dog a bipolar electrode with an interelectrode distance of 3 mm was sutured to the epicardial surface of the right atria1 free wall. In addition, a 6F bipolar catheter with an interelectrode distance of 8 mm was advanced to the high right atria1 endocardial surface through a femoral vein under fluoroscopic guidance. Contact pressures were not measured with either the epicardial or endocardial method. DC was applied by means of a commercially available 9 V battery (Procell; Duracell USA, Bethel, Conn.). The current between the two tip electrodes of the pacing catheters measured 10 mA. For AF induction, the proximal plugs of the catheters were simply connected to the positive and negative poles of the battery by hand for 0.7 to 15.2 seconds (mean, 4.3 k 3.5 seconds). A total of 58 DC applications were tested, 36 epicardial and 22 endocardial. AF was instantaneously induced in all dogs (Figs. 1 and 2). After termination of DC stimulation, AF lasted for 0.5 to 90.8 seconds (mean, 13.4 + 23.9 seconds). AF was confirmed by visual inspection of atria1 activity, the typical surface ECG
Fig. 1. Endocardial catheter induction of AF by DC with a commercial 9 V battery. Arrows indicate onset and offset of DC stimulation. Solid Circle shows spontaneous termination of AF. ECG lead II, 25 mm/set, 16 mm/mV.