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Comparison of echocardiographic and angiographic measurement of patent ductus arteriosus and implications for coil closure
388
Abstracts
401B
BETECTIONOF SEPTALCORONARYCOLLATERALSBY DOPPLERCOLORFLOWMAPPINGIS A MARKERFOR ANOMALOUSORI(;INOF THE CORONARYARTERYFROM THE PULMONARYARTERY MicbeleA. FrommeltMD, PeterC. FrommellMD, AndrewN.PelechMD, EIaineMillerRDCS,JeffWilliamson,KarenKinderRDCS.Children's HospitalofWisconsin,MedicalCollegeofWisconsin,Milwaukee
lournal o f the American Society of Echocardiography May-June 1996
401D COMPARISON OF ECHOCARDIOGRAPHIC AND ANGIOGRAPHIC MEASUREMENT OF PATENT DUCTUS ARTERIOSUS AND IMPLICATIONS FOR COIL CLOSURE Michael M. Brook, MD and Phillip Moore, MD Department,of Pediatrics, University of California-San Francisco Coil closure is rapidly becoming the treatment of choice for most patients with patent ductus arteriosus (PDA). Unsuccessful coil closure, however, results in patients undergoing two procedures. We retrospectively evaluated echocardiographic (echo) measurements of PDA size and flow in 30 patients undergoing coil closure from 7/9412/95, to determine criteria which may predict unsuccessful closure. Echo measurements were compared to angiographic / hemodynamic measurements and left heart dimensions were compared to normal values by calculation of Z-scores. Patients were an average of 5.6 y (5mo-15y), with a BSA of 0.8 m 2 (0.3 m2-1,7 m2). Measurement Cath Echo P PDArain diam (mm) 1.9-1:1.4 2.4-+1.7 .096 PDA length (ram) 7.4+3.7 %3+3.2 .682 PDA ampulla (ram) 7.3:t:3.8 5.9-+2.0 .029 LPA diam (ram) 9.15:1.9 11.5+_2.8 .001 DAn diana (ram) 12.5+3.3 12.7+3.2 .527 PDA Sys grad (mmHg) 73.9~20.2 61.5+_25.9 .033 PDA Dias grad (mmHg) 45.75:19.4 29.5+14. I .001 Echo accurately predicted PDA diameter, length, and descending aortic (DAn) diameter, but underestimated PDA ampulla diameter, and PDA gradient. Echo overestimated LPA diameter. Coil embolization was unsuccessful in 2/30 patients. Both patients had a PDA rain diameter of > 4.5 mm (only 1/28 successes), an LA Z-score >1.5 ( onl~ 1/28 successes), retrograde aortic flow throughout diastole (only 1/28 successes), and a left to right shunt >3:1 (0/28 successes). Conclusions: Echo accurately predicts PDA size and length, but underestimates ampulla size and gradient. These dimensions impact catheter/coil size. Echo also accurately predicts DAn diameter but not LPA diameter. Evidence of a high PDA flow by either LA size, retrograde flow, or large calculated shunt at catheterization may predict unsuccessful closure in patients with large PDAs. Further elucidation of potential factors associated with unsuccessfui closure may eliminate unnecessary procedures.
Betweeng/91and 12/95, I0 pts havebeendiagnosedwith anomalousoriginofthe left (n-9) or right(n-I) coronaryarteryfromthe puhnonaryarlerySPA)bytwodimensionaland Dopplerechocm'diographyat the Children'sIlospita[of Wisconsin. Fourof the 1Opts werelessthan 6 masof age,and presentedwitheongeslivehearl failureand a dilatedcardiom?y~pathy:I'he diagnosisof anomalouscoronaryarterywas suspectedand echecardiographywas ableto directlyvisualizethe mmmahmscoronary insertion intothe PAin 3 of4 pta; all pts had retrogradefillingofthe LADbycolor Doppler. The remaining6 pts wereolderat the timeat'diagnosis(mean6.5 yrs), asymptomaticfbnma cm'diovascularstandpoint,and net suspectedof havinganomalous origin of the coronaryarteryfromthe pulmanaryartery.All werereferredfor echecardiographicevaIuationsecondmyto a marmarand/orcardiemegalyon CXR. Standard2-D,pulsedand colorDopplerecho,cardiographywinsperthrmedand revealed wellpreservedveatricularlhnctieain all pts (meanEF 6I/%). ColorDoppler interrogationat'theveatricalarseptnardemonstratedmultipleunusualcoIortroy signals h~all 6 pts; pulsedDopplerrevealeda Imvvelocity,phasiccontinuersflew patternwithdiastolicpredomiaasce.]freseflowsignalsincreasedsuspicionof a colenaryarteryabnormality,and pronrptedmoredetailedviewsto assesstlaecoronary arteries.Imagingafthe insertional'the maanalouscoronaryinto the PA~saspossiblein all pts. Fiveofthe 6 pts hadan anomalousleftcoronaryartery; 1 pt had an anonmlous right coronaryarmry. All pLswithan mlemalousleftcaranaryhad evidenceJbr retrogradetitlingofthe LADbyeater1)opp)er; the rightcoronaryarterywas also dilated thr age. Twooftim6 pts bad mitralvalveprolapse~ith mitralinsufficiency and isolatediscgemiechangesofthe papillarymuscles.Weconcludetlmtthe echoeardiogTaphicdetectionof septat coronarycollateralsis a markerfor anomalans origin el'the coronaryarteryItemthe pulmonaryartery,and shouldimprove recognitionoflhis defectin the older,asymptomaticchildwithwellpreserved ventricalartianction. Thisstudyhighlightsthe impartaneaof perlbrminga complete2D madDopplerechoeardiagramwithcolortroy mappingofthe ventricularseptumfrom multiplevieu~in all pts rel~rredIbr echocardiogrephicstudy.
401C The Abnormal Contralateral Atrioventricular Valve in Mitral and Tricuspid Atresia in Neonates: An Eehocardiographic Study Shanl BarAm, Achi Ludomirsky, Annika Rydberg, Dag E. Teien, Roger P. Vermilion, C. S. Matt Children's Hospital, University of Michigan, Ann Arbor, MI Fontan procedure has become the preferred surgical modality for the treatment of single ventricles. Abnormalities of the mitraI (MV) or tricuspid valve (TV) morphology and/or function may result in early morbidity and mortality. The purpose of this study was to determine the incidence of different types of contralateral atrioventricular valve (AVV) pathologies in mitral and tricuspid valve atresia. We retrospectively reviewed the echocardiographic and Doppler data of 70 consecutive neonates: 50 patients with mitral atresia and 20 patients with tricuspid atresia. Appearance of the papillary muscles, chordae tendinae and valve leaflets was assessed by two independent observers. AVV regurgitation was semiquantitated by color flow Doppler and AVV annulus was measured, indexed to body weight and compared to established normal values. Tricuspid valve abnormalities were found in 12/50 (24%) of patient with mitral atresia. Myxomatous TV-4/50, redundant leaflet-3/50, TV prolapse-2/50 and moderate TV regurgitation-3/50. In 29/50 (58%) TV annulus size was > 95% of predicted normal values. Mitral valve abnormalities were found in 8/20 (40%) of patients with tricuspid atresia. Myxomatous MV-9/20, redundant leaflets-5/20, MV prolapse-4/20. In 18/20 (90%) MV annulus size was > 95% of predicted normal values. Conclusion: Contralateral AVV abnormalities in tricuspid and mitral valve atresia are common and should be assessed carefully before surgical procedures.
401E
INTRAVASCULAR ULTRASOUND STUDIES TO DETERMINE SIZE AND SHAPE OF PATENT DUCTUS ARTERIOSUS AND TO ASSESS EXTENT OF COIL PROTRUSION: COMPARISON WITH ANGIOGRAPHY Ziyad M. Hijazi MD, Gerald R. Marx MD, Robert L. Geggel MD, Steven Schwartz MD, David R. Fulton MD. Tufts-New England Medical Center, Boston, M A Transcatheter coil occlusion (TCC) has become an established method for closure of patent ductus arteriosus (PDA) using single or multiple Gianturco coils. This requires delineation of the size and shape of the PDA. Although angiography can provide measurements of its length and general shape, the exact diameter may be difficult to discern. Therefore we prospectively used intravascular ultrasound (IVUS) pro closure to determine the size and shape of the PDA at its narrowest point. After coil closure, we imaged the desending aorta opposite the ductal ampulla to determine the extent of coil protrusion into the aorta. 22 patients (13 female, 9 male) underwent TCC of PDA. The median age of the patients was 2 yr, (range, 2 months-34 yr.) and median weight was 12.5 kg (range ¢.2-80 kg). IVUS was successfully obtained in all using 3.5F, 30 MHz or 4.8F, 20 MHz catheters. By IVUS, the shape of the narrowest diameter was circular in 12 and oblong in 10 patients while by angiography 18 patients had type A and t w o type B, and one each C and E. The mean + SD PDA diameter by IVUS was 3 . 4 + 0 , 1 mm and by angiography was 3 . 2 ! 0 . 8 ram, p < 0 . 0 2 . There was good correlation between IVUS and angiography y = 0 , 1 X + 0 . 9 , r = 0 . 8 7 . After closure, coils could be seen protruding into the aorta in all patients with a mean percentage of 1 7 4 - 1 1 . 6 % of the aortic diameter. In one patient the coil protruded into more than 5 0 % of the aortic diameter, this was corrected by pushing the coil into the ductal ampulla using a balloon tipped catheter. At a median follow-up interval of 1.2 yr.(range 1-18 months) there has been no clinical evidence of thromboembolic events. Moreover, on mid-term follow-up, the minimal coil protrusion (as assessed by IVUS) into the aorta seems to be benign. We conclude that IVUS is accurate and useful in assessing the size and shape of the narrowest PDA diameter and in guiding TCC of PDA.
Abstracts
401B
BETECTIONOF SEPTALCORONARYCOLLATERALSBY DOPPLERCOLORFLOWMAPPINGIS A MARKERFOR ANOMALOUSORI(;INOF THE CORONARYARTERYFROM THE PULMONARYARTERY MicbeleA. FrommeltMD, PeterC. FrommellMD, AndrewN.PelechMD, EIaineMillerRDCS,JeffWilliamson,KarenKinderRDCS.Children's HospitalofWisconsin,MedicalCollegeofWisconsin,Milwaukee
lournal o f the American Society of Echocardiography May-June 1996
401D COMPARISON OF ECHOCARDIOGRAPHIC AND ANGIOGRAPHIC MEASUREMENT OF PATENT DUCTUS ARTERIOSUS AND IMPLICATIONS FOR COIL CLOSURE Michael M. Brook, MD and Phillip Moore, MD Department,of Pediatrics, University of California-San Francisco Coil closure is rapidly becoming the treatment of choice for most patients with patent ductus arteriosus (PDA). Unsuccessful coil closure, however, results in patients undergoing two procedures. We retrospectively evaluated echocardiographic (echo) measurements of PDA size and flow in 30 patients undergoing coil closure from 7/9412/95, to determine criteria which may predict unsuccessful closure. Echo measurements were compared to angiographic / hemodynamic measurements and left heart dimensions were compared to normal values by calculation of Z-scores. Patients were an average of 5.6 y (5mo-15y), with a BSA of 0.8 m 2 (0.3 m2-1,7 m2). Measurement Cath Echo P PDArain diam (mm) 1.9-1:1.4 2.4-+1.7 .096 PDA length (ram) 7.4+3.7 %3+3.2 .682 PDA ampulla (ram) 7.3:t:3.8 5.9-+2.0 .029 LPA diam (ram) 9.15:1.9 11.5+_2.8 .001 DAn diana (ram) 12.5+3.3 12.7+3.2 .527 PDA Sys grad (mmHg) 73.9~20.2 61.5+_25.9 .033 PDA Dias grad (mmHg) 45.75:19.4 29.5+14. I .001 Echo accurately predicted PDA diameter, length, and descending aortic (DAn) diameter, but underestimated PDA ampulla diameter, and PDA gradient. Echo overestimated LPA diameter. Coil embolization was unsuccessful in 2/30 patients. Both patients had a PDA rain diameter of > 4.5 mm (only 1/28 successes), an LA Z-score >1.5 ( onl~ 1/28 successes), retrograde aortic flow throughout diastole (only 1/28 successes), and a left to right shunt >3:1 (0/28 successes). Conclusions: Echo accurately predicts PDA size and length, but underestimates ampulla size and gradient. These dimensions impact catheter/coil size. Echo also accurately predicts DAn diameter but not LPA diameter. Evidence of a high PDA flow by either LA size, retrograde flow, or large calculated shunt at catheterization may predict unsuccessful closure in patients with large PDAs. Further elucidation of potential factors associated with unsuccessfui closure may eliminate unnecessary procedures.
Betweeng/91and 12/95, I0 pts havebeendiagnosedwith anomalousoriginofthe left (n-9) or right(n-I) coronaryarteryfromthe puhnonaryarlerySPA)bytwodimensionaland Dopplerechocm'diographyat the Children'sIlospita[of Wisconsin. Fourof the 1Opts werelessthan 6 masof age,and presentedwitheongeslivehearl failureand a dilatedcardiom?y~pathy:I'he diagnosisof anomalouscoronaryarterywas suspectedand echecardiographywas ableto directlyvisualizethe mmmahmscoronary insertion intothe PAin 3 of4 pta; all pts had retrogradefillingofthe LADbycolor Doppler. The remaining6 pts wereolderat the timeat'diagnosis(mean6.5 yrs), asymptomaticfbnma cm'diovascularstandpoint,and net suspectedof havinganomalous origin of the coronaryarteryfromthe pulmanaryartery.All werereferredfor echecardiographicevaIuationsecondmyto a marmarand/orcardiemegalyon CXR. Standard2-D,pulsedand colorDopplerecho,cardiographywinsperthrmedand revealed wellpreservedveatricularlhnctieain all pts (meanEF 6I/%). ColorDoppler interrogationat'theveatricalarseptnardemonstratedmultipleunusualcoIortroy signals h~all 6 pts; pulsedDopplerrevealeda Imvvelocity,phasiccontinuersflew patternwithdiastolicpredomiaasce.]freseflowsignalsincreasedsuspicionof a colenaryarteryabnormality,and pronrptedmoredetailedviewsto assesstlaecoronary arteries.Imagingafthe insertional'the maanalouscoronaryinto the PA~saspossiblein all pts. Fiveofthe 6 pts hadan anomalousleftcoronaryartery; 1 pt had an anonmlous right coronaryarmry. All pLswithan mlemalousleftcaranaryhad evidenceJbr retrogradetitlingofthe LADbyeater1)opp)er; the rightcoronaryarterywas also dilated thr age. Twooftim6 pts bad mitralvalveprolapse~ith mitralinsufficiency and isolatediscgemiechangesofthe papillarymuscles.Weconcludetlmtthe echoeardiogTaphicdetectionof septat coronarycollateralsis a markerfor anomalans origin el'the coronaryarteryItemthe pulmonaryartery,and shouldimprove recognitionoflhis defectin the older,asymptomaticchildwithwellpreserved ventricalartianction. Thisstudyhighlightsthe impartaneaof perlbrminga complete2D madDopplerechoeardiagramwithcolortroy mappingofthe ventricularseptumfrom multiplevieu~in all pts rel~rredIbr echocardiogrephicstudy.
401C The Abnormal Contralateral Atrioventricular Valve in Mitral and Tricuspid Atresia in Neonates: An Eehocardiographic Study Shanl BarAm, Achi Ludomirsky, Annika Rydberg, Dag E. Teien, Roger P. Vermilion, C. S. Matt Children's Hospital, University of Michigan, Ann Arbor, MI Fontan procedure has become the preferred surgical modality for the treatment of single ventricles. Abnormalities of the mitraI (MV) or tricuspid valve (TV) morphology and/or function may result in early morbidity and mortality. The purpose of this study was to determine the incidence of different types of contralateral atrioventricular valve (AVV) pathologies in mitral and tricuspid valve atresia. We retrospectively reviewed the echocardiographic and Doppler data of 70 consecutive neonates: 50 patients with mitral atresia and 20 patients with tricuspid atresia. Appearance of the papillary muscles, chordae tendinae and valve leaflets was assessed by two independent observers. AVV regurgitation was semiquantitated by color flow Doppler and AVV annulus was measured, indexed to body weight and compared to established normal values. Tricuspid valve abnormalities were found in 12/50 (24%) of patient with mitral atresia. Myxomatous TV-4/50, redundant leaflet-3/50, TV prolapse-2/50 and moderate TV regurgitation-3/50. In 29/50 (58%) TV annulus size was > 95% of predicted normal values. Mitral valve abnormalities were found in 8/20 (40%) of patients with tricuspid atresia. Myxomatous MV-9/20, redundant leaflets-5/20, MV prolapse-4/20. In 18/20 (90%) MV annulus size was > 95% of predicted normal values. Conclusion: Contralateral AVV abnormalities in tricuspid and mitral valve atresia are common and should be assessed carefully before surgical procedures.
401E
INTRAVASCULAR ULTRASOUND STUDIES TO DETERMINE SIZE AND SHAPE OF PATENT DUCTUS ARTERIOSUS AND TO ASSESS EXTENT OF COIL PROTRUSION: COMPARISON WITH ANGIOGRAPHY Ziyad M. Hijazi MD, Gerald R. Marx MD, Robert L. Geggel MD, Steven Schwartz MD, David R. Fulton MD. Tufts-New England Medical Center, Boston, M A Transcatheter coil occlusion (TCC) has become an established method for closure of patent ductus arteriosus (PDA) using single or multiple Gianturco coils. This requires delineation of the size and shape of the PDA. Although angiography can provide measurements of its length and general shape, the exact diameter may be difficult to discern. Therefore we prospectively used intravascular ultrasound (IVUS) pro closure to determine the size and shape of the PDA at its narrowest point. After coil closure, we imaged the desending aorta opposite the ductal ampulla to determine the extent of coil protrusion into the aorta. 22 patients (13 female, 9 male) underwent TCC of PDA. The median age of the patients was 2 yr, (range, 2 months-34 yr.) and median weight was 12.5 kg (range ¢.2-80 kg). IVUS was successfully obtained in all using 3.5F, 30 MHz or 4.8F, 20 MHz catheters. By IVUS, the shape of the narrowest diameter was circular in 12 and oblong in 10 patients while by angiography 18 patients had type A and t w o type B, and one each C and E. The mean + SD PDA diameter by IVUS was 3 . 4 + 0 , 1 mm and by angiography was 3 . 2 ! 0 . 8 ram, p < 0 . 0 2 . There was good correlation between IVUS and angiography y = 0 , 1 X + 0 . 9 , r = 0 . 8 7 . After closure, coils could be seen protruding into the aorta in all patients with a mean percentage of 1 7 4 - 1 1 . 6 % of the aortic diameter. In one patient the coil protruded into more than 5 0 % of the aortic diameter, this was corrected by pushing the coil into the ductal ampulla using a balloon tipped catheter. At a median follow-up interval of 1.2 yr.(range 1-18 months) there has been no clinical evidence of thromboembolic events. Moreover, on mid-term follow-up, the minimal coil protrusion (as assessed by IVUS) into the aorta seems to be benign. We conclude that IVUS is accurate and useful in assessing the size and shape of the narrowest PDA diameter and in guiding TCC of PDA.