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Single Therapeutic Catheterization to Treat Coexisting Coarctation of the Aorta and Patent Ductus Arteriosus
for cardiac amyloidosis: successful one-year outcome despite recurrence of the disease. J Heart Transplant 1988;7:165–167. 2. Valentine HA, Billingham ME. Recurrence of amyloid in a cardiac allograft four months after transplantation. J Heart Transplant 1989;8:337– 341. 3. Hosenpud JD, DeMarco T, Frazier H, Griffith BP, Uretsky BF, Menkis AH, O’Connell JB, Olivari M-T, Valentine HA. Progression of systemic disease and reduced long-term survival in patients with cardiac amyloidosis undergoing heart
transplantation: follow-up results of a multicenter survey. Circulation 1991;84(suppl III):III338 – III-343. 4. Deng M, Park J-W, Roy-Chowdury R, Knieriem H-J, Reinhard U, Heinrich KW. Heart transplantation for restrictive cardiomyopathy: development of cardiac amyloidosis in preexisting monoclonal gammopathy. J Heart Lung Transplant 1992; 11:139–141. 5. Hall R, Hawkins PN. Cardiac transplantation for AL amyloidosis. Br Med J 1994;309:1135 – 1137.
6. Dubrey S, Simms RW, Skinner M, Falk RH. Re-
currence of primary (AL) amyloidosis in a transplanted heart with four-year survival. Am J Cardiol 1995;76:739–741. 7. Saffitz JE, Sazama K, Roberts WC. Amyloidosis limited to small arteries causing angina pectoris and sudden death. Am J Cardiol 1983;51:1234 – 1235. 8. Roberts WC, Waller BF. Cardiac amyloidosis causing cardiac dysfunction: analysis of 54 necropsy patients. Am J Cardiol 1983; 52:137 – 146.
Single Therapeutic Catheterization to Treat Coexisting Coarctation of the Aorta and Patent Ductus Arteriosus Frank F. Ing,
MD,*
William S. McMahon, MD, Greg L. Johnson, and Charles E. Mullins, MD
he coexistence of coarctation of the aorta (COA) and patent T ductus arteriosus (PDA) is well documented.1 Transcatheter treatment of COA and PDA as isolated lesions is also well reported.2 – 10 Balloon dilation of native COA has proven to be safe and efficacious in several large series, especially in children beyond infancy.2 – 6 Successful transcatheter occlusion of small to moderate size PDAs with the Gianturco coil has also been reported.7 – 10 We report a case of a pediatric patient found to have both a COA and PDA who underwent balloon dilation of the COA and coil occlusion of the PDA in a single cardiac catheterization. Review of the English literature revealed no previous reports of this combination of transcatheter interventions during a single catheterization procedure. jjj A 3 12 -year-old boy who was hospitalized with pneumonia also presented with clinical signs of a COA and a PDA which was confirmed with echocardiography. At cardiac catheterization, he was found to have a discrete preductal From the Department of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas. Dr. Ing’s address is: Department of Pediatric Cardiology, Texas Children’s Hospital, 6211 Fannin Street, Houston, Texas 77030. Manuscript received July 16, 1996; revised manuscript received and accepted September 24, 1996.
COA measuring 4.3 mm in diameter and a 44 mm Hg peak systolic gradient (Figure 1). The aortic isthmus diameter measured 11.0 mm. A small type C PDA, based on the criteria of Krichenko,11 with a minimum diameter of 1.5 mm just distal to the COA was visualized. Retrograde balloon dilation of the COA was carried out using a previously described technique.4 Following dilation with a 12-mm Tyshak balloon (B. Braun Medical Inc.,
MD,
G. Wesley Vick,
Bethlehem, Pennsylvania), the gradient decreased to 6 mm Hg (Figure 2). A repeat descending aortogram with a balloon angiographic catheter placed prograde (through a transseptal puncture) demonstrated marked improvement of the COA diameter with no aneurysm or extravasation of contrast noted. Without crossing the COA site, an 0.018-in PlatinumPlus exchanged guidewire (MediTech Inc., Watertown, Massachusetts) with a very soft tip was
FIGURE 1. Descending aortogram in lateral projection demonstrates a discrete coarctation of the aorta (COA) measuring 4.3 mm in diameter. A type C patent ductus arteriosus (PDA) with a minimum diameter of 1.5 mm is visualized just distal to the coarctation. Contrast is seen filling the descending aorta (AoD) and the main pulmonary artery (MPA).
Q1997 by Excerpta Medica, Inc.
0002-9149/97/$17.00 PII S0002-9149(96)00807-7
All rights reserved.
/ 2w19 0792 Mp
535
MD, PhD,
Monday Jan 27 01:40 PM
EL–AJC (v. 79, no. 4 ’97)
0793
535
FIGURE 2. Dilation of the coarctation of the aorta is carried out with a 12-mm diameter balloon dilation catheter advanced in retrograde fashion. A balloon catheter is seen in the ascending aorta transseptally and is used to perform aortograms and measure simultaneous pressures across the coarctation following dilation.
FIGURE 3. Repeat descending aortogram demonstrates marked improvement at the coarctation site. A snare is seen ‘‘holding’’ a 3-mm diameter coil which has slipped too far into the patent ductus arteriosus (PDA) during delivery. Note the PDA diameter has almost doubled (2.9 mm) compared to Figure 1.
advanced through the ductus into the main pulmonary artery (MPA). A Berenstein catheter (Medi-Tech Inc., Watertown, Massachusetts) was advanced into the MPA over the guidewire. An 536
0.038-in gauge, 4-cm length, 3mm diameter Gianturco coil (Cook, Inc., Bloomington, Indiana) was delivered using the ‘‘snare’’ technique described by Sommer.9 However, the coil
THE AMERICAN JOURNAL OF CARDIOLOGYT
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Monday Jan 27 01:40 PM
slipped through the PDA and was retrieved while still secured in the snare. Further inspection and remeasurement of the PDA dimensions showed that the minimum ductal diameter had increased to 2.9 mm following angioplasty (Figure 3). Using the same technique, an 0.038-in gauge, 5-cm length, 5-mm diameter Gianturco coil was then implanted into the PDA and adjusted so that there was no coil protrusion into the aorta. The snare and Berenstein catheter were removed and a repeat descending aortogram demonstrated no evidence of residual shunting across the PDA. The previously dilated COA site measured 9.5 mm (Figure 4). Cephalexin (25 mg/kg) was administered and continued for 24 hours. The patient was discharged the following day with no blood pressure differential between the arms and legs. jjj Although there are case reports of transcatheter treatment of coexisting COA and PDA, the procedures were performed sequentially at different catheterizations.12 – 14 All underwent balloon dilation of the COA first, followed by PDA occlusion at a much later date. This is because of the concern of aortic dissection or aneurysm at the newly dilated coarctation site caused by further catheter or wire manipulation during the ductal occlusion procedure. The concern is legitimate and because the PDAs were all hemodynamically insignificant, the decision to delay the occlusion to allow for healing of the aorta is reasonable. The disadvantage of this strategy is one of cost and inconvenience of an additional cardiac catheterization. Recognizing the potential for dissection in the newly dilated COA site in our patient, coil occlusion of the PDA was carried out with extreme care only after we recognized that passage of a catheter into the more distally located ductus could be accomplished without traversing the dilated COA site. The coil delivery catheter was advanced into the MPA with the aid of a guidewire with a very soft tip. The wire
FEBRUARY 15, 1997
EL–AJC (v. 79, no. 4 ’97)
0793
In conclusion, we report the case of a patient with COA and PDA who underwent cardiac catheterization and successful balloon dilation of a COA and coil occlusion of a PDA during a single procedure.
1. Behrer MR, Peterson FD, Goldring D, Crawford
FIGURE 4. Final descending aortogram demonstrates complete occlusion of the patent ductus arteriosus with a 5-mm diameter coil. The postdilation diameter of the coarctation of the aorta (COA) measured 9.5 mm. No aneurysm or extravasation of contrast is seen.
was advanced with extreme caution such that the soft tip did not distort and there was no resistance during its advancement. The original coil selected was based on the minimum diameter of the PDA as measured on the predilated angiogram. We followed the reported recommendation of using a coil with a helical diameter twice the minimum diameter of the PDA.7,8 The PDA dimensions increased following COA dilation. The first coil slipped into the MPA during delivery but was easily retrieved while still secured in the snare (Figure 3). A repeat angiogram demonstrated the PDA minimum diameter had almost doubled and a larger coil was used. Consistent with a type C ductal configuration, there was little to no aortic ampulla in which to seat the distal coil loops and the snare technique was useful in adjusting the coil position to minimize any protrusion into the aortic flow. While we demonstrate this combination of procedures to be
feasible, several important points are highlighted. First, because of the potential for aneurysm formation or dissection of the aortic wall, we emphasize the importance of not crossing the freshly dilated COA site. This combined procedure was only possible because the PDA was located distal to the COA and could be approached without traversing the COA site. The transseptal approach to reach the proximal descending aorta for follow-up angiograms and simultaneous blood pressures recordings above and below the COA site also avoids further trauma to the dilated site. Second, passage of a catheter into the MPA for PDA occlusion should be performed initially with a guidewire with a very soft tip and the wire should be advanced with extreme caution. Third, it is important to remeasure the PDA minimum diameter following balloon angioplasty of the COA since the PDA dimension may change, as demonstrated in our case.
C. Coarctation of the aorta and associated patent ductus arteriosus. II. Postoperative studies in infants. J Pediatr 1960;56:246–252. 2. Fletcher SE, Nihill MR, Grifka RG, O’Laughlin MP, Mullins CE. Balloon angioplasty of native coarctation of the aorta: midterm follow-up and prognostic factors. J Am Coll Cardiol 1995;25:730– 734. 3. Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol 1990;65:790–792. 4. Rao PS, Galal O, Smith PA, Wilson AD. Five to nine year follow-up of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol 1996;27:462–470. 5. Mendelsohn AM, Lloyd TR, Crowley DC, Sandu SK, Kocis KC, Beekman RH. Late follow-up of balloon angioplasty in children with a native coarctation of the aorta. Am J Cardiol 1994;74:696–700. 6. Lababidi Z. Percutaneous balloon coarctation angioplasty: long-term results. J Interv Cardiol 1992;5:57–61. 7. Lloyd TR, Fedderly R, Mendelsohn AM, Sandhu SK, Beekman RH. Transcatheter occlusion of patent ductus arteriosus with Gianturco coils. Circulation 1993;88:1412–1420. 8. Moore JW, George L, Kirkpatrick SE, Mathewson JW, Spicer RL, Uzark K, Rothman A, Cambier PA, Slack MC, Kirby WC. Percutaneous closure of the small patent ductus arteriosus using occluding spring coils. J Am Coll Cardiol 1994;23:759–765. 9. Sommer RJ, Gutierrez A, Lai WW, Parness IA. Use of preformed nitinol snare to improve transcatheter coil delivery in occlusion of patent ductus arteriosus. Am J Cardiol 1994;94:836–839. 10. Ing FF, Bierman FZ. Percutaneous transcatheter coil occlusion of the patent ductus arteriosus aided by the nitinol snare: further observations. Cardiovasc Interv Radiol 1995;18:222–226. 11. Krichenko A, Benson LN, Burrows P, Moes CAF, McLaughlin P, Freedom RM. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol 1989;63:877–880. 12. Pavlovic D, de Lezo JS, Medina A, Romero M, Hernandez E, Pan M, Tejero I, Melian F. Sequential transcatheter treatment of combined coarctation of aorta and persistent ductus arteriosus. Am Heart J 1992;123:249–250. 13. Galal O, Al-Fadley F, Wilson N. Successful transcatheter closure of patent arterial duct six years after balloon dilatation of coarctation of the aorta. Int J Cardiol 1992;35:123–125. 14. Geggel RL, Hijazi ZM, Rhodes J. Interventional cardiac catheterization therapy for combined coarctation of the aorta and patent ductus arteriosus: successful outcome in two infants. Cathe Cardiovasc Diagn 1996;38:67–70.
CASE REPORTS
/ 2w19 0792 Mp
537
Monday Jan 27 01:40 PM
EL–AJC (v. 79, no. 4 ’97)
0793
537
transplantation: follow-up results of a multicenter survey. Circulation 1991;84(suppl III):III338 – III-343. 4. Deng M, Park J-W, Roy-Chowdury R, Knieriem H-J, Reinhard U, Heinrich KW. Heart transplantation for restrictive cardiomyopathy: development of cardiac amyloidosis in preexisting monoclonal gammopathy. J Heart Lung Transplant 1992; 11:139–141. 5. Hall R, Hawkins PN. Cardiac transplantation for AL amyloidosis. Br Med J 1994;309:1135 – 1137.
6. Dubrey S, Simms RW, Skinner M, Falk RH. Re-
currence of primary (AL) amyloidosis in a transplanted heart with four-year survival. Am J Cardiol 1995;76:739–741. 7. Saffitz JE, Sazama K, Roberts WC. Amyloidosis limited to small arteries causing angina pectoris and sudden death. Am J Cardiol 1983;51:1234 – 1235. 8. Roberts WC, Waller BF. Cardiac amyloidosis causing cardiac dysfunction: analysis of 54 necropsy patients. Am J Cardiol 1983; 52:137 – 146.
Single Therapeutic Catheterization to Treat Coexisting Coarctation of the Aorta and Patent Ductus Arteriosus Frank F. Ing,
MD,*
William S. McMahon, MD, Greg L. Johnson, and Charles E. Mullins, MD
he coexistence of coarctation of the aorta (COA) and patent T ductus arteriosus (PDA) is well documented.1 Transcatheter treatment of COA and PDA as isolated lesions is also well reported.2 – 10 Balloon dilation of native COA has proven to be safe and efficacious in several large series, especially in children beyond infancy.2 – 6 Successful transcatheter occlusion of small to moderate size PDAs with the Gianturco coil has also been reported.7 – 10 We report a case of a pediatric patient found to have both a COA and PDA who underwent balloon dilation of the COA and coil occlusion of the PDA in a single cardiac catheterization. Review of the English literature revealed no previous reports of this combination of transcatheter interventions during a single catheterization procedure. jjj A 3 12 -year-old boy who was hospitalized with pneumonia also presented with clinical signs of a COA and a PDA which was confirmed with echocardiography. At cardiac catheterization, he was found to have a discrete preductal From the Department of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas. Dr. Ing’s address is: Department of Pediatric Cardiology, Texas Children’s Hospital, 6211 Fannin Street, Houston, Texas 77030. Manuscript received July 16, 1996; revised manuscript received and accepted September 24, 1996.
COA measuring 4.3 mm in diameter and a 44 mm Hg peak systolic gradient (Figure 1). The aortic isthmus diameter measured 11.0 mm. A small type C PDA, based on the criteria of Krichenko,11 with a minimum diameter of 1.5 mm just distal to the COA was visualized. Retrograde balloon dilation of the COA was carried out using a previously described technique.4 Following dilation with a 12-mm Tyshak balloon (B. Braun Medical Inc.,
MD,
G. Wesley Vick,
Bethlehem, Pennsylvania), the gradient decreased to 6 mm Hg (Figure 2). A repeat descending aortogram with a balloon angiographic catheter placed prograde (through a transseptal puncture) demonstrated marked improvement of the COA diameter with no aneurysm or extravasation of contrast noted. Without crossing the COA site, an 0.018-in PlatinumPlus exchanged guidewire (MediTech Inc., Watertown, Massachusetts) with a very soft tip was
FIGURE 1. Descending aortogram in lateral projection demonstrates a discrete coarctation of the aorta (COA) measuring 4.3 mm in diameter. A type C patent ductus arteriosus (PDA) with a minimum diameter of 1.5 mm is visualized just distal to the coarctation. Contrast is seen filling the descending aorta (AoD) and the main pulmonary artery (MPA).
Q1997 by Excerpta Medica, Inc.
0002-9149/97/$17.00 PII S0002-9149(96)00807-7
All rights reserved.
/ 2w19 0792 Mp
535
MD, PhD,
Monday Jan 27 01:40 PM
EL–AJC (v. 79, no. 4 ’97)
0793
535
FIGURE 2. Dilation of the coarctation of the aorta is carried out with a 12-mm diameter balloon dilation catheter advanced in retrograde fashion. A balloon catheter is seen in the ascending aorta transseptally and is used to perform aortograms and measure simultaneous pressures across the coarctation following dilation.
FIGURE 3. Repeat descending aortogram demonstrates marked improvement at the coarctation site. A snare is seen ‘‘holding’’ a 3-mm diameter coil which has slipped too far into the patent ductus arteriosus (PDA) during delivery. Note the PDA diameter has almost doubled (2.9 mm) compared to Figure 1.
advanced through the ductus into the main pulmonary artery (MPA). A Berenstein catheter (Medi-Tech Inc., Watertown, Massachusetts) was advanced into the MPA over the guidewire. An 536
0.038-in gauge, 4-cm length, 3mm diameter Gianturco coil (Cook, Inc., Bloomington, Indiana) was delivered using the ‘‘snare’’ technique described by Sommer.9 However, the coil
THE AMERICAN JOURNAL OF CARDIOLOGYT
/ 2w19 0792 Mp
536
VOL. 79
Monday Jan 27 01:40 PM
slipped through the PDA and was retrieved while still secured in the snare. Further inspection and remeasurement of the PDA dimensions showed that the minimum ductal diameter had increased to 2.9 mm following angioplasty (Figure 3). Using the same technique, an 0.038-in gauge, 5-cm length, 5-mm diameter Gianturco coil was then implanted into the PDA and adjusted so that there was no coil protrusion into the aorta. The snare and Berenstein catheter were removed and a repeat descending aortogram demonstrated no evidence of residual shunting across the PDA. The previously dilated COA site measured 9.5 mm (Figure 4). Cephalexin (25 mg/kg) was administered and continued for 24 hours. The patient was discharged the following day with no blood pressure differential between the arms and legs. jjj Although there are case reports of transcatheter treatment of coexisting COA and PDA, the procedures were performed sequentially at different catheterizations.12 – 14 All underwent balloon dilation of the COA first, followed by PDA occlusion at a much later date. This is because of the concern of aortic dissection or aneurysm at the newly dilated coarctation site caused by further catheter or wire manipulation during the ductal occlusion procedure. The concern is legitimate and because the PDAs were all hemodynamically insignificant, the decision to delay the occlusion to allow for healing of the aorta is reasonable. The disadvantage of this strategy is one of cost and inconvenience of an additional cardiac catheterization. Recognizing the potential for dissection in the newly dilated COA site in our patient, coil occlusion of the PDA was carried out with extreme care only after we recognized that passage of a catheter into the more distally located ductus could be accomplished without traversing the dilated COA site. The coil delivery catheter was advanced into the MPA with the aid of a guidewire with a very soft tip. The wire
FEBRUARY 15, 1997
EL–AJC (v. 79, no. 4 ’97)
0793
In conclusion, we report the case of a patient with COA and PDA who underwent cardiac catheterization and successful balloon dilation of a COA and coil occlusion of a PDA during a single procedure.
1. Behrer MR, Peterson FD, Goldring D, Crawford
FIGURE 4. Final descending aortogram demonstrates complete occlusion of the patent ductus arteriosus with a 5-mm diameter coil. The postdilation diameter of the coarctation of the aorta (COA) measured 9.5 mm. No aneurysm or extravasation of contrast is seen.
was advanced with extreme caution such that the soft tip did not distort and there was no resistance during its advancement. The original coil selected was based on the minimum diameter of the PDA as measured on the predilated angiogram. We followed the reported recommendation of using a coil with a helical diameter twice the minimum diameter of the PDA.7,8 The PDA dimensions increased following COA dilation. The first coil slipped into the MPA during delivery but was easily retrieved while still secured in the snare (Figure 3). A repeat angiogram demonstrated the PDA minimum diameter had almost doubled and a larger coil was used. Consistent with a type C ductal configuration, there was little to no aortic ampulla in which to seat the distal coil loops and the snare technique was useful in adjusting the coil position to minimize any protrusion into the aortic flow. While we demonstrate this combination of procedures to be
feasible, several important points are highlighted. First, because of the potential for aneurysm formation or dissection of the aortic wall, we emphasize the importance of not crossing the freshly dilated COA site. This combined procedure was only possible because the PDA was located distal to the COA and could be approached without traversing the COA site. The transseptal approach to reach the proximal descending aorta for follow-up angiograms and simultaneous blood pressures recordings above and below the COA site also avoids further trauma to the dilated site. Second, passage of a catheter into the MPA for PDA occlusion should be performed initially with a guidewire with a very soft tip and the wire should be advanced with extreme caution. Third, it is important to remeasure the PDA minimum diameter following balloon angioplasty of the COA since the PDA dimension may change, as demonstrated in our case.
C. Coarctation of the aorta and associated patent ductus arteriosus. II. Postoperative studies in infants. J Pediatr 1960;56:246–252. 2. Fletcher SE, Nihill MR, Grifka RG, O’Laughlin MP, Mullins CE. Balloon angioplasty of native coarctation of the aorta: midterm follow-up and prognostic factors. J Am Coll Cardiol 1995;25:730– 734. 3. Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol 1990;65:790–792. 4. Rao PS, Galal O, Smith PA, Wilson AD. Five to nine year follow-up of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol 1996;27:462–470. 5. Mendelsohn AM, Lloyd TR, Crowley DC, Sandu SK, Kocis KC, Beekman RH. Late follow-up of balloon angioplasty in children with a native coarctation of the aorta. Am J Cardiol 1994;74:696–700. 6. Lababidi Z. Percutaneous balloon coarctation angioplasty: long-term results. J Interv Cardiol 1992;5:57–61. 7. Lloyd TR, Fedderly R, Mendelsohn AM, Sandhu SK, Beekman RH. Transcatheter occlusion of patent ductus arteriosus with Gianturco coils. Circulation 1993;88:1412–1420. 8. Moore JW, George L, Kirkpatrick SE, Mathewson JW, Spicer RL, Uzark K, Rothman A, Cambier PA, Slack MC, Kirby WC. Percutaneous closure of the small patent ductus arteriosus using occluding spring coils. J Am Coll Cardiol 1994;23:759–765. 9. Sommer RJ, Gutierrez A, Lai WW, Parness IA. Use of preformed nitinol snare to improve transcatheter coil delivery in occlusion of patent ductus arteriosus. Am J Cardiol 1994;94:836–839. 10. Ing FF, Bierman FZ. Percutaneous transcatheter coil occlusion of the patent ductus arteriosus aided by the nitinol snare: further observations. Cardiovasc Interv Radiol 1995;18:222–226. 11. Krichenko A, Benson LN, Burrows P, Moes CAF, McLaughlin P, Freedom RM. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol 1989;63:877–880. 12. Pavlovic D, de Lezo JS, Medina A, Romero M, Hernandez E, Pan M, Tejero I, Melian F. Sequential transcatheter treatment of combined coarctation of aorta and persistent ductus arteriosus. Am Heart J 1992;123:249–250. 13. Galal O, Al-Fadley F, Wilson N. Successful transcatheter closure of patent arterial duct six years after balloon dilatation of coarctation of the aorta. Int J Cardiol 1992;35:123–125. 14. Geggel RL, Hijazi ZM, Rhodes J. Interventional cardiac catheterization therapy for combined coarctation of the aorta and patent ductus arteriosus: successful outcome in two infants. Cathe Cardiovasc Diagn 1996;38:67–70.
CASE REPORTS
/ 2w19 0792 Mp
537
Monday Jan 27 01:40 PM
EL–AJC (v. 79, no. 4 ’97)
0793
537