Transfemoral closure of patent ductus arteriosus in adult patients

Transfemoral closure of patent ductus arteriosus in adult patients

International Journal of Cardiology, 39 (1993) 18I - 186 0 1993 Elwier 181 Scientific Publishers Ireland Ltd. All rights reserved. 016%5273/93/%06...

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International Journal of Cardiology, 39 (1993) 18I - 186

0 1993 Elwier

181

Scientific Publishers Ireland Ltd. All rights reserved. 016%5273/93/%06.00

CARD10 01697

Transfemoral closure of patent ductus arteriosus in adult patients Philipp Bonhoeffera, Adele Borghi”, Eustaquio Onoratob and Mario Carminati” “Department

of Cardiology, Ospedoli Riuniti di Bergamo. Italy and bDepartment of Cardiology, Centro Maian, San Donato Milanese, holy

(Received 21 September 1992; revision accepted 11 January 1993)

Patent ductus arteriosus is an uncommon anomaly in adult patients. Surgical closure of patent ductus arteriosus in this age group presents difficult problems to.the surgeon. We report our experience of 21 adult patients (19-62 years of age, mean 40 years) who underwent closure of the ductus by transfemoral implantation of a Rashkind double umbrella device. The patients came to light because of atria1 fibrillation, congestive heart failure, residual flow after surgical ligation of the duct or because of incidental diagnosis made during physical examination or chest X-ray. In ten patients the pulmonary arterial pressure was normal (systolic pressure < 30 mmHg), in eleven it was elevated (systolic pressure from 30 to 100 mmHg, mean 50 mmHg). In seven patients the duct was clearly calcified and the size of the duct varied from 3 to 9 mm (mean 4.3 mm). In 16 patients the ductus resulted perfectly closed after implantation of the first double umbrella device, two patients had minimal residual aortopulmonary flow, whereas in three patients the residual shunt was significant; two of these also developed haemolysis and went to surgery, in the latter the shunt was completely abolished after implantation of a second 17-mm device 16 months later. In conclusion transcatheter closure of patent ductus arteriosus in adults is feasible, even in the presence of calcifications and/or pulmonary hypertension; taking into account the significant surgical risk, PDA umbrella closure should be considered the first choice procedure in this group of patients. Key words: Umbrella occlusion; Ductus arteriosus; Adult

Introduction Patent ductus arteriosus is now an uncommon anomaly in adults, since it is usually treated in childhood; some patients tolerate this anomaly well into adult life and the diagnosis is made only incidentally or with the onset of symptoms. The most common clinical sign is heart-failure but also Correspondence to: Philipp Bonhoeffer, Department of Cardiology, Ospedali Riuniti di Bergamo, Largo Barozzi I, 24100 Bergamo, Italy.

other symptoms have been described [1,2]. Surgical closure of the ductus in the adult is still controversial and the indications are not well defined. The improvement in symptoms following duct closure in the adult is not always well predicted and there are relatively higher risks of surgery associated with calcification of the duct [3-61. Transfemoral ductal closure is already a well established technique in children but reports about successful closure in adults are still rare [7-91. We report our experience of transcatheter closure of patent ductus arteriosus in 21 adult patients.

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Materials and Methods Between October 1990 and October 1992, 21 patients between 19 and 62 years of age (mean 40 years) and between 50 and 90 kg in weight (mean 74 kg) underwent transfemoral closure of patent ductus arteriosus in the departments of Cardiology of the Ospedali Riuniti Bergamo and the Centro Malan in San Donato Milanese. One patient came to light because of recurrent atria1 fibrillation (Patient 18), three as a result of stable atria1 fibrillation (Patients 16, 17 and 21) and three due to residual aortopulmonary bloodflow after surgical ligation of the duct (Patients 5, 6 and 20) between 18 and 19 years prior to implantation of the device. In the other patients diagnosis was made incidentally during pregnancy, sports examination or because of cardiomegaly diagnosed by chest X-ray performed for other indications. Nine patients required pharmacological treatment prior to duct closure.

a

The diagnosis was confirmed in all patients by clinical examination, chest X-ray, echocardiography and cardiac catheterization. In ten patients the pulmonary arterial pressure was normal (systolic pressure c 30 mmHg), in eleven it was elevated (systolic pressure from 30 to 100 mmHg, mean 50 mmHg). The morphology of the duct and its relation to the anterior wall of the trachea was evaluated by aortography. The minimal diameter of the duct varied from 3 to 9 mm (mean 4.3 mm). In 14 patients no calcification of the duct (Fig. 1) could be recognized whereas in the other seven patients the duct was clearly calcified. The Rashkind double umbrella device was implanted according to the technique described by others by transfemoral venous approach in nineteen and arterial approach in two patients. In the patients without calcification the approach to occlude the duct did not differ fundamentally from the one used routinely in children.

b

Fig. 1. (a) Case 21. Lateral view: the venous catheter is crossing the duct; calcifications are indicated by the arrow. The anterior border of the trachea (small arrows) is well behind the position of the duct. (b) A 17-mm device (*) was implanted; (c) the aortogram shows no residual flow across the duct.

a

b

d Fig. 2. (a) Case 15. Antero-posterior view: residual shunt through a 17-mm device is indicated by the arrow. A faint opacification of the enlarged pulmonary artery can be seen. (b) The catheter entered the residual orifice of the duct (*) from the arterial side; the wire was snared in the pulonary artery,then pulled through the right heart chambers (arrows) and eventually extruded from the right femoral vein. (c) A second 17-mm device was positioned (still connected to the delivery system in this particular frame); (d) the aortogram shows complete closure of the residual shunt.

In the patients who underwent closure of residual shunt after surgical ligation (Patients 5, 6 and 20), the procedure was accomplished easily. In three patients (11, 15 and 16) it was difficult to pass the delivery sheath through the duct. This was eventually achieved by increasing the stiffness of the guidewire: a long guidewire was advanced retrogradely across the duct into the main pulmonary artery, and then snared through the in-

traducer by a sling wire (Fig. 2B). The guidewire was then withdrawn through the access femoral vein. It could be stiffened by gently applying tension to both ends. This manoeuvre allowed the sheath and dilator to be advanced across the patent ductus arteriosus [ 101. In the child in lateral fluoroscopic vision, the anterior part of the trachea is a very useful reference point to determine the point of release for the device. In our ex-

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perience this reference point could not be used in patients with calcified ducts. In this group the calcification of the duct, which was visible in fluoroscopy turned out to be a reliable reference point. In fact in one patient antero-posterior view was preferred to locate the site of release since the ductus could not be visualized in the lateral vision. Two 12-mm and 20 17-mm devices were implanted.

Results Complete closure of the duct was achieved in 16 patients with the first umbrella. Residual shunt was more frequent in patients with ample ducts. Residual flow was significant in three patients two of whom (7 and 14) developed haemolytic anemia in the first weeks after implantation. In one patient (14) an attempt to perform an occlusion of the residual shunt with a second umbrella was per-

TABLE

1

Clinical

data of the patients.

Patient

Sex

Age (yea&

Ductus

Calcification

formed. In this case the second umbrella unfortunately embolized into the left pulmonary artery probably because the size of the residual shunt was underestimated. Both patients underwent an uneventful surgical closure. The third patient (15) with significant residual shunt underwent succesful implantation of a second 17-mm device with complete abolition of the residual flow (Fig. 2). One patient (18) who had recurrent episodes of tachycardia before the catheterization, developed atria1 fibrillation during the procedure, which was readily converted into sinus rhythm by electric cardioversion after the duct closure.

Discussion Patent ductus arteriosus is usually detected in childhood and treated either surgically or by transfemoral closure at a young age. However, in some patients diagnosis is not made during

PAP

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

19 20 22 27 27 27 28 29 31 31 35 40 40 47 52

F M M F F F F F F M F F F F F

3.0 4.5 4.2 3.5 3.5 3.0 6.0 4.2 4.0 4.5 3.5 3.0 3.0 9.0 >5.0

Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Not calcified Calcified Calcified

25110 20/10 20/10 22/4 40122 48120 48122 2018 2016 30/8 18/8 36112 28/10 50/30 100140

16 17 18 19 20 21

52 59 59 60 62 62

F F F F F M

4.0 4.2 3.5 4.5 3.5 6.0

Calcified Calcified Calcified Calcified Not calcified Calcified

(Second 40/20 2017 50/30 18/8 46112 65125

arterial

pressure.

Results

(mm) mmHg

PAP, pulmonary

Device

(mm) Mean 18 15 13 10 32 33 33 10 IO 15 11 24 15 40 70 umbrella) 30 14 40 12 28 40

12 17 17 17 17 17 17 17 17 17 17 17 17 17 17

Complete closure Complete closure Complete closure Complete closure Complete closure Complete closure Significant residual shunt Comlpete closure Complete closure Complete closure Complete closure Complete closure Minimal residual shunt Significant residual shunt Significant residual shunt

17 17 17 12 17 17 17

Complete closure Complete closure Minimal residual shunt Complete closure Complete closure Complete closure

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childhood and patent ductus arteriosus is detected only with the onset of symptoms. Heart-failure and dyspnoea are probably the most common symptoms in adults but bacterial endocarditis, supraventricular arrhythmias, angina and even sudden death have been reported [ 1,2]. Surgical closure of patent ductus arteriosus in the adult has long been a controversial issue. As reported by many authors surgical duct closure in children and young adults can be easily achieved. However, the few cases of patent ductus arteriosus not detected in childhood create difficult problems to the surgeon [3-61. Many patients have to be operated on with cardio-pulmonary by-pass and there are still considerably high mortality rates (about 3%) reported by various authors. In addition bleeding, recanalization of the duct and recurrent laryngeal nerve palsy may complicate the surgical outcome [3-61. In fact in our experience of 21 adult patients, three came to light because of residual aorto-pulmonary flow after surgical ligation of the duct. Advanced age and calcification of the duct were considered to be contraindications to the surgical management of this anomaly. However, the reduced life-expectancy of patients with patent ductus arteriosus long-term and the encouraging haemodynamic results in patients who have undergone successful closure, indicate the benefit of interrupting aortopulmonary bloodflow [ 11. Calcification of the duct is not a contraindication for the closure with double umbrella device. In fact it can be of technical advantage during the procedure. The reference point in lateral fluoroscopic vision of the anterior wall of the trachea to position the dellice in cliildren, is not reliable in all adult patients (Fig. 1A). Therefore calcification seen in fluoroscopy can be helpful to locate the site of release for the device. Twenty-one adults, seven of whom had calcified ducts, underwent closure of patent ductus arteriosus in two institutions. After implantation of the device two patients had a minimal residual shunt and three a significant residual aortopulmonary flow. As pointed out by other authors 181, residual shunts are more frequent in ducts of ample dimensions. In addition to that, we think that calcification of the duct is a risk factor for residual aortopulmonary flow. This could be due to

the rigid vessel wall which does not perfectly adhere to the device. Two of our patients (7 and 14) required closure of the residual shunt because of haemolytic anemia which occurred after implantation of the double umbrella device. In one patient duct closure with a second device was attempted, but the prosthesis embolized into the left pulmonary artery. Both patients were then sent for surgical ligation of the duct and no further problems were encountered. In the third patient with significant residual flow a second 17-mm device was implanted and the shunt was completely abolished (Fig. 2). In patients with minimal residual shunt the clinical conditions improved and the cardiothoracic index decreased in spite of the residual transductal flow. Closure of the ductus in childhood with the Rashkind device is now widely accepted as a successful technique. In adults the procedure is also feasible even in the presence of calcification and/or pulmonary hypertension. As pointed out by our experience and that of other authors residual flow after surgical ligation of the duct is probably underestimated. In fact Sorensen et al. [l l] report residual flow of surgically ligated ducts in 23% of their patients. Three of the 21 adult patients (Table I, Patients 5, 6 and 20) who underwent duct closure in our institution came to light because of recanalization of a surgically ligated duct. In Patient 20 an aortic valve was implanted in the same surgical session as the duct ligation 19 years ago. She came to our attention because of stenosis of the prosthetic valve. Having considered her age - 62 years - we preferred to occlude the duct with a double umbrella device 3 days prior to valve reimplantation in order to simplify the surgical approach. In all these patients complete closure of the duct was achieved. Considering the substantial surgical difficulty and complications of duct closure in the adult, we conclude that the transfemoral closure of patent ductus arteriosus in adult patients is technically possible and should be considered as a first choice procedure. References 1

2

Ng ASH, Vlietstra RE, Danielson GK, Smith HC. Puga FJ. Patent ductus arteriosus in patients more than 50 years old. Int J Cardiol 1986; 11: 277-285. Marquis RM, Miller HC, McCormack RJM. Matthews MB, Kitchin AH. Persistence of ductus arteriosus with

86 left to right shunt in the older patient. Br Heart J 1982; 48: 469-484. 3 Wright JS, Newman DC. Ligation of the patent ductus. J Thorac Cardiovasc Surg 1978; 75: 695-698. 4 Morgan JM, Gray HH, Miller GA, Oldershaw PJ. The clinical features, management and outcome of persistence of the arterial duct presenting in adult life. Int J Cardiol 1990; 27 (2): 193-202. 5 Wernly JA, Ameriso JL. Intra-aortic closure of the calcified patent ductus. J Thorac Cardiovasc Surg 1980; 80: 206-210. 6 John S, Murahdharan S, Jairaj PS et al. The adult ductus. J Thorac Cardiovasc Surg 1981; 82: 314-319. 7 Yamaguchi T, Fukuoka H, Yamamoto K, Katsuta S, Ohta M. Transfemoral closure of patent ductus arteriosus: an alternative to surgery in older patients. Cardiovasc Intervent Radio1 1990; 13: 291-293

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Landzberg MJ, Bridges ND, Perry SB, Keane JF, Faherty CE, Lock JE. Transcatheter occlusion - the treatment of choice for the adult with patent ductus arteriosus. Circulation 1991; 84 (4): 11-67. 9 Sievert H, Bussmann WD, Kaltenbach M et al. transfemoral ductus Botalli occlusion in patients over 60 years of age. Z Kardiol 1991; 80 (5): 330-332. 10 Yousef SA, Khan A, Mullins CE, Sawyer W. Use in children of an additional umbrella for transcatheter occlusion of residual patency of the arterial duct following initial insertion of an umbrella device. Cardiol Young 1992; 2: 353-356. 11 Sorensen KE, Kristensen BO, Hansen OK. Frequency of occurence of residual ductal flow after surgical ligation by color-flow mapping. Am J Cardiol 1991; 67: 653-654.