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26—COARCTATION AND PDA CLOSURE 309
AB
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Initial Assessment
Most patients referred now adays for device closure of patent ductus arteriosus have clinical evidence of its presence with a continuous machinery type murmur noted at the left upper sternal
border. Recognition of a significant PDA beyond the first month of life should warrant efforts to
better define the nature of the lesion and its significance. Significant left-to-right shunt and evidence of left heart enlargement should be documented by standard transthoracic echocardiography and color flow imaging studies. Based on these observations, recommendations can be made
for either further clinical observation or efforts for surgical or device closure of the patent ductus
arteriosus.
6
Fig. 26.14 illustrates typical echocardiographic and Doppler findings in simple patent
ductus arteriosus with left-to-right shunting and left ventricular volume overload.
Recognition of significant right-to-left shunting and pulmonary hypertension as observed in
Fig. 26.10 should warrant further investigation with additional imaging studies including MRI,
CT, and cardiac catheterization. In such instances, the use of MRI and CT angiography would
provide significant additional anatomy and hemodynamic information to allow recognition of any
other associated anomalies such as anomalous pulmonary venous connection or pulmonary vascular abnormalities not evident by echocardiography. Earlier intervention, whether by catheter device
closure, surgical closure, or medical therapy, would be determined by the catheterization data.
AHA Guidelines
PDA closure in adults is recommended if left atrial or LV enlarge-
I C-LD
ment is present and attributable to PDA with net left-to-right
shunt, PA systolic pressure less than 50% systemic and pulmonary vascular resistance less than one third systemic
PDA closure in adults may be considered in the presence of a
IIb B-NR
net left-to-right shunt if PA systolic pressure is 50% or
greater systemic, and/or pulmonary vascular resistance is
greater than one third systemic
PDA closure should not be performed in adults with a net
right-to-left shunt and PA systolic pressure greater than
III:
Harm
C-LD
two thirds systemic or pulmonary vascular resistance
greater than two thirds systemic
(From Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller
S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC guideline for the
management of adults with congenital heart disease: executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018.)
Fig. 26.14 A. Two-dimensional echocardiographic images demonstrating the classic ductal view to show
both pulmonary artery branches and the ductus arteriosus. The color flow imaging section demonstrates the
left-to-right shunt from the aorta through the ductus into the pulmonary artery. B. Continuous-wave Doppler
interrogation of a patent ductus arteriosus demonstrating a high-velocity continuous jet consistent with low
pulmonary artery pressure and a large continuous left-to-right shunt.
310 8—ACHD INTERVENTIONS
A
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Morphology of PDA
The size and anatomy of the patent ductus arteriosus as well as age and size (weight) of the patient will determine the appropriate method and type of device utilized for device closure of the
patent ductus. Anatomy of the duct varies between persons and may have narrowings at either
the aortic or the pulmonary end of the duct.
8
Krichenko et al.9 found that type F morphology
was the most common in prematures but that Type E was the most common in a series of
100 consecutive patients of all ages (Fig. 26.15).
Percutaneous Device Closure of PDA
A variety of devices have been developed to effective percutaneously close the ductus (Fig. 26.16).
The Cook Gianturco, currently the MReye®, embolization coils, became a popular method for
closing the PDA because of their simplicity and low cost, but have largely been superseded by
newer devices. The Flipper® detachable coil also from Cook was utilized because of its great
safety of controlled release.
The most widely used PDA occluder approved by the FDA in 2003 was the Amplatz duct
occluder I or ADO-I™, currently marketed by Abbott. The devices range in size from 5/4 to
12/10 mm devices in the US and are delivered through a 5 or 6 Fr Amplatz delivery sheath.
Type A: “Conical” ductus,
with well defined aortic
ampulla and constricted
pulmonary artery end.
B
C
D
E
F
Fig. 26.15 Proposed classification of PDAs: PDA morphology of premature children that did not fit the
Krichenko et al. classification were grouped as Type F. To the left of the descriptive text is a figure of the different PDA types with their companion lateral aortograms before and after transcatheter device closure. To
the right of the text is the concomitant 2D and color Doppler echocardiogram image of the different PDA
types. The type F PDAs were relatively larger and longer compared with other types with a tortuous connection to the PAgiving an appearance of a hockey stick.
Type B: “Window” ductus,
with short length, slightly
constricted aortic end and
wide pulmonary artery end.
Type C: “Tubular” ductus,
without any constrictions at
the aortic end or the
pulmonary artery end.
Type D: “Saccular” ductus,
with constricted aortic end
and pulmonary artery end
with a wide center.
Type E: “Elongated” ductus,
which is narrow with a
constricted pulmonary
artery end.
Type F: “Fetal Type” ductus,
Found exclusively in
children born prematurely
and is long, wide and
tortuous.
26—COARCTATION AND PDA CLOSURE 311
EFG
Amplatz Piccolo
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The pfm Nit-Occlud PDA™ coil system underwent successful trials in the US and was eventually
released for routine clinical use in 2013. The coils range in size from 4 3 4 mm to 14 3 6 mm
and lengths from 3.5 to 6.5 mm. They are delivered through 4 or 5 Fr implantation catheters.
The Amplatz duct occluder II™ marketed by Abbott was designed for ductal occlusion in in-
fants less than 6 months and 6 kg and was approved by the FDA with premarket approval in March
2016. The device ranges in size from 3 to 6 mm in diameter with length of 4.25 to 6.25 mm. It is
delivered through a 4 or 5 Fr Amplatz delivery catheter. Because the disc tended to be too long or
protrude into the aorta, a separate ADOII AS device was developed. Now designated by Abbott as
the Amplatz Piccolo™ PDA occluder, this device was approved by the FDA in June 2019 for pre-
mature infants older than 3 days of age and weighing .700 gm. The Piccolo is implantable through
AB C
B
A
MReye
D
A: Device diameter at descending aorta (mm)
B: Device diameter at pulmonary artery (mm)
C: Retention skirt diameter (mm)
D: Device length (mm)
C
Flipper pfm Nit-occlud
ADOI
D
AVP IADO II
PDA occluder
Fig. 26.16 A variety of devices currently available for device closure of PDA. A, MReye. B, Flipper.
C, pfm Nit-Occlud. D, ADOI. E, AVP I. ADO II. G, Amplatz Piccolo.
Continued on following page
312 8—ACHD INTERVENTIONS
A occluder
H
J
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A: Visual diameter (mm)
AC
B
B: Length between retention discs (mm)
C: Disc diameter (mm)
Amplatz Piccolo PD
I
Fig. 26.16 cont’d
AVP II
Microvascular
plug
H, ADO II AS. I, AVP II. J, Microvascular plug.
a 4 Fr Amplatz catheter with sizes ranging from 3-5 mm waist size and 2-6 mm length. Since this
device had not been available in the US, some interventionists have instead utilized the Amplatz
Vascular plug II™ (AVPII), which has similar features as the ADOII AS. The AVPII ranges in size
from 3-22 mm in diameter and 6-18 mm in length. It is delivered through a 5-9 Fr guide catheter.
The Piccolo has become the standard device for PDA closure in premature infants. Another device
introduced in 2013 that has been used for PDA occlusion in small infants has been the Medtronic
Micro Vascular Plug™. The device is a PTFE covered nitinol plug ranging in size from 3 to 9 mm
and ranging in length from 12 to 18 mm. It can be delivered through an 0.021–0.027 inch internal
diameter microcatheter. Although designed as a peripheral vascular plug, with its open distal end,
it seems ideally suited for antegrade ductal delivery.
result in some protrusion into the pulmonary artery and aorta.
The conical-shaped type A PDA with a larger aortic ampula represents the most common
type of PDA observed and is well suited to the ADO-I (Fig. 26.10). Fig. 26.17 A, B and
Video 26.3 illustrate the angiographic demonstration of a type A PDA in a 7-year-old patient
and the subsequent complete occlusion of the duct with a 6/4 size Amplatz ADOI. The aortic
disc fits nicely into the aortic ampulla without any protrusion into the aorta, and the pulmonary end
of the device is slightly bulbous as it sits in the dome of the main pulmonary artery (Fig. 26.17D).
The pulmonary artery angiogram demonstrates the device in the dome of the main pulmonary
artery and widely patent right and left pulmonary arteries (Fig. 26.17C and Video 26.4).
9
However, it final length of 12 mm will still
A
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B
C
E
Fig. 26.17 A,B. Lateral views of descending aortogram illustrating a Type A moderate patent ductus arterio-
sus with measurements of the pulmonary artery end narrowing and the size of the aortic ampulla. There is
moderate opacification of the main pulmonary artery with the injection. C,D. Lateral view of pulmonary artery
and aortic injections after delivery of a 6/4 ADO I. The lateral view shows normal well-positioned aortic disc
in the aortic ampulla and the slightly bulbous pulmonary end sitting in the dome of the pulmonary artery. There
is no obstruction of either the left pulmonary artery or the descending aorta by the device. E, Ilustrates lateral
view of aortic injection showing the ADO I partially pulled into the PDA so that the aortic disc is positioned
within the tubular portion of the PDA.
D
314 8—ACHD INTERVENTIONS
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It is important to determine that the device obstructs neither the descending aorta nor the
left pulmonary artery. With some ADO I placement, one edge of the device may project toward the aorta without significant obstruction. For this reason, in a more tubular PDA, some
interventionists may prefer to pull the device aortic disc partially into the ductus as illustrated
in Fig. 26.17E. In some instances, it may not be possible to advance a catheter across the ste-
notic pulmonary end of the ductus. Usually a wire can be advanced from the aortic end of the
ductus through the stenosis and into the main pulmonary artery but will not allow catheter
passage. In such instances it may be necessary to snare the wire in the pulmonary artery to
create a wire rail that will allow one to advance a delivery catheter ante grade through the PDA
and into the descending aorta.
Type C PDA is illustrated in Fig. 26.18. Some have virtually no narrowing throughout the
duct and represents a challenge for device closure. Some have considered the AVPII or the
Amplatz muscular VSD occluder in such instances of very large PDAs. Type E PDA is observed
in Fig. 26.19A with a longer tubular duct and a stenosis at the pulmonary artery end. In these
examples, a Flipper detachable coil (Fig. 26.19B) or the Nit-Occlud detachable coil could be
A
C
Fig. 26.18 A,B. Lateral view of a large type D PDA with a 4-mm narrowing at the aortic and pulmonary artery
end and 17 mm in length in a 3-year-old boy. C. Lateral view of the PDA occluded in the same patient with
a 12-mm AVP II vascular plug. Because of the size and length of the duct, the device did not obstruct either
the aorta or the LPA.
B
26—COARCTATION AND PDA CLOSURE 315
CD
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A
Fig. 26.19 A. Lateral view of descending aortogram illustrating a small tubular PDA with a significant stenosis
at the pulmonary end in a 3-year-old male. B illustrates closure of this PDA with 3 3 5 mm Flipper coil still
attached at the pulmonary end. C. Aortogram following release shows complete occlusion of the PDA with
no aortic obstruction. D. Lateral view illustrating a flipper coil placed retrogradely in the PDA just after release.
delivered to effectively occlude the PDA. An advantage of the Flipper coil and the ADOII AS
is that they can be delivery from a retrograde approach if necessary. Retrograde delivery of a
flipper coil is illustrated in Fig. 26.14D. Fig. 26.20 illustrates placement of a 9/6 Nit-Occlud coil
in a larger PDA in an 11-month-old 9.6-kg infant with complete occlusion of the ductus.
B
Procedural Steps
Femoral arterial and venous access is obtained with ultrasound guidance. The sheath size and
delivery system will depend on the patient size and intended type and size of the device closure.
PDA occlusion in the premature infants represents a more challenging and perhaps complicated
effort in view of their hemodynamic instablity. The complete details of the Piccolo device may be
found in its instruction for use.
316 8—ACHD INTERVENTIONS
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1 cm/div
A
Fig. 26.20 A,B. Lateral and AP view of a moderate PDA in an 11-month-old 9.6-kg infant. There is moderate
opacification of the main pulmonary artery. C illustrates lateral view of placement of a 9/6 NitOcclud PDA coil
in the PDA. The coiled segment in the aortic ampulla is well positioned with the pulmonary coil segment attached in the MPA. D Lateral view after release of the coil leaving a single coil in the MPA. A small residual
shunt is observed, which resolved by the next day by echocardiography.
B
Complications
The procedure is typically safe and well tolerated. The major risk is device extrusion into the aorta
or pulmonary artery, potentially leading to stenosis in the long term. Device embolization is
uncommon. Other risks include vascular damage and stroke.
Conclusions and Future Directions
Despite the availability of a variety of devices for effective PDA occlusion, the primary remaining
concerns for PDA device occlusion relate to safety with avoidance of aortic or LPA stenosis by
the device. Interventionists in the US have been encouraged since the Piccolo occluder has
achieved approval by the FDA for clinic use in the United States in premature infants.
26—COARCTATION AND PDA CLOSURE 317
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Fig. 26.21 A pigtail catheter is advanced via the femoral artery to the left ventricle and the left ven-
tricular pressure measured. Aortic angiography is performed first to identify the anatomy. Angiographic
demonstration of the ductal size and anatomy is important as a preliminary step to avoid ductal spasm dur-
ing right heart catheterization. The catheter may need to be pulled back to just proximal to the site of the PDA
to enable better visualization. Right heart catheterization is then performed with right heart pressure measure-
ments and shunt determination.
Fig. 26.22 The PDA can be crossed from the pulmonary artery (antegrade) or aortic (retrograde)
approach. A JR4 guide catheter and a 0.035” angle guide wire can be used to cross the PDA.
318 8—ACHD INTERVENTIONS
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Fig. 26.23 If the catheter can be advanced across the PDA, it can be used to deploy an ADO-1, AVP-II
plug or a coil such as the NitOcclude coil. Based on the angiographic demonstration of the PDA previ-
ously obtained, the appropriate size of device is selected.
Fig. 26.24 If the PDA is particularly stenotic at the pulmonary artery end, the retrograde approach may
be necessary to cross the PDA. Usually a wire can be advanced from the aortic end of the ductus through
the stenosis and into the main pulmonary artery but may not allow catheter passage. In such instances it may
be necessary to snare the wire in the pulmonary artery to create a wire rail that will allow one to advance a
delivery catheter ante grade through the PDA and into the descending aorta. Once the angle guide wire is
advanced from the aorta into the pulmonary artery through the PDA, a snare (Ensnare or gooseneck) is used
to create the rail and allow tension to be held on the wire to enable advancement of the catheter. Alternatively,
an AVP-II plug could be placed retrograde via a delivery sheath advanced into the pulmonary artery. The plug
is positioned retrograde into the PDA and released from the arterial side.
Conclusions
n
PDA closure in adults is recommended if left atrial or LV enlargement is present and at-
tributable to PDA with net left-to-right shunt, providing the PA systolic pressure is less
than 50% systemic and the pulmonary vascular resistance is less than one-third systemic.
n
A wide variety of closure devices are available, and choice will be dictated by local and
national regulations as well as anatomic shape of the lesion.
n
Percutaneous closure can be performed via the retrograde or anterograde approach. If a
catheter will not advance across the lesion, a rail is formed for catheter and then the device
is advanced across the PDA.
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