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9.5 Patent Ductus Arteriosus (PDA)
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feasible, open-thoracic surgery or transcatheter closure may be performed to close
the PDA, as mentioned in Sect. 5.2.6.
Transcatheter closure of PDA in infants is a viable alternative to surgical ligation
[1, 2] (as depicted in Fig. 5.1). It is particularly considered when an infant with
extremely low birth weight (ELBW) continues to experience heart failure despite
receiving appropriate medical treatment and positive pressure ventilation [3, 4].
This alternative approach is discussed in Fig.9.11.
a
b
c
Fig. 9.11 A 6-week-old premature baby weighing 2kg, who had undergone patent ductus arteriosus device closure at 16days of age in another hospital. The device had migrated to the aorta,
causing severe obstruction and requiring surgical intervention. The baby was admitted for this
procedure. (a) On admission, a 2D view from the suprasternal notch in the short-axis view (right
plane with color image) shows a patent ductus arteriosus (PDA) status post-transcatheter closure
with an Abbott Amplatzer Piccolo Occluder (5/2mm #) without any residual shunt. (b) In the right
plane color image, it can be seen that the Piccolo PDA Occluder (#) has migrated to the descending
aorta, causing severe obstruction (indicated by the arrow) with a pressure gradient of 27mmHg.
(c) This intraoperative photograph shows the successful surgical removal of the Piccolo PDA
Occluder (bottom right), which had migrated and caused aortic obstruction (indicated by the
arrow) at the junction of the left pulmonary artery and descending aorta. (Please note that no transesophageal echocardiogram (TEE) was available for this sick patient)
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9 Unusual Shunt andFistula
Device-related complications [5, 6] of transcatheter PDA closure include device
embolization (when the device becomes dislodged and travels to another part of the
blood vessels), device malposition, and migration (improper positioning of the
device to close the PDA). The management of device migration, particularly when
it causes obstruction of the descending aorta in a premature baby, is discussed in
Fig.9.11.
References
1. Azhar AS, Abd El-Azim AA, Habib HS.Transcatheter occlusion of PDA is safe
and effective alternative to surgery. Ann Pediatr Cardiol. 2009;2:36–40.
2. Butera G, De Rosa G, Chessa M, etal. Transcatheter closure of persistent ductus
arteriosus with the Amplatzer duct occluder in very young symptomatic children. Heart. 2004;90:1467–70.
3. Muacevic A, Adler JR. Transcatheter closure of a Patent Ductus Arteriosus
Occluder using a Piccolo Ductu occluder. Cureus. 2022;14:e28226.
4. Malekzadeh-Milani S, Akhavi A, Douchin S, etal. Percutaneous closure of pat-
ent ductus arteriosus in premature infants: a French National Survey. Catheter
Cardiovasc Interv. 2020;95:71–7.
5. Chien YH, Wang HH, Lin MT, etal. Device deformation and left pulmonary
artery obstruction after transcatheter patent ductus arteriosus closure in preterm
infants. Int J Cardiol. 2020;312:50–5.
6. Tomasulo CE, Gillespie MJ, Munson D, etal. Incidence and fate of device-
related left pulmonary artery stenosis and aortic coarctation in small infants
undergoing transcatheter patent ductus arteriosus closure. Catheter Cardiovasc
Interv. 2020;96:889–97.
Postoperative Residual Defect
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10
Catheter-based interventions can be an alternative to additional surgery when there
is a remaining shunt or defect following certain congenital heart surgeries.
Reoperating on these residual defects or shunts carries increased risks and mortality
rates. Unlike typical defects or shunts, postoperative residual defects or shunts often
exhibits morphological irregularities. These irregularities can make it challenging to
determine the diameter of the remaining defects or shunts and difcult in selecting
the appropriate devices for transcatheter procedures.
Indications for transcatheter intervention for residual shunt includes:
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S.-K. Tsai et al., Transesophageal Echocardiography in Pediatric Congenital Cardiac
Surgery and Catheter Intervention, https://doi.org/10.1007/978-981-99-6582-3_10
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10 Postoperative Residual Defect
10.1 Residual ASD
When there is a residual defect such as ASD [1, 2] (as shown in Fig.10.1) after
surgery.
a
d
Fig. 10.1 A 10-year-old boy with exertional dyspnea underwent a device closure to address a
residual atrial septal defect (ASD). (a) A 2D TEE image depicts a residual 8-mm ASD due to a
detached surgical patch (indicated by an arrow) as seen in a ME AV SAX view. (b) A 2D TEE in
the four-chamber view depicts the deployment of the left disk (LD) of a 10-mm Amplatzer septal
occluder. (c) A 3D TEE image in a similar view displays a detached surgical patch and the deployment of the left disk of the occluder in the left atrium (LA). (d) A 2D TEE image displays the
successful deployment of the occluder in the four-chamber view. (e) A 3D TEE image in a similar
view displays the nal position of the occluder (RD indicating right disk, MV indicating mitral
valve, and IAS indicating interatrial septum). (f) A post-procedural chest uoroscopy image displays the surgical wire and the nal position of the deployed occluder (O)
bc
e
f
ab
10.2 Residual VSD
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227
10.2 Residual VSD
Postoperative residual VSD [3, 4] (as shown in Fig.10.2).
Fig. 10.2 A 12-year-old boy with exertional dyspnea underwent a device closure to address a
residual ventricular septal defect (VSD). (a) A 2D color TEE image depicts a residual 6-mm VSD
due to a detached surgical patch (indicated by white arrowheads) as seen in a ME AV SAX view.
(b) A 3D color Doppler TEE image in the ME AV SAX view displays a detached surgical patch
(indicated by a white arrow) and successful deployment of a Lifetech Scientic KONAR-MF
10/8mm VSD occluder in a good position (indicated by a blue arrow for the right disk and a blue
arrowhead for the left disk) without any residual shunt
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10 Postoperative Residual Defect
10.3 Recurrent PDA
Catheter intervention can be used for recurrent PDA closure [5, 6] (as shown in
Fig.10.3).
b
Fig. 10.3 Device closure for a recurrent patent ductus arteriosus (PDA) after a loosened PDA
surgical ligation during infancy. (a) A 2D TEE image depicts a 7mm diameter patent ductus arteriosus (PDA) seen from an upper esophageal descending aortic view, with accompanying color
Doppler image (right plane) showing left-to-right shunting through the ductus. (b) A 3D TEE
image with color Doppler, in a similar view, depicts ow from the patent ductus arteriosus (PDA)
to the junction of the pulmonary arteries. (c) 2D TEE image of a 10mm ADO (Amplatzer ductal
occluder) deployed, as seen from a UE DAo view. (d) A 3D TEE image in a similar view displays
the ADO occluder securely positioned in the ductus without any remaining shunting
bc
10.4 Fenestration Closure
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229
10.4 Fenestration Closure
Catheter-based intervention for closure of penetration holes after TCPC (as shown
in Fig.10.4) is safe and effective, with high success rates and low complication rates.
a
Fig. 10.4 Closure of a fenestration with an Amplatzer septal occluder in a 13-year-old patient
with ccTGA/TA/PS/ASD/VSD following total cavo-pulmonary connection (TCPC). (a) A cardiac
CT study depicts a fenestration with a diameter of 0.44cm between the extracardiac conduit (C) of
the TCPC and the common atrium. (* indicates VSD). (b) A 2D TEE image of a fenestration (F)
as seen from a ME four-chamber view, along with a color Doppler image in the right diagram,
displays shunting through the fenestration (F) between the RA and the conduit (C). (c) A 2D TEE
image with color Doppler in a similar view after the implantation of an occluder displays a 5-mm
Amplatzer septal occluder (O) securely positioned in the fenestration hole without any residual
shunting
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Catheter interventions for residual defects or shunts after some CHD surgeries
have advantages over reoperation because they are:
1. Less Invasive: They are minimally invasive and do not require a large incision in
the chest, resulting in faster recovery time, less pain, and scarring.
2. Lower Risk: They have a lower risk of complications like bleeding, infection,
and damage to surrounding structures compared to reoperation.
3. Quicker Recovery: Patients may be able to return to their normal activities
sooner with catheter interventions.
4. Cost-Effective: They are typically less expensive than reoperation due to shorter
hospital stays and lower complication rates.
5. Better Cosmetic Outcome: They result in minimal scarring, which is important
for patients concerned about their outlooking after surgery.
10 Postoperative Residual Defect
References
1. Krasuski RA.Catheter-based interventions versus repeat surgical procedures for
patients with residual septal defects. J Invasive Cardiol. 2006;18(7):305–10.
2. Butera G, Carminati M, Chessa M, etal. Transcatheter closure of residual shunts
after surgical closure of atrial septal defects: early and midterm results. J Thorac
Cardiovasc Surg. 2005;129(3):497–501.
3. Momenah TS, Ebeid MR, Al-Fayyadh MM, etal. Percutaneous device closure
of residual shunts following surgical repair of atrial septal defects: a systematic
review and meta-analysis. Heart Lung Circ. 2020;29(2):250–5.
4. Forbes TJ, Kim DW, Du W, etal. Comparison of surgical, stent, and transcathe-
ter closure of ventricular septal defects: a multicenter prospective study. JACC
Cardiovasc Interv. 2018;11(23):2459–65.
5. Bass JL, Lucas VW, Brauner R, etal. Amplatzer duct occluder to treat recurrent
patent ductus arteriosus after surgical ligation. JACC Cardiovasc Interv.
2008;1(1):84–6.
6. Jayaram N, Beekman R, Benson L, etal. Recurrent ductal patency after surgi-
cal ligation and transcatheter closure: a comparative study. Heart.
2011;97(24):2034–9.
7. Nguyen HT, Kim DW, Nguyen T, etal. Transcatheter closure of residual fenes-
trations after Fontan operation. JACC Cardiovasc Interv. 2015;8(8):1142–8.
Hybrid Procedure forCongenital Heart
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Diseases (CHDs)
11.1 Perventricular Device Closure ofVSDs
The transcatheter closure of VSD using various devices has shown positive outcomes for over two decades, as reported in studies [1]. However, the perventricular
technique for VSD device closure is a hybrid procedure that accesses the heart
through a small chest wall incision under general anesthesia. Transesophageal echocardiography (TEE) is used to locate the VSD. A guided wire is then inserted
through the incision and carefully directed across the VSD from the right ventricle
to the left ventricle, guided by TEE.Once the delivery sheath is correctly positioned, the occluder device is deployed and released to seal the defects. The procedure involves a minimally invasive technique, enabling easy passage through the
defects and precise device placements [2].
Transcatheter closure of muscular VSDs in infants [3–5] is challenging and
poses a high risk of complications due to the disparity between the sheath size and
the vascular access in the patient. Figure 11.1 addresses the minimally invasive
perventricular device closure technique for muscular VSDs.
Additionally, in children with an outlet VSD, the spiraling path of the ventricular
septum adds complexity to percutaneous transcatheter closure procedures. However,
the perventricular approach allows for easier passage of a short sheath directly
through the defect and precise device positioning [6]. This technique is detailed in
Fig.11.2.
11
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S.-K. Tsai et al., Transesophageal Echocardiography in Pediatric Congenital Cardiac
Surgery and Catheter Intervention, https://doi.org/10.1007/978-981-99-6582-3_11
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11 Hybrid Procedure forCongenital Heart Diseases (CHDs)
a
Fig. 11.1 A one-month-old infant with a muscular ventricular septal defect underwent a hybrid
procedure for device closure. (a) A 2D TEE image of a muscular ventricular septal defect measuring 7.4mm is shown in a four-chamber view, with a color Doppler image that displays left-to-right
shunting through the defect. (b) A 2D TEE image in the modied four-chamber view reveals a
perventricular catheter passing through the right ventricular wall to the left ventricle via the muscular ventricular septal defect, as guided by TEE. (c) A 2D TEE image in the modied fourchamber view shows the deployment of the left disk in the left ventricle. (d) A similar view of TEE
displays the nal position of a 10-mm muscular occluder
b
References
1. Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital
ventricular septal defects: results of the European Registry. Eur Heart
J. 2007;28:2361–8.
2. .Xing Q, Pan S, An Q, etal. Minimally invasive perventricular device closure of
perimembranous ventricular septal defect without cardiopulmonary bypass:
multicenter experience and mid-term follow-up. J Thorac Cardiovasc Surg.
2010;139:1409–15.
3. Holzer R, Balzer D, Cao QL, etal. Device closure of muscular ventricular septal
defects using the Amplatzer muscular ventricular septal defect occluder: immediate and mid-term results of a U.S. registry. J Am Coll Cardiol. 2004;43:1257–63.
4 Bacha EA, Cao QL, Galantowicz ME etal. Multicenter experience with perven-
tricular device closure of muscular ventricular septal defects. Pediatr Cardiol.
2005;26:169–175.
5. Bacha EA, Cao QL, Galantowicz ME.Multicenter experience with perventricu-
lar device closure of muscular ventricular septal defects. Pediatr Cardiol
2005;26:169–75.
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