PDA Closure Refined: A Simplified Transcatheter Solution

By Liang-long Chen, MD, PhD, FACC

During my training in the mid-1980s and in my early years as a clinical and research cardiologist before 1990, surgical ligation first described by Gross and Hubbard in 1939 remained the major treatment of persistent ductus arteriosus (PDA) in our country. Although conventional surgical ligation is effective and safe, there are several unavoidable pitfalls, including postoperative pain and procedure-related complications, as well as cosmetic and psychosomatic problems associated with the thoracotomy and incision scar. Transcatheter duct closure, to avoid thoracotomy, was pioneered by Portsmann et al by introducing a conical Ivalon plug in 1967, and by Rashkind and Cuaso using an umbrella-type device in 1979. These devices were rather big and cumbersome to implant, requiring large introducer sheaths and frequently leaving residual shunting. Until 1992 after Cambier et al reported the clinical use of Gianturco coils, transcatheter duct closure quickly became a broadly used technique for closure of the small-to-moderate PDA. Subsequently, newer devices developed such that moderate and large patent ductuses are usually amenable to closure simply by transcatheter approaches, particularly with using the Amplatzer duct occluder (ADO). Nevertheless, the current standard method for transcatheter duct closure using the ADO still requires puncturing the femoral artery for angiography to determine the duct morphology in order to choose a proper ADO and to monitor residual shunting and occluding results.

Angiography introduces potential vascular complications that may accompany femoral artery puncture, x-ray radiation, and contrast agent side effects or toxicity, thus increasing the procedural time and complexity. If the duct configuration and size can be accurately assessed by non-invasive transthoracic echocardiography (TTE), the procedure will be further simplified. To overcome these drawbacks, we have developed a simplified method for transcatheter duct closure by using TTE as a main procedural guidance except for brief fluoroscopy to create the device delivery track, thereby avoiding the femoral artery puncture and multiple intraprocedural aorta-angiographies. The experience over 15 years in our center has shown that the simplified method is not only as safe and efficacious as the standard method for duct occlusion, but also superior to the standard method in reduction of procedural time and complexity, cumulative radiation dose, and vascular complications, and is also particularly suitable for duct closure in younger children with low body weight, infants, and neonates. In parallel with the simplified method for transcatheter duct closure, surgeons at our center have also attempted less invasive surgical techniques, ie, transthoracic peripulmonary duct closure; however, it seems not to offer extra benefits for patients.

Imagine — if we can close PDAs with a faster, simpler, and safer technique, or fix it within half an hour, what an exciting thing it will be!

Professor Lianglong Chen, MD is the Chairman of Cardiology at the Affiliated Union Hospital, Fujian Medical University, The PR of China.

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