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Canadian Journal of Cardiology

Device Closure of Patent Ductus Arteriosus in Adults

  • Michael L. O’Byrne
    Correspondence
    Corresponding author: Dr Michael L. O’Byrne, Division of Cardiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, Pennsylvania 19104, USA. Tel.: +1-215-5900-1790.
    Affiliations
    Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

    Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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  • Christopher L. Smith
    Affiliations
    Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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  • Matthew J. Gillespie
    Affiliations
    Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Published:October 25, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.022
      Patent ductus arteriosus (PDA) are essentially universally present at birth, although most close in the first few weeks of life. Persistence of PDA beyond this period occurs in between 2 and 4 per 1000 live births.
      • Hoffman J.I.E.
      • Kaplan S.
      • Liberthson R.R.
      Prevalence of congenital heart disease.
      ,
      • Hoffman J.I.E.
      • Kaplan S.
      The incidence of congenital heart disease.
      Surgical ligation of PDA was first performed by Gross and colleagues in 1939,
      • Gross R.E.
      • Hubbard J.P.
      Surgical ligation of a patent ductus arteriosus: report of first successful case.
      but the development of the Amplatzer Duct Occluder (Abbott, Santa Clara, CA [St. Jude Medical, St Paul, MN]) has allowed for device closure of PDA by interventional cardiologists with excellent technical success and minimal morbidity, supplanting operative ligation in all but the smallest patients. In recent years, interventional cardiologists have adapted existing technology and have demonstrated that PDA closure can be accomplished in even the smallest premature infants,
      • Sathanandam S.
      • Balduf K.
      • Chilakala S.
      • et al.
      Role of transcatheter patent ductus arteriosus closure in extremely low birth weight infants.
      • Schwartz M.
      • Glatz A.C.
      • Rome J.J.
      • Gillespie M.J.
      The Amplatzer vascular plug and Amplatzer vascular plug II for vascular occlusion procedures in 50 patients with congenital cardiovascular disease.
      • Abu Hazeem A.A.
      • Gillespie M.J.
      • Thun H.
      • et al.
      Percutaneous closure of patent ductus arteriosus in small infants with significant lung disease may offer faster recovery of respiratory function when compared to surgical ligation.
      • Zahn E.M.
      • Peck D.
      • Phillips A.
      • et al.
      Transcatheter closure of patent ductus arteriosus in extremely premature newborns: early results and midterm follow-up.
      • Backes C.H.
      • Rivera B.K.
      • Bridge J.A.
      • et al.
      Percutaneous patent ductus arteriosus (PDA) closure during infancy: a meta-analysis.
      • Backes C.H.
      • Kennedy K.F.
      • Locke M.
      • et al.
      Transcatheter occlusion of the patent ductus arteriosus in 747 Infants.
      • O'Byrne M.L.
      • Millenson M.E.
      • Grady C.B.
      • et al.
      Trends in transcatheter and operative closure of patent ductus arteriosus in neonatal intensive care units: an analysis of data from the Pediatric Health Information Systems Database.
      a trend that will likely accelerate with availability of the Piccolo PDA occluder (formerly referred to as the Amplatzer Duct Occluder II Additional Sizes). An initial case series describing the use of this device in older patients has been published,
      • Bruckheimer E.
      • Godfrey M.
      • Dagan T.
      • Levinzon M.
      • Amir G.
      • Birk E.
      The Amplatzer Duct Occluder II Additional Sizes device for transcatheter PDA closure: initial experience.
      and trial data of its use in premature infants are expected soon.

      Limited Contemporary Data About PDA Closure in Adults

      Even with some controversy regarding the utility of closing small-diameter PDA,
      • Fortescue E.B.
      • Lock J.E.
      • Galvin T.
      • McElhinney D.B.
      To close or not to close: the very small patent ductus arteriosus.
      • O'Byrne M.L.
      • Kennedy K.F.
      • Rome J.J.
      • Glatz A.C.
      Variation in practice patterns in device closure of atrial septal defects and patent ductus arteriosus: An analysis of data from the IMproving Pediatric and Adult Congenital Treatment (IMPACT) registry.
      • Feltes T.F.
      • Bacha E.
      • Beekman R.H.
      • et al.
      Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association.
      the vigilance of primary care physicians, combined with the ability to close PDA with minimal morbidity in the catheterization laboratory, has led to most PDA being treated well before patients reach adult age. Consequently, there is a dearth of information regarding PDA closure in older patients in the current era. In the largest series of PDA closure in practice from the United States Improving Pediatric and Adult Congenital Treatment (IMPACT) registry, 2.5% of cases were performed in adults.
      • O'Byrne M.L.
      • Kennedy K.F.
      • Rome J.J.
      • Glatz A.C.
      Variation in practice patterns in device closure of atrial septal defects and patent ductus arteriosus: An analysis of data from the IMproving Pediatric and Adult Congenital Treatment (IMPACT) registry.
      Outcomes were excellent, with no reported cases of residual shunt or device embolization.
      • Moore J.W.
      • Vincent R.N.
      • Beekman R.H.
      • et al.
      Procedural results and safety of common interventional procedures in congenital heart disease: initial report from the National Cardiovascular Data Registry.
      Compared with non-infant children, adult patients were more likely to have spontaneous bacterial endocarditis prophylaxis and pulmonary hypertension as indications for intervention, although left-ventricular volume overload remained the most common indication.
      • Moore J.W.
      • Vincent R.N.
      • Beekman R.H.
      • et al.
      Procedural results and safety of common interventional procedures in congenital heart disease: initial report from the National Cardiovascular Data Registry.
      Though data from this large registry are helpful, they have provided limited insight into the specific technical concerns in adults. In addition, in its initial iteration, the registry does not contain data about outcomes after hospital discharge for any patients. In the last 10 years, several small case series of PDA closure in adults have been published,
      • Putra S.T.
      • Djer M.M.
      • Idris N.S.
      • Sastroasmoro S.
      Transcatheter closure of patent ductus arteriosus in adolescents and adults: a case series.
      • Sudhakar P.
      • Jose J.
      • George O.K.
      Contemporary outcomes of percutaneous closure of patent ductus arteriosus in adolescents and adults.
      • Behjati-Ardakani M.
      • Rafiei M.
      • Behjati-Ardakani M.A.
      • Vafaeenasab M.
      • Sarebanhassanabadi M.
      Long-term results of transcatheter closure of patent ductus arteriosus in adolescents and adults with Amplatzer Duct Occluder.
      but they also are limited by their relatively small individual size and lack of postprocedural follow-up.

      PDA Closure in Adults: The Toronto Experience

      In this current issue of the Canadian Journal of Cardiology, Wilson and colleagues report on a 17-year 161-patient experience of transcatheter PDA closure,
      • Wilson W.M.
      • Shah A.
      • Osten M.D.
      • et al.
      Clinical outcomes postpercutaneous patent ductus arteriosus closure in adults.
      which is, to our knowledge, the largest series in the literature. It is an impressive experience for a single centre. The authors should be congratulated for carefully collecting patient-level data and using predefined definitions of left-ventricular volume overload and pulmonary hypertension, which helps the reader to understand their case mix. This allows readers to apply data from this series to their own practices with confidence. This is especially an improvement over the early experience with the IMPACT registry, in which discrepancies between measured hemodynamics and the reported indication for the procedure were common.
      • O'Byrne M.L.
      • Kennedy K.F.
      • Rome J.J.
      • Glatz A.C.
      Variation in practice patterns in device closure of atrial septal defects and patent ductus arteriosus: An analysis of data from the IMproving Pediatric and Adult Congenital Treatment (IMPACT) registry.
      The authors' experience is substantial, and their results are excellent. Consistent with studies in children,
      • Moore J.W.
      • Vincent R.N.
      • Beekman R.H.
      • et al.
      Procedural results and safety of common interventional procedures in congenital heart disease: initial report from the National Cardiovascular Data Registry.
      technical success was achieved in almost all cases with small residual shunts in 2 of 161 cases (1.2%; 95% CI, 0.1%-4.4%). Moreover, because of their pooled experience, they can provide insights into closure that are useful for structural or congenital cardiologists for whom PDA closure in adult patients is relatively rare. For instance, with the exception of window-like PDA, they were able to use the first-generation Amplatzer Duct Occluder. They also suggest “upsizing” the device relative to the package indications for use, which recommend selecting a device with a smallest diameter 2 mm greater than the smallest diameter of the duct. In smaller patients, there is pressure to use smaller devices and other shapes to avoid impingement or compression of surrounding vascular structures: specifically, compression of the roof of the left pulmonary artery (LPA) or extension of the larger diameter disk into the aorta. The authors' experience demonstrates that these conventional concerns are less of a concern in an adult-sized patient than inadvertently undersizing a device. This is especially true because PDA tissue has demonstrated the capacity to spasm during catheterization.
      • Batlivala S.P.
      • Glatz A.C.
      • Gillespie M.J.
      • Dori Y.
      • Rome J.J.
      Ductal spasm during performance of transcatheter ductal occlusion.
      Second, even in a series with a high prevalence of documented pulmonary hypertension (36% of cases), the authors were able to use the asymmetric first-generation Amplatzer Duct Occluder. Previous studies have advocated using a device that places discs on both sides of the duct to better secure it in cases of patients with pulmonary hypertension.
      • Yan C.
      • Zhao S.
      • Jiang S.
      • et al.
      Transcatheter closure of patent ductus arteriosus with severe pulmonary arterial hypertension in adults.
      The authors do not report if any of their cases had severe elevation of pulmonary vascular resistance, but it may prove possible (with device oversizing) that a large pulmonary artery disc is not necessary.
      Finally, the authors provide postprocedural follow-up (median: 2 months) with no episodes of late complications. They should be applauded for providing for their effort and transparency. There have not been reports of late complications, but providing this information (which is not in any other series to our knowledge) is helpful.
      Collectively, the authors have detailed a unique experience, which represents a useful contribution to the structural and congenital interventional cardiology communities’ knowledge about this procedure in this special population.

      Funding Sources

      Dr O’Byrne receives research support the United States National Institue of Health/National Heart Lung and Blood Institute (K23 HL130420-01) and the Robyn Barst Fund. The funding agencies had no role in the planning or execution of this editorial. The manuscript represents the opinions of the authors alone.

      Disclosures

      Dr Gillespie is a consultant for Abbott and Medtronic. Both companies manufacture devices currently in use for PDA closure in small infants. Dr O’Byrne and Smith have no conflicts of interest to disclose.

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