Intracardiac Echocardiography as a Guide for Transcatheter Closure of Patent Ductus Arteriosus

Abstract

Background: Transcatheter closure of patent ductus arteriosus (TC-PDA), conventionally guided by aortography, has become the standard treatment of this disease. The purposes of this study were to evaluate whether intracardiac echocardiography (ICE) may be used for measuring PDA size and be used as a guide for TC-PDA.

Methods: This study had 2 phases. In phase 1, we compared the measurements of PDA size: pulmonary artery side diameter (PA-D), length, and aortic side diameter (Ao-D) of PDA, as measured by ICE with those measured by aortography or cardiac computed tomography (AoG/CCT) in 23 patients who underwent TC-PDA. In phase 2, we compared the demographics, fluoroscopic time, contrast volume, and complications of the TC-PDAs between 10 adult patients with ICE guidance and 16 without it.

Results: In phase 1, we found great correlation and agreement between ICE and AoG/CCT in PA-D (r = 0.985, bias -0.077 to 0.224), but moderate to poor correlation and agreement in length (r = 0.653, bias -0.491 to 3.065) and Ao-D (r = 0.704, bias 0.738 to 4.732), respectively. Nevertheless, all patients underwent successful TC-PDA with ICE guidance that allowed us to continuously monitor the whole process. In phase 2, TC-PDA required a significantly lower contrast volume with ICE guidance than without it, and there was no significant difference in the remaining variables between the 2 groups.

Conclusion: ICE is comparable to AoG/CCT in providing accurate PA-D of the PDA and may be a safe alternative to guide TC-PDA as compared to conventional aortography.

Figure 1

Representative image of MPA and LPA views of PDA using ICE. (a) The MPA view shows the aortic short axis view. (b) The LPA view shows the PDA long axis. A‐Ao, ascending aorta; Ao, aorta; ICE, intracardiac echocardiography; LPA, left pulmonary artery; MPA, main pulmonary artery; PA, pulmonary artery; PDA, patent ductus arteriosus.

Figure 2

PDA measurement methods in LPA view using ICE. (A) The pulmonary artery side diameter of the PDA. (B) The lower contour PDA length between the end of the PA and the starting point of the aortic ampulla. (C) The aortic side diameter of the PDA. Ao, aorta; ICE, intracardiac echocardiography; PA, pulmonary artery; PDA, patent ductus arteriosus; LPA, left pulmonary artery.

Figure 3

Representative case where ICE is a valuable guide for TC-PDA. Patient 23 has a large Krichenko type B PDA that was not delineated by an aortography (a) but was clearly visualized by ICE (closed circle) with a 11.1 mm PA side diameter and a 3.9 mm length (b). We chose Amplatzer septal occluder 17 mm for the closure of this PDA. During TC-PDA, ICE showed all process of procedure. We advanced a long sheath (arrowhead) through the PDA (c), opened the aortic skirt in the aorta (d), and pulled the entire system back and deployed right atrial disc (e). Finally, ICE showed small residual shunt just beside the body of device (f) and we finished the procedure successfully. Ao, aorta; ICE, intracardiac echocardiography; PA, pulmonary artery; PDA, patent ductus arteriosus; TC- PDA, transcatheter closure of patent ductus arteriosus.

Figure 4

Correlations of measurements between the ICE and aortography or CCT. There was significantly highly positive correlation in measurements of the PA side diameter between ICEs and aortographies or CCTs ((a) r = 0.985, 95% confidence interval 0.967–0.993, p < 0.0001), but moderate correlation in measurements of the length ((b) r = 0.653, 95% confidence interval 0.356–0.830, p < 0.0003) and aortic side diameter of the PDA ((c) r = 0.704, 95% confidence interval 0.435–0.858, p < 0.0001) between them. AoG, aortography; CCT, cardiac computed tomography; ICE, intracardiac echocardiography; PA, pulmonary artery; PDA, patent ductus arteriosus.

Figure 5

Bland–Altman plots between the ICE and aortography or CCT. On the Bland–Altman plot, there were the greatest agreement in the PA side diameter between ICE and aortography or CCT ((a) mean bias 0.074 mm with 95% confidence interval −0.077 to 0.224), but moderate agreement in length ((b) mean bias 1.287 mm with 95% confidence interval −0.491 to 3.065) and poor agreement in the aortic side diameter ((c) mean bias 2.735 with 95% confidence interval 0.738 to 4.732) with statistically significantly higher value measured by aortography or CCTs (p < 0.01). AoG, aortography; CCT, cardiac computed tomography; ICE, intracardiac echocardiography; PA, pulmonary artery; PDA, patent ductus arteriosus.