Transcatheter Closure of Patent Ductus Arteriosus in Infants With Weight Under 1,500 Grams

Abstract

Persistent patent ductus arteriosus (PDA) is very common in preterm infants, especially in extremely preterm infants. Despite significant advances in management of these vulnerable infants, there has been no consensus on management of PDA-when should we treat, who should we treat, how should we treat and in fact there is no agreement on how we should define a hemodynamically significant PDA. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) remains the first line of therapy with moderate success rate in closing the PDA. Paracetamol has been reported to be a safe and equally effective medical therapy for closure of PDA. However, additional studies on its long-term safety and efficacy in extremely low birth weight infants are needed before paracetamol can be recommended as standard treatment for a PDA in preterm infants. Surgical ligation of PDA is not without an increased risk of mortality and co-morbidities. Recently, there has been a significant interest in percutaneous transcatheter closure of PDA in preterm infants, including extremely low birth weight infants. Transcatheter PDA closure in preterm ELBW infants is technically feasible with high PDA occlusion success rates and acceptable complication rates as compared to surgical ligation. Many centers have reported promising early- and mid-term follow-up results. However, they need to be further tested in the prospective well-designed studies and randomized controlled trials comparing the results and outcomes of this technique with current treatment strategies including medical treatment before they can be used as the new standard of care for PDA closure in extremely low birth weight infants.

Keywords: extremely preterm infants; patent ductus arteriosus; patent ductus arteriosus (PDA); percutaneous closure; prematurity; transcatheter closure.

Figure 1

Devices generally used for percutaneous PDA closure in premature babies. (A) Amplatzer Ductus Occluder II Additional Sizes / Piccolo Occluder (Abbott). (B) Amplatzer vascular plug II (Abbott). (C) MVP Microvascular Plug (Medtronic).

Figure 2

Most common ductal morphology in premature babies undergoing percutaneous closure. (A,B) Showing type “C” tubular ductus without any constrictions at the aortic end or the pulmonary artery end. (C,D) Showing a “fetal type” ductus, which is typical long, wide and tortuous.

Figure 3

PDA morphology and size are extremely variable in premature babies. Angiogram helps to delineate duct features, accurately measures both PDA's aortic and pulmonary ends and choose the most appropriate device. Angiogram performed through a catheter via RV—MPA—PDA—Descending aorta. Six types of described PDA morphologies have been demonstrated in figures (A–F). (A) Relatively long duct with mid-course constriction. (B) Long and tortuous duct with pulmonary end constriction. (C) Long and tortuous duct with widely open pulmonary and aortic ends. (D) Short duct with pulmonary end constriction and LPA origin stenosis. (E) Extremely large and dilated duct (note that its diameter is bigger than descending aorta) and (F) Long and tortuous duct with variable diameter along its course (RV, right ventricle; MPA, main pulmonary artery; LPA, left pulmonary artery; PDA, patent ductus arteriosus).

Figure 4

Complications encountered after PDA device closure. (A) Shows LPA origin stenosis following percutaneous closure, which is fully resolved 5 months after follow-up (B). (C) Mild aortic coarctation after device deployment, which is fully resolved after 11 months of follow-up (D). (E) Tricuspid valve trauma noted after successful PDA device closure. (F) Tricuspid regurgitation is trivial 12 months after the procedure.