1. PDA closure
G Agnoletti
Citta’ della Salute
gagnoletti@cittadellasalute.to.it
Torino, Italy
IPC 9th Milan, March 2013

2. Is PDA a congenital heart
disease?

3. • PDA is not a congenital heart disease
• can be life saving
• can be unuseful
• can be dangerous WE WANT TO CLOSE IT
• can be lethal

4. Embriology
•Absent or
anomalous in PA
type III-IV
•Absent
pulmonary
valve…
•Truncus
arteriosus

5. Prenatal circulation
O2 saturation : 55% Cardiac output : 59%

6. At Birth
PVR/SVR from 10 to 1/3 in few s.
In the preterm infant:
osystolic steal, reversed flow, pulmonary
congestion
In the newborn:
ospontaneous constriction, due to increased PaO2,
then fibrous occlusion
PDA if the arterial duct is still patent after 1 month

7. Classification

8. What ONLY matters for clinical
implications of ISOLATED DBP is its size
What matters for percutaneous closure are
patient age and weight, PDA size, PDA
shape (size of the aortic isthmus, size of the
ampulla, lenght of the PDA, size of LPA...)

9. Imaging in children and adult patients

10. PDA
Small: no symptoms, sometimes systolic
murmur, low risk of endocarditis
Attitude: varies in accordance with the
institution policy
Large: ventricular overload, pulmonary
hypertension, congestive heart failure
Attitude: percutaneous closure

11. Eisenmenger ?

12. PDA in preterm infants
Attitude: closure
o medical treatment
o surgical treatment (ligation - suture)
medical - surgical implications, residual shunt
o percutaneous treatment (?????) few cases
reported - technical implications

13. PDA in babies, children, adults
Attitude: closure
• if ventricular overload
• if PH
• if murmur
• to prevent endocarditis?
• to allow intense physical activity?

14. Endocarditis?
Silent patent ductus arteriosus endarteritis. Heart 2000

15. All PDAs should be closed?

16. Is easy to close a PDA?

17. Devices and ideas
How shall I close a hole?
Generally putting something
inside....or simply covering it....
cover
occlude
(dissection)

18. The beginning
Percutaneous transfemoral closure of the the patent
ductus arteriosus - an alternative to surgery
Porstmann W Semin Roentgenol. 1981
First percutaneous procedure: Rashkind 60s

19. Double umbrella Raskind device
To close a communication I want to
cover both sides
Drawbacks: residual shunt, obstruction,
migration, fracture, retrievability but no
repositionability…

20. Coils bare and hairy

21. Coils
oFrom venous or arterial side
oMultiple coils possible
oRetrievability and repositionability
oBetter for small PDA
oCheap
Drawbacks: residual shunt (hemolysis),
migration

22. Coils
o Not too large..
o Not tubular..
o Not window like..
o Not too small…
oNo tortuous..
Still I do use coils…..

23. Complications
Severe intravascular hemolysis.. J Invasive Cardiol 2005
Residual shunt at 24 h 30-57% …

24. Occluding devices
To close a communication I
want to stent it….

25. ADO I

26. Stenting the duct with an occlusive
device
The AGA system
ADO I ADO II

27. AGA system : ADO I
Advantages
• From the venous side
• Retrievable
• Repositionable
• High rate immediate
occlusion
• Occlusion of large PDA
Disadvantages
• Iatrogenic coarctation
• Absence of pulmonary disc
• Migration (aorta or PA)
• Difficult retrivability after
migration
• Residual shunt and
haemolysis
• Bleeding !

28. Complications
migration

29. Complications
migration

30. AGA system : ADO I
Very large PDAs can be closed
3yr-old african girl with heart failure
LL OAD post 14-12…..

31. AGA system : ADO I
Very large PDAs can be closed
post 16-14..

32. AGA system : ADO I
Large PDAs in small babies
LL OAD large ampulla and
isthmus

33. AGA system : ADO I
Large PDAs in small babies

34. AGA system : ADO I
Large PDAs in small children
Concerns: Anatomy of the PDA, tricuspid angle,
rigidity of the system, small aortic isthmus

35. AGA system : ADO I
Large PDAs in very small children ???
Concerns: Anatomy of the PDA, tricuspid angle,
rigidity of the system +++, small aortic isthmus,
venous/arterial access.. (< 2Kg babies…)

36. Peculiar cases…
Spasm of the arterial duct

37. Peculiar cases…
Spasm of the arterial duct
Heart 2005
Rev Esp Cardiol. 2012

38. The ADO II device
ADO II:fabric-free fine nitinol wire, 2 very low profile
disks, articulated connecting waist. Antegrade or
retrograde approach.
Advantages: reduced sheath sizes and softer shape
Reports: protrusion into the aortic isthmus or pulmonary
artery

39. The ADO II device
?
easy to retrieve…

40. ADO II AS
•Few preliminary reports
•Good results
•Easy, premounted (generally..), navigability +++
•No obstruction, no migration, no residual shunt,
variety of different anatomies …
Early clinical experience with a modified Amplatzer ductal Occluder for transcatheter arterial duct
occlusion in infants and small children. Kenny D et al, Catheter Cardiovasc Interv 2012
Closure of the patent ductus arteriosus with the new duct occluder II addotional sizes device.
Agnoletti G et al Catheter Cardiovasc Interv 2012
Closure of a large ductus arteriosus in a preterm infant using the ADO II AS device. Agnoletti G et al.
Heart 2012

41. PDA closure in preterm babies?

42. Occlusion of a PDA in a 2 Kg baby with
heart failure

43. Occlusion of a PDA in a 2 Kg baby with
heart failure

44. Peculiar cases…
PDA and aortic coarctation

45. ADO II AS for different types of PDAs

46. ADO II AS for different types of PDAs

47. ADO II AS for different types of PDAs

48. ADO II AS
from the venous side

49. ADO II AS
from the arterial side
You can inject in the sheath

50. PDAs in twins …coils or ADO II AS?
Enea and Jacopo

51. J Invasive Cardiol 2011
Nit-Occlud PDA-R
(Reverse) Device

52. Large PDA in small children
After failed percutaneous closure
Perventricular Device Closure of Patent Ductus Arteriosus:
A Secondary Chance
Ann Thorac Surg 2012

53. PDA or APW?
1800 g

54. Conclusions
•All PDAs can be closed percutaneously ?
•All PDAs should be closed percutaneously ?
•Almost always feasible
•Almost always successful…
•Different devices for different patients…
•Complications can occur

55. Conclusions
Good new: you recover from DA patency
!

56. Also for our pet friends…