Echocardiographic versus Angiographic Measurement of the Patent Ductus Arteriosus in Extremely Low Birth Weight Infants and the Utility of Echo Guidance for Transcatheter Closure

Abstract

Background: Transthoracic echocardiography (TTE) is increasingly utilized for guiding transcatheter closure of patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objectives of this study were to compare PDA size measurements by TTE with angiographic measurements and to describe TTE techniques used in guiding transcatheter PDA closure (TCPC) in ELBW infants.Methods: One hundred twenty-five consecutive ELBW infants (gestational age < 27 weeks, birth weight < 1 kg) who underwent TCPC before 8 weeks of age under TTE guidance were included. Patent ductus arteriosus sizes were measured from the procedural TTE and angiograms retrospectively by blinded observers. The TTE PDA diameters at the aortic (ED1) and pulmonary end (ED2) were compared with the corresponding angiographic diameters (CD1 and CD2). The TTE PDA lengths, obtained by two techniques (EL1, a straight line between ED1 and ED2; and EL2, a curvilinear line along the PDA), were compared with the PDA length by angiography (CL). Transthoracic echocardiography was used to guide accurate device positioning within the PDA. Results:The procedure weight was 600-1,460 g. The TTE and angiographic PDA diameters were comparable (mean ED1 vs CD1 = 4.5 6 0.68 vs 4.4 6 0.85 mm, P = .26; and mean ED2 vs CD2 = 3.1 6 0.72 vs 3.2 6 0.94 mm, P = .14). The angiographic length was underestimated by EL1 by 2.6 6 1.6 mm (P < .0001), while EL2 estimated it better (mean EL2 vs CL = 11.0 6 1.83 vs 10.8 6 2.15 mm; P = .40). Transcatheter PDA closure was successful in 100% of the cases using TTE guidance. There were no intraprocedural complications.Conclusions: Transthoracic echocardiography guidance during TCPC in ELBW infants eliminates the need for aortograms via femoral arterial access, preventing the complications associated with it. Transthoracic echocardiography PDA measurements are comparable to angiographic measurements, thereby assisting in appropriate device size selection.

Consensus Guidelines for the Prevention and Management of Periprocedural Complications of Transcatheter Patent Ductus Arteriosus Closure with the Amplatzer Piccolo Occluder in Extremely Low Birth Weight Infants

“…Therefore, it is important to also assess the PDA dimensions using TTE prior to instrumentation. However, TTE may underestimate the PDA length [8]. • If there is inconsistency between angiography and TTE regarding the PDA size, then consider selecting the device size based on the modality that provides the larger PDA size.…”

“…With increased procedural experience a modified technique for transcatheter PDA closure was developed to minimize adverse events in ELBW infants [4][5][6]. The modified implant technique avoids arterial access and exclusively utilizes a transvenous antegrade approach guided by fluoroscopy, venous angiography, and transthoracic echocardiography (TTE) with placement of the entire device within an intraductal position to avoid aortic and pulmonary artery protrusion [7,8].…”

Use of the Medtronic Microvascular Plug 7Q for transcatheter closure of large patent ductus arteriosus in infants weighing less than 2.5 kg

“…To date, only the Amplatzer Piccolo Occluder (Abbott Structural Heart), is Food and Drug Administration (FDA) approved for preterm infants weighing ≥700 g 7 . However, this device is only suitable for PDA diameters measuring up to 4 mm and therefore up to 20% of hemodynamically relevant PDA's may be too large for closure with this device 2,3,7 …”

“…[4][5][6] To date, only the Amplatzer Piccolo Occluder (Abbott Structural Heart), is Food and Drug Administration (FDA) approved for preterm infants weighing ≥700 g. 7 However, this device is only suitable for PDA diameters measuring up to 4 mm and therefore up to 20% of hemodynamically relevant PDA's may be too large for closure with this device. 2,3,7 The MicroVascular Plug (MVP; Medtronic) is FDA approved and CE marked for vascular embolization. 8 The PDA morphology in extremely premature infants is long and tubular and resembles its fetal counterpart (F-type PDA).…”

“…[1][2][3] There is a growing body of evidence outlining the safety and efficacy of transcatheter PDA closure in this cohort. [4][5][6] To date, only the Amplatzer Piccolo Occluder (Abbott Structural Heart), is Food and Drug Administration (FDA) approved for preterm infants weighing ≥700 g. 7 However, this device is only suitable for PDA diameters measuring up to 4 mm and therefore up to 20% of hemodynamically relevant PDA's may be too large for closure with this device. 2,3,7 The MicroVascular Plug (MVP; Medtronic) is FDA approved and CE marked for vascular embolization.…”