Fate of the Left Pulmonary Artery and Thoracic Aorta After Transcatheter Patent Ductus Arteriosus Closure in Low Birth Weight Premature Infants

Abstract

Transcatheter patent ductus arteriosus closure (TCPC) is an emerging treatment for low birth weight extremely premature neonates (EPNs). Left pulmonary artery (LPA) and descending aorta (DAO) obstruction are described device-related complications, however, data on mid- and long-term vascular outcomes are lacking. A retrospective analysis of EPNs who underwent successful TCPC at our institution from 03/2013 to 12/2018 was performed. Two-dimensional echocardiography and spectral Doppler velocities from various time points before and after TCPC were used to identify LPA and DAO flow disturbances. A total of 44 EPNs underwent successful TCPC at a median (range) procedural weight of 1150 g (755–2500 g). Thirty-two (73%) patients were closed with the AVP II and 12 (27%) with the Amplatzer Piccolo device. LPA and DAO velocities on average remained within normal limits and improved spontaneously in long-term follow up (26.1 months, range 1–75 months). One patient, who had concerning LPA flow characteristics immediately after device implant (peak velocity 2.6 m/s) developed progressive LPA stenosis requiring stent placement 3 months post-procedure. In the remaining infants, including 7 (16%) who developed LPA and 3 (7%) who developed DAO flow disturbances (range 2–2.4 m/s), all had progressive normalization of flow velocities over time. TCPC can be performed safely in EPNs with a low incidence of LPA and DAO obstruction. In the absence of significant progressive vascular obstruction in the early post-procedure period, mild increases in LPA and DAO flow velocities tend to improve spontaneously and normalize in long-term follow-up.

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

“…A Doppler velocity greater than 2.5 m/s in combination with an obstructive flow pattern and twodimensional color Doppler imaging showing possible protrusion should not be ignored and warrants repositioning the device if can be done safely. Following PDA closure, the Doppler velocity in the descending aorta typically decreases, while the Doppler velocity in the LPA increases slightly, and in most cases the velocity remains below 2 m/s [29]. Intra-procedural Doppler velocity alone may not be a reliable indicator to declare an increased or decreased risk for subsequent obstruction and must be used in context with other imaging modalities noted herein.…”

Utility of Follow-Up Echocardiograms in Uncomplicated PDA Device Closures Performed After Infancy

“…Of these complications, left pulmonary artery and descending aorta stenosis are the complications that may be noted weeks to months after device placement [20,21,24,30]. Previous studies in infants have noted increased velocities in the LPA and DAo immediately after PDA device placement that generally remained stable or improved over time [18,20,25]. Actual catheterization or surgical interventions to relieve LPA or DAo stenosis in infants is relatively rare with the incidence ranging from 0 to 4% [20][21][22]25].…”

“…Complications associated with PDA device closure are well documented and include venous vascular damage, tricuspid valve damage, device embolization, left pulmonary artery stenosis, and descending aorta stenosis [18][19][20][21][22][23][24][25][26][27][28]. That said, most of these complications are noted early after device placement [20,21,24,28]. Close echocardiographic followup in patients with device complications are clearly indicated.…”

Spontaneous Closure of the Arterial Duct after Transcatheter Closure Attempt in Preterm Infants

“…Percutaneous closure is now considered safe, with high rates of success [ 3 , 4 , 5 ] even in infants <1000 g [ 6 ]. Still, there remain concerns about traumatic tricuspid regurgitation [ 7 , 8 ], iatrogenic left pulmonary artery (LPA) stenosis and coarctation of the aorta [ 9 ], and device embolization or migration, among other more anecdotic complications [ 10 ]. These rare complications can be life threatening and consensus guidelines have recently been published to prevent them, and to treat them in case of occurrence [ 11 ].…”