Incidence and fate of device‐related left pulmonary artery stenosis and aortic coarctation in small infants undergoing transcatheter patent ductus arteriosus closure

Abstract

Objectives: To evaluate short-and middle-term outcomes after transcatheter patent ductus arteriosus (TC-PDA) closure in small infants, specifically device-related left pulmonary artery (LPA) stenosis and aortic coarctation, risk factors, and changes over time. Background: Recent studies have demonstrated successful transcatheter PDA (TC-PDA) closure in small infants. LPA stenosis and aortic coarctation have been seen after TC-PDA, but it is not clear whether device-related LPA/aortic obstruction persists. Methods: A single-center retrospective study of infants ≤4 kg who underwent TC-PDA closure from February 1, 2007 to September 1, 2018 was performed, evaluating the incidence and risk factors for LPA stenosis and coarctation. Results: Forty-four patients underwent successful TC-PDA with Amplatzer Vascular Plug II (AVPII; n = 30), Amplatzer Duct Occluder II-Additional Sizes (n = 10), Amplatzer Duct Occluder I (n = 3), and coil-filled AVPI (n = 1) devices, all via an antegrade approach. Median birthweight and procedural weight were 890 g (range: 490-3,250) and 2.8 kg (range: 1.2-4.0), respectively. Median follow-up was 0.7 years (range: 2 days-7 years). Thirty-eight patients had post-procedure echocardiograms assessing LPA/aortic obstruction. Of those, 17 had LPA flow acceleration/stenosis (≥1.5 m/s), which improved or resolved in all patients with available follow-up; 3 developed mild coarctation (>2 m/s), which improved in the two with more than short-term follow-up; 4 developed mild flow acceleration (1.5-2 m/s) in the descending aorta, which resolved in three and increased in one (2.4 m/s). Flow acceleration in the LPA was associated with younger procedural age, larger PDA minimal diameter, and placement of a device other than the AVPII. There was no device-related mortality or need for reintervention. Conclusion: TC-PDA in small infants is effective, without significant complications. Device-related LPA/aortic obstruction can improve with time/growth.

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

“…Even in those few patients where LPA velocity increased to values above normal (2.0-2.4 m/s) during implant and/or the first 24 h post-procedure, true LPA stenosis did not develop in follow-up, and in fact velocities returned to normal pre-procedural levels over time. This is similar to other published reports, which suggest that mild intraprocedural increases in LPA velocity can be a common finding (20-39% reported in the literature) [23,36] but largely transient, with the development of true LPA stenosis in follow-up occurring in only 0-3% of patients and even fewer requiring any intervention [13-15, 23, 26, 32]. The single patient in the current study who developed significant device-related LPA stenosis had an immediate post-implant LPA Doppler velocity > 2.5 m/s, suggesting that while post-implant LPA velocity of 2.0 m/s or slightly higher is typically benign, there may be a Doppler velocity cutoff value where stenosis is more likely to develop.…”

“…A smaller but significant number of cases of post-procedural DAO obstruction have been reported following TCPC in EPNs [23,35,36]. When DAO obstruction is mild and associated with only mild increases in Doppler velocity (< 2.0 m/s) it appears to be most often related to the superior aspect of the aortic disk of either the AVP II or Piccolo device extending slightly out of the aortic ductal ampulla and into the aortic lumen, despite proper device positioning and sizing.…”

“…A large multi-center French national registry study recently reported on successful TCPC in 101/102 infants weighing < 2.3 kg, with 3 patients developing LPA obstruction requiring treatment (2 surgery, 1 angioplasty) and 2 cases of DAO obstruction (1 requiring surgery and 1 with no evidence of clinical coarctation) [35]. Recently, Tomasulo et al [36] reported device-related LPA Doppler flow velocity acceleration in 39% (17/44) of cases in a population weighing < 4 kg who underwent TCPC. While this relatively high incidence may be partially explained by a lower threshold for defining flow acceleration or stenosis (> 1.5 m/s), all patients with LPA acceleration in their study appeared to improve in follow-up, as did 3/4 patients with DAO flow acceleration.…”

“…Increased risk for LPA or DAO obstruction has been linked to smaller patient size, larger PDA diameter and shorter ductal length (high ductal diameter:length ratio), type of ductus (e.g., window-like), and larger device [30,[36][37][38][39]. All of these factors may contribute to LPA flow disturbances and obstruction resulting from two potential mechanisms: proximal disk protrusion from the ductus directly obstructing the LPA orifice, and/or external compression of the LPA from an oversized device in the ductus exerting radial force upon it after implantation.…”

Early experience with the Micro Plug Set for preterm patent ductus arteriosus closure

“…Some report transient LPA stenosis from ductal spasm 1 or device obstruction both which improve with somatic growth and time. 21 We acknowledge direct comparison of our early report of a small series of patients to larger [n = 22 (median); 10-200], predecessor reports may be flawed.…”