William C. Kirby

Percutaneous closure of the small (< 2.5 mm) patent ductus arteriosus using coil embolization

Persistently patent ductus arteriosus (PDA) is a common form of congenital heart disease, occurring between 0.01 to 0.08% of live births.1 Surgical ligation by lateral thoracotomy is effective, yet carries procedural risks (potential bleeding, recurrent laryngeal nerve injury, exposure to general anesthesia and death [<1%]).2 In 1971, Porstmann et al3 described the first nonsurgical PDA closure with an Ivalon plug with an 18Fr arterial conduit. More recently, the Rashkind PDA double disc occlusion system has undergone extensive evaluation, with flow occlusion accomplished in 72 to 88% of cases attempted.4–6 The smaller Rashkind occluder requires an 8Fr delivery system. Rao et al7 described an occluder which may be introduced through a 7Fr catheter and reduces the crossing profile required. Nevertheless, technical limitations persist in patients whose PDA internal diameter is <2.5 mm. Techniques to facilitate cannulation of the very small ductus by the Rashkind delivery system, involving arterial cannulation and rendezvous of an exchange wire from femoral vein to contralateral artery,8 and ductal dilation with balloon angioplasty,9 have been described. These techniques require additional manipulations and procedural time, and may potentially increase patient morbidity. This report describes experience with an alternative technique for transcatheter closure of the very small ductus arteriosus using stainless steel coil embolization.

Use of an intravascular endoprosthesis (stent) to establish and maintain short-term patency of the ductus arteriosus in newborn lambs.

The feasibility of stenting the ductus arteriosus with a balloon-expandable vascular endoprosthesis was tested in 8 newborn lambs. Tantalum wire and stainless steel mesh coronary stents were implanted antegrade or retrograde by percutaneous transfemoral catheterization. One lamb died during the procedure from perforation of the aorta. In 7 lambs, the ductus arteriosus was crossed using endhole catheters and wires, and stents mounted on angioplasty catheters were expanded in the ductus arterisus. Six lambs had successful implantation and had maintained a sizeable patent ductus arteriosus at 2 h. We conclude that the feasibility of percutaneous stenting of the newborn ductus was demonstrated. By providing patency of the ductus arteriosus, stents may offer nonsurgical alternatives for palliation of cyanotic congenital heart disease and hypoplastic left heart syndrome

Stenting of the ductus arteriosus in hypoplastic left heart syndrome as an ambulatory bridge to cardiac transplantation

Abstract In this report, we describe an infant with HLHS, who underwent PDA stenting which allowed the infant to thrive as an outpatient without intervening surgical palliation. The patient eventually underwent successful cardiac transplantation at 3 months of age. The infant is well at 1 year after transplant follow-up.

Gastrointestinal hemorrhage after combined percutaneous angioplasty of aortic coarctation and valvuloplasty of aortic stenosis in an infant.

SummaryGastrointestinal hemorrhage has not been previously reported as a complication of dilating left-sided obstructive lesions. This report describes an infant who developed significant intestinal bleeding after combined angioplasty for aortic coarctation and valvuloplasty for aortic stenosis.

Hemodynamics and coronary blood flow during experimental aortic valvuloplasty: Comparison of the dual versus the single catheter methods

During thoracotomy 12 anesthetized swine were instrumented and valvuloplasty catheters were positioned at the aortic anulus. Thirty-second occlusions of the left ventricular outflow tract were performed with a single catheter (n = 34) and with simultaneous inflation of dual catheters (n = 47). Left anterior descending coronary artery blood flow fell to minimums of 15% of baseline flow (SD 13.9%) during single balloon occlusion and to 63.8% of baseline flow (SD 22.8%) during dual balloon occlusion. Main pulmonary artery flow fell to minimums of 13.6% of baseline flow (SD 17.3%) during single balloon occlusion and to 66.9% of baseline flow (SD 18.3%) during dual balloon occlusion. Femoral artery systolic pressure dropped to 20.1% of baseline pressure (SD 5.6%) during single balloon occlusion and to 82.6% of baseline pressure (SD 8.1%) during dual balloon occlusion. During single balloon occlusion, 8.5 (SD 3.5) premature ventricular contractions were observed and 2.8 (SD 1.6) premature ventricular contractions occurred during dual balloon occlusion. After deflation of the valvuloplasty catheters, the time to return of baseline flow in the left anterior descending coronary artery was 28.4 second (SD 23.2 seconds) with the single balloon method and 4.8 seconds (SD 3.7 seconds) with the dual balloon method. All of these differences were statistically significant (p less than .001). During occlusion of the left ventricular outflow tract by dual valvuloplasty catheters, there were better hemodynamics, higher coronary blood flows, and fewer premature ventricular contractions than during occlusion by a single catheter. After occlusion by dual catheters, returns to baseline coronary flows were more rapid than after single catheter occlusions. These data may have application to clinical aortic valvuloplasty.

Tolerance of normal aorta to oversized dual balloon valvuloplasty. Observations in a swine model: Technical note

The damage threshold during aortic valvuloplasty was determined in 12 normal swine subjected to inflation of oversized dual balloons. Catheters with combined balloon diameters of 1.2–2.0 times the aortic annulus were selected. Following completion of the procedure, the animals were sacrificed and examined for pathology. With combined balloon diameters less than or equal to 1.7 times the aortic annulus, there was no gross, or microscopic damage. In animals with combined diameters equal to 2 times the aortic annulus, there was rupture of the aorta. This data provides further basis for the selection of catheter sizes in dual balloon aortic valvuloplasty.