Percutaneous closure of the small patent ductus arteriosus using occluding spring coils.

OBJECTIVES: This report summarizes our experience with the use of occluding spring coils to close the small patent ductus arteriosus. BACKGROUND: Several patent ductus arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent ductus arteriosus in a small group of patients. This report describes our series of patients having patent ductus arteriosus closure with occluding spring coils. METHODS: Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent ductus arteriosus closure by occluding spring coils. Selection criteria were age > 6 months and narrowest patent ductus arteriosus internal dimension < or = 3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent ductus arteriosus and into the aortic diverticulum. Patent ductus arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging. RESULTS: Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent ductus arteriosus. Average ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent ductus arteriosus noted on color flow imaging. One patient did not have successful implantation. This patient had a 3.2-mm ductus, and two coils migrated to the distal left pulmonary artery and could not be retrieved. There were no deaths or any significant complications noted during early or late follow-up in these patients. CONCLUSIONS: Occluding spring coils may have additional application in closing the small patent ductus arteriosus.

High-risk angioplasty. Coarctation of the aorta after Norwood Stage 1.

This report describes 2 patients with hypoplastic left heart syndrome who developed severe coarctations of the aorta after Norwood Stage I procedures and subsequently survived recurrent ventricular fibrillation during successful percutaneous angioplasty. Although ventricular fibrillation has not been associated with hypoplastic left heart syndrome, postoperative Norwood Stage I, or angioplasty of isolated coarctations of the aorta, we believe that the complex physiology of our patients created conditions that precipitated ventricular tachycardia and ventricular fibrillation. We strongly recommend that follow-up of infants with hypoplastic left heart syndrome after Norwood Stage I operations be meticulous; that even mild coarctation be treated aggressively, to avoid progression to high-risk situations; and that interventionalists be prepared to manage malignant ventricular dysrhythmias whenever postoperative Norwood Stage I patients undergo percutaneous angioplasty for coarctation of the aorta.

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

Gastrointestinal 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.

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 arteriosus. 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.

Intraosseous infusion of dobutamine and isoproterenol.

Intraosseous infusion has been advocated as an emergency route in sick infants and children when intravenous access is not readily obtainable. Dobutamine hydrochloride and isoproterenol hydrochloride are useful emergency drugs that have not been studied when administered into the bone marrow. In a swine model, we compared the physiologic responses (heart rate, arterial pressure, and cardiac output) of dobutamine and isoproterenol infusions delivered intravenously and intraosseously during 20-minute intervals. We observed statistically significant effects of both dobutamine and isoproterenol delivered by the intraosseous route. In addition, the effects resulting from intraosseous infusion were statistically similar to those resulting from intravenous administration of these drugs. We conclude that the intraosseous infusion of dobutamine and isoproterenol is an effective and useful method for emergency administration of these medications.

Partial anomalous pulmonary venous drainage associated with 45,X Turner's syndrome.

Turner's syndrome has well-described associations with congenital heart disease. Up to one third of patients with karyotype 45,X may have coarctation of the aorta. In addition, patients with hypertrophic cardiomyopathy, septal defects, dextrocardia, and anomalous pulmonary venous drainage have been reported anecdotally. Twenty-one consecutive patients with Turner's syndrome were prospectively evaluated. All patients underwent examination by a pediatric cardiologist, electrocardiogram, chest radiograph, and echocardiogram. Three patients with evidence of right ventricular volume overload had cardiac catheterization. Of 12 patients with karyotype 45,X 3 had partial anomalous pulmonary venous drainage with intact atrial septum. One of the 3 also had moderate aortic stenosis. Two additional patients with 45,X had coarctation of the aorta and bicuspid aortic valve, and 4 other patients had minor cardiac defects. Of 9 patients with mosaic karyotype, 1 had a minor cardiac defect. The observations suggest that there may be a significant association of 45,X Turner's syndrome and partial anomalous pulmonary venous drainage.

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.

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.

Development of pulmonary arteriovenous malformations after modified Fontan operations.

Two patients with complex cyanotic congenital heart disease and without previous Glenn anastomosis underwent modified Fontan operations. Postoperatively, pulmonary arteriovenous malformations developed that resulted in cyanosis from significant intrapulmonary right-to-left shunting. These malformations were detected by pulmonary angiograms and contrast echocardiograms. Pulmonary arteriovenous malformations may be a major cause of late clinical deterioration in patients treated with modified Fontan operations.