Dealing With a Nightmare: A Case Report of Successful Percutaneous Treatment of an Embolized Occluder Device Complicating a Minimal-Fluoroscopy Patent Ductus Arteriosus Closure.

Patent ductus arteriosus (PDA) is one of the most prevalent acyanotic congenital heart diseases. Percutaneous closure of PDA has been the preferred treatment recommended by the guidelines due to relatively low complications and rapid patient recovery. However, device emboli remain the most frequent and disastrous complication, necessitating percutaneous or surgical treatment. We present a case of a large PDA closure in pulmonary arterial hypertension paediatric patients complicated with device emboli that was successfully retrieved using the snaring technique. Transcatheter retrieval, although technically challenging, is a feasible treatment and offers the advantage of avoiding the need for surgical intervention.

Comparison of Blalock-Taussig-Thomas Shunts With Patent Ductus Arteriosus Ligated Versus Left Open.

BACKGROUND: The optimal approach to patent ductus arteriosus management during systemic-to-pulmonary artery shunt placement is currently unknown. The purpose of this study is to examine the outcomes of variable strategies for patent ductus arteriosus management during Blalock-Taussig-Thomas shunt surgery. METHODS: A retrospective cohort study of infants who underwent shunt placement was performed, comparing those who had the ductus ligated with those who had the ductus left open. Indicators of low cardiac output syndrome, development of necrotizing enterocolitis, and secondary outcomes such as resuscitation events were examined. RESULTS: Thirty-six infants were included all of whom had their shunt placed via median sternotomy. Twenty infants had their ductus ligated at the time of the shunt, and they were compared with 16 infants whose ductus was left open. There was no statistical difference in preoperative baseline characteristics, including corrected gestational age, age in days, weight, mechanical ventilation, vasoactive use, heterotaxy, and gastrointestinal anomalies. There was also no statistical difference in postoperative indicators of low cardiac output, including urine production, total fluids given, renal injury, maximum lactate, and vasoactive-inotropic score. Three patients had postoperative renal injury, and all were in the ligated duct group. There was also no statistical difference in any secondary outcomes, including the development of necrotizing eneterocolitis, resuscitation events, reinterventions, length of intubation, total length of stay, and mortality. CONCLUSIONS: This study provides evidence that variable management of the ductus during shunt placement does not significantly impact outcomes. Leaving the ductus open allows for a potential rescue source of pulmonary blood flow and does not appear to increase the risk of postoperative low cardiac output.

Echocardiographic evaluation of left atrial volume and comparative analysis to left atrial to aortic root ratio in premature neonates and infants with patent ductus arteriosus.

PURPOSE: Left atrium to aortic root ratio (LA/Ao) is an echocardiographic marker of hemodynamically significant patent ductus arteriosus (PDA). Since 2-dimensional measurement of the ratio is geometrically limited, left atrial volume (LAV) which has 3-dimensional characteristics was investigated. The aim of this study was to determine a correlation between LA/Ao ratio and LAV as well as holodiastolic flow reversal in preterm neonates with and without a PDA. METHODS: A retrospective evaluation of neonates with and without PDA was performed. Targeted neonatal echocardiography evaluation of LA/Ao and LAV was measured from parasternal long-axis view and the apical 4 and 2-chamber views, respectively. Univariate and linear regression analysis were performed. RESULTS: 200 patients were included of whom 158 (79.0%) had a PDA shunt. The median gestational age at the time of echo was 27.4 weeks (IQR: 25.7-29.4 weeks). The median LA/Ao ratio was 1.51 (IQR: 1.26-1.83) and median LAV indexed to weight was  .91 mL/kg (IQR: .65-1.18 mL/kg). There was a significant correlation between LA/Ao and LAV indexed to weight in the PDA group (r2 = .080, p = .0003). LA/Ao ratio and LAV indexed to weight differed significantly between those with diastolic flow reversal versus no-flow reversal (LA/Ao, p = .003; LAV, p = .001). CONCLUSIONS: This study demonstrated a significant correlation between LA/Ao and LAV in preterm infants with PDA, with greater magnitude of discordance for LAV. The power of LAV versus LA/Ao in monitoring hemodynamically significant PDA requires prospective evaluation.

Narrative Review on Echocardiographic Evaluation of Patent Ductus Arteriosus in Preterm Infants.

Persistent Patent Ductus Arteriosus (PDA) is prevalent among extremely preterm infants, with its occurrence inversely related to gestational age. A persistent PDA correlates with increased mortality and morbidities such as intraventricular hemorrhage, pulmonary hemorrhage, chronic lung disease, bronchopulmonary dysplasia, and necrotizing enterocolitis as observed clinically. Conversely, numerous randomized controlled trials have failed to demonstrate significant benefits from PDA treatment. One contributing factor to these conflicting findings is that PDA affects each individual differently depending on the cardiovascular decompensation and its hemodynamic impact. PDA management should be based on the hemodynamic significance, rather than just the presence or size of PDA. This comprehensive narrative review paper describes echocardiographic parameters that allow a better understanding of the hemodynamic impact of PDA. A newer modality, like lung ultrasound, is also described here as an adjunct to assess the PDA impact on the lungs from pulmonary overcirculation.

Biventricular repair in low-weight patient with interrupted aortic arch and aortic atresia.

BACKGROUND: Aortic atresia with ventricular septal defect is a very rare congenital cardiac anomaly, especially in combination with aortic arch interruption. It is always challenging to choose the optimal treatment tactics for such patients. One of the possible types of intervention is the Yasui procedure. There are only 19 reported cases in the literature of aortic atresia with interruption of the aortic arch type B or C, and not a single clinical case of type A. CASE PRESENTATION: The proband was a 2-day-old boy with diagnosis: aortic atresia with a ventricular septal defect and interruption of the aortic arch type B. The child underwent a Yasui procedure without serious postoperative complications and with good long-term result. CONCLUSIONS: The Yasui procedure in patients with aortic atresia and interrupted aortic arch can be performed with minimal complications, even in low-weight patients.

A Comparison of Ductal Stenting and Surgical Shunts for Infants with Duct-Dependent Pulmonary Blood Flow: The Impact of Single Versus Biventricular Repair Pathways on Outcomes.

Ductal stenting (DS) is an alternative to the Blalock-Taussig-Thomas Shunt (BTTS) as initial palliation for congenital heart disease with duct-dependent pulmonary blood flow (DDBPF). We sought to analyze the impact of intended single ventricle (SV) and biventricular (BiV) repair pathways on the outcome of DS and BTTS in infants with DDPBF. A single-center, retrospective comparison of infants with DDPBF who underwent either DS (2012-2022) or BTTS procedures (2013-2017). Primary outcomes included all-cause mortality and risk of unplanned re-intervention. Participants were divided into four groups: 1.SV with DS, 2.SV with BTTS, 3.BiV with DS, and 4.BiV with BTTS. Fifty-one DS (SV 45%) and 86 BTTS (SV 49%) procedures were undertaken. For those who had DS, mortality was lower in the BiV compared to SV patients (BiV: 0/28, versus SV: 4/23, p = 0.04). Compared to BiV DS, BiV BTTS had a higher risk of combined death or unplanned re-intervention (HR 4.28; CI 1.25-14.60; p = 0.02). In SV participants, there was no difference for either primary outcome based on procedure type. DS was associated with shorter intensive care length of stay for SV participants (mean difference 5 days, p = 0.01) and shorter intensive care and hospital stay for BiV participants (mean difference 11 days for both outcomes, p = 0.001). There is a survival benefit for DS in BiV participants compared with DS in SV and BTTS in BiV participants. Ductal stenting is associated with a shorter intensive care and hospital length of stay.

A rare association of the absence of left pulmonary artery with ventricular septal defect, pulmonary hypertension, and more interestingly, patent ductus arteriosus in an adult patient: Case report and literature review.

Key Clinical Message: In this study, we introduced one of the rarest concomitants of the absence of left pulmonary artery (LPA), which was seen in our patient along with patent ductus arteriosus (PDA) and ventricular septal defect (VSD). Abstract: Unilateral absence of pulmonary artery (UAPA) is a congenital heart disease in association with other abnormalities such as tetralogy of Fallot and septal defects or isolated in 30% of cases and occurs in the right lung in two thirds of cases. Our case is a 33-year-old man who was hospitalized with symptoms of cough, shortness of breath, and hemoptysis. The echocardiography revealed a large ventricular septal defect, absent left pulmonary artery, and severe pulmonary hypertension (PH) along with patent ductus arteriosus. These findings were confirmed by CT angiography. This association has rarely been found in past studies. Due to PH and pulmonary infection, the patient was treated with intravenous prostaglandin and antibiotics. However, in cases of timely diagnosis and treatment of UAPA, fatal complications such as pulmonary hypertension, morbidity, and mortality are reduced. This case emphasizes the importance of awareness of this abnormality and its associated anomalies to enable early diagnosis and treatment.

Histomorphometric Study of the Tunics of Ductus Arteriosus in Human Fetal Cadavers Using the ImageJ Software.

INTRODUCTION: The ductus arteriosus (DA) connects the left pulmonary artery with the aorta during fetal life. Although it connects two elastic arteries, histological studies have shown that it is a muscular artery. There are very few studies on the histomorphometry of human fetal cadaveric DA. There are few studies on the changes in the tunics of the DA at various stages of fetal development. The present study aimed to observe the histomorphometric features of DA and its histological variations according to the gestational age of the fetus. METHODS: The study sample was DA dissected from 34 fetal cadavers of different gestational ages and stained with standard hematoxylin and eosin staining (H&E). We studied the structure of DA under a light microscope. We used ImageJ software (National Institutes of Health, Bethesda, Maryland) to measure the thickness of all three layers of the DA wall. RESULTS: The thickness of the DA wall was directly proportional to the gestational age of the fetus. In each trimester, we observed distinct histological changes in the tunics. CONCLUSION: The formation of multiple intimal mounds and the increase in intimal thickness observed during the last trimester are responsible for the closure of the ductus after birth. Elastosis is associated with patent DA. The disappearance of elastosis at a later gestational age ensures the closure of the ductus.

Use of echocardiography in percutaneous closure of patent ductus arteriosus at the Instituto Nacional de Salud del Niño, San Borja, Lima - Peru.

Objetive: Percutaneous occlusion of patent ductus arteriosus (PDA) has classically been performed entirely by fluoroscopy, however in recent years, transthoracic echocardiography (TE) has been used as an aid to fluoroscopy or entirely by echocardiography, which avoids access of femoral artery, use of contrast and decrease in time and dose of radiation exposure. The objective of this study was to evaluate the success rate with the use of TE in percutaneous PDA closure. Material and method: Descriptive, comparative, retrospective study between patients in whom PDA closure was performed with fluoroscopy plus angiography (group 1) and fluoroscopy plus ET (group 2), between January 2018 and December 2022. The data were obtained from the clinical history electronic and procedure report. Results: One hundred eight patients were analyzed, fluoroscopy group (n: 57) and TE (n: 51). The success rate in PDA occlusion using TE was 100% and 98% for the fluoroscopy group, with no statistically significant difference The average age of group 2 was 2.9 years, while the average age of group 1 was 5 years (p=0.001), the average fluoroscopy time in group 1 was 16.9 min and 4.71 min in group 2 (p < 0.001); the fluoroscopy dose in group 1 was 68.98 mGy and 5.17 mGy in group 2 (p<0.001). Krichenko, but without significant difference in both groups. Conclusions: The success rate of percutaneous PDA closure using echocardiography and fluoroscopy is appropiate, with a success rate similar to the classic technique. In addition, it makes it possible to reduce the dose and time of fluoroscopy, avoid the use of contrast, and access the femoral artery.

Objetivo: La oclusión percutánea del ductus arterioso persistente (DAP) clásicamente se ha realizado por fluoroscopía y angiografía; sin embargo, en los últimos años se está utilizando la ecocardiografía transtorácica (ETT) como ayuda a la fluoroscopía o íntegramente por ETT, lo que evita el acceso de arteria femoral, uso de contraste y disminución de tiempo y dosis exposición a la radiación. El objetivo del estudio fue evaluar la tasa de éxito con la utilización de la ETT en el cierre percutáneo del DAP. Materiales y métodos: Estudio descriptivo de tipo comparativo, retrospectivo, entre pacientes en quienes se realizó el cierre del DAP con fluoroscopía más angiografía (grupo 1) y fluoroscopía más ETT (grupo 2), entre enero 2018 y diciembre 2022. Los datos fueron obtenidos de la historia clínica electrónica y del informe del procedimiento. Resultados: Se analizaron 108 pacientes, de los cuales 57 pertenecen al grupo de fluoroscopía más angiografía y 51 al grupo de fluoroscopía más ETT. La tasa de éxito en la oclusión del DAP utilizando fluoroscopía más ETT fue del 100% y 98% para el grupo de fluoroscopía más angiografía, sin diferencia estadísticamente significativa. La edad promedio del grupo 2 fue de 2,9 años, mientras que la edad promedio del grupo 1 fue 5 años (p< 0,001), el tiempo promedio de fluoroscopía en el grupo 1 fue de 16,9 min y 4,7 min en el grupo 2 (p < 0,001); la dosis de fluoroscopía en el grupo 1 fue de 68,98 mGy y 5,17 mGy en el grupo 2 (p< 0,001). Se encontró que el tipo de DAP predominante fue el tipo A de Krichenko, pero sin diferencia significativa en ambos grupos. Conclusión: La tasa de éxito del cierre percutáneo del DAP con el uso de la ecocardiografía y fluoroscopia es adecuada, con un nivel de éxito similar a la técnica clásica, esto permite, además, disminuir la dosis y tiempo de fluoroscopia, evitar el uso de contraste y el acceso de la arteria femoral.

Hybrid palliation to promote growth of left ventricle and left ventricular outflow tract.

OBJECTIVES: In patients with borderline left hearts or a severe left ventricular outflow tract obstruction, hybrid palliation can be used to stabilize the patient and postpone biventricular repair (BVR). In this study, we analysed growth of left-sided structures and outcomes of these patients. METHODS: We conducted a retrospective cohort study including patients who received hybrid palliation between January 2010 and September 2023. Echo measurements were collected at hybrid palliation, BVR and last follow-up. Growth of left ventricular structures were analysed. RESULTS: In 38 patients, hybrid palliation was used to promote growth of left ventricular structures. In total, 15 patients received a Ross-Konno/Yasui procedure, while 23 patients received conventional BVR. In patients with a conventional BVR, a significant increase was found in left ventricular volume indexed by body surface area, Z-score of aortic valve and left ventricular outflow tract between hybrid palliation and BVR. Mitral valve Z-score did not increase significantly. After BVR until follow-up, only increase of the aortic valve Z-scores and left ventricular volume indexed by body surface area was found significant. Of all included patients (n = 38), additional surgical procedures were necessary in 8 patients during the interstage period and 15 patients after BVR. Additional catheter interventions were needed in 14 patients in the interstage period and 15 after BVR. Six patients died, with no mortality in the conventional BVR group. CONCLUSIONS: Hybrid palliation as part of a staged BVR is a safe and effective initial step and promotes the growth of left ventricular structures in patients with small left-sided heart structures. Close follow-up is mandatory because extra catheter or surgical interventions are frequently needed.

Patent ductus arteriosus and the association between lung ultrasound score and bronchopulmonary dysplasia: a secondary analysis of a prospective study.

Moderate-to-large patent ductus arteriosus (PDA) has been linked to increased risk of bronchopulmonary dysplasia (BPD), while lung ultrasound score (LUS) has been demonstrated to accurately predict BPD. We aimed to investigate the correlation of LUS as a marker of interstitial pulmonary edema and the severity of the ductal shunt in predicting future BPD development in very preterm infants. This secondary analysis of a prospective study recruited preterm infants with gestational age < 30 weeks. LUS on postnatal days 7 and 14, and echocardiographic data [PDA diameter and left atrium-to-aortic root ratio (LA/Ao)] near LUS acquisition were collected. Correlation coefficient, logistics regression analysis, and the area under the receiver operating characteristic (AUROC) procedure were used. A statistically significant and positive correlation existed between LUS and PDA diameter (ρ = 0.415, ρ = 0.581, and p < 0.001) and LA/Ao (ρ = 0.502, ρ = 0.743, and p < 0.001) at postnatal days 7 and 14, respectively, and the correlations of LUS and echocardiographic data were generally stronger in the non-BPD group. In the prediction of BPD, LUS incorporating echocardiographic data at postnatal days 7 obtained significantly higher predictive performance compared to LUS alone (AUROC 0.878 [95% CI 0.801-0.932] vs. AUROC 0.793 [95% CI 0.706-0.865]; Delong test, p = 0.013). CONCLUSIONS: There is a statistically significant correlation between LUS and echocardiographic data, suggesting their potential role as early predictors for respiratory outcomes in very preterm infants. WHAT IS KNOWN: • Lung ultrasound score (LUS) has shown good reliability in predicting bronchopulmonary dysplasia (BPD) development. • Some echocardiographic data that characterized ventricular function was reported to be used to predict severe BPD. WHAT IS NEW: • There is a positive and statistically significant correlation between LUS and echocardiographic data at postnatal days 7 and 14. • The integrated use of LUS and echocardiographic data may have potential value in predicting BPD.

Comparison of Immediate Intensive Care Outcomes of Patent Ductus Arteriosus Stenting Versus Modified Blalock-Taussig-Thomas Shunt in Infants With Ductal-Dependent Pulmonary Circulation.

Patent Ductus Arteriosus (PDA) stenting is an alternative to Modified Blalock-Taussig-Thomas Shunt (BT) to increase pulmonary blood flow in ductal-dependent pulmonary circulation. The objective of this study is to compare the immediate Intensive Care Unit (ICU) outcomes of PDA stent versus BT shunt in infants with ductal-dependent pulmonary circulation. This is a single center, retrospective study in infants less than 6 months with ductal-dependent pulmonary circulation palliated with either PDA stenting or BT shunt from January 2015 till December 2023. Data were reviewed from pediatric ICU database. Demographics details, ICU parameters, mortality and morbidity were compared. The propensity score with inverse probability weighting was used to control the effect of covariates. A total of 302 patients with PDA stenting and 100 patients with BT shunt were included. Majority of the patients had intervention at first month of life. 126 (41.7%) patient underwent PDA stenting while 36 (36%) had BTS. The PDA stenting group has shorter ICU stay, 3 (2.0,6.0) days versus 8 (4.8,13.0) days (p < 0.001), shorter length of hospital stay, 9 (6.8,15.0) days versus 16 (11.0,22.0) days (p < 0.001), shorter ventilation days, 2 (1.0,4.0) days versus 3 (2.0,7.0) days (p < 0.001) and lower mortality, 7 (2.3%) versus 16 (16.0%) (p < 0.001). At 3 months follow-up, the survival was higher in the PDA stenting group (p < 0.001). Conclusion: PDA stenting in infants with ductal-dependent pulmonary blood flow has a more favorable intensive care outcomes with shorter ICU and hospital stay. PDA stenting has a better survival outcome.

Premature Closure of the Ductus Arteriosus and Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Neonates: A 10-Year Single-Center Retrospective Study.

To describe critically ill neonates with premature closure of the ductus arteriosus (DA) and assess the frequency as well as predictive factors for extracorporeal membrane oxygenation (ECMO) support in the latter. This was a monocentric retrospective observational study conducted in the NICU of a French academic medical center between 01/01/2013 and 01/01/2023. All neonates diagnosed with premature closure of the DA were included. Exclusion criteria were associated congenital heart disease amenable to urgent surgery or contraindication for ECMO. Eleven neonates with complete premature closure of the DA were included. Births were full-term with a weight of 3.60 kg [3.16-3.89]. Only one case (9%) was diagnosed antenatally. Premature closure of the DA was idiopathic in seven neonates (64%) and associated to maternal exposure to non-steroidal anti-inflammatory drugs (NSAIDs) in three (27%). All newborns had pulmonary hypertension (PH) and right ventricular hypertrophy. Three neonates (27%) were supported on veno-arterial ECMO and appeared to have more pathological adaptation to extra-uterine life, greater need for vasopressor and/or inotropic support, and higher frequency of bi-ventricular failure (100%) or morphological anomaly of the tricuspid valve (67%). No patient died but more than half had non-cardiological sequelae. Veno-arterial ECMO support is not uncommon in critically ill neonates with premature DA closure and appeared to be associated with more pathological adaptation to extra-uterine life, greater need for vasoactive-inotropic support and higher frequency of bi-ventricular failure or morphological anomaly of the tricuspid valve. These parameters can help clinicians to identify neonates likely to require such an assistance.

Interventions for Pulmonary Vein Stenosis.

Pulmonary vein stenosis (PVS) is a rare and unique disease of infants and young children. PVS is attended by high morbidity and mortality, and for many decades, effective therapy eluded the practitioner. However, in the most recent era, interventional techniques when employed in combination with systemic (primary) therapy have had a remarkable impact on outcomes in these at-risk children. Despite apparent complete relief of PVS in a discrete region of a pulmonary vein, stenosis reliably recurs and progresses. In this review, we discuss the current state-of-the-art interventional techniques, through the lens of our collective experiences and practices.

PDA Stent Placement *6: High-Impact Limitations of Angiography to Delineate a Complex PDA.

This is a case of an infant with duct-dependent pulmonary circulation, who required 6 stents delivered over three procedures to fully stent the arterial duct, which originated in a very unusual fashion. The attainable angiographic projections were unable to profile its origin, and only a CT scan was ultimately able to delineate the (stenotic) ductal origin from the aorta.

Diagnostic approach and treatment of ventricular septal defect associated with PDA, coarctation of aorta, hypoplastic aortic arch and multiple valvular heart disease in a tertiary center: An infrequent association.

Ventricular septal defect is the most common congenital heart disease in children and is associated with patent ductus arteriosus in 1%-7% of cases. The coexistence of both malformities with hypoplastic aortic arch and aortic coarctation is even rarer. We present the case of a 6-year-old girl referred to our hospital because of dyspnea on feeding, recurrent respiratory infections, poor weight gain, and a heart murmur. The image studies revealed a ventricular septal defect, patent ductus arteriosus, severe hypoplasia of the aortic arch with critical stenosis of the proximal portion, severe dilatation of the pulmonary artery and pulmonary, mitral, tricuspid, and aortic regurgitation. We will discuss the diagnostic approach and treatment in a tertiary reference center for patients with cardiovascular diseases.