Radio! Oncol 1995; 29: 9-11.
Transcatheter occlusion of patent ductus arteriosus in adults
Dušan Pavčnik,1 Pavle Berden,1 Mirta Koželj2
' Institute for Radiology, Clinical Medical Centre, Ljubljana, 2Department of Cardiovascular Disease, Clinical Medical Centre, Ljubljana, Slovenia
Patent ductus arteriosus (PDA) may escape clinical detection and persist into adulthood. Far the purpose of PDA occlusion a new transcatheter technique with double Rashkind umbrella was developed. We present two successful closures of PDA in adult patients with this device. The two years follow-up findings testify to the favourable clinical course, with disappearance of the continous murmur and a normal colour flow echocardiography examination.
Key words: ductus arteriosus, patent therapy; catheterisation
Introduction
Isolated patent ductus arteriosus (PDA) occurs in 1 in 2000 live, fullterm birth, accounting for approximately 5 % to 10 % of all types of congenital heart defects. PDA is very common in premature infants, and infants born at high altitude have an increase incidence. There is female preponderance with a ration ranging from 2 : 1 to 3 : l. 1
The clinical significance of the PDA is determined by magnitude of the shunting through the PDA. The direction of the flow will depend upon relative pulmonary and systemic vascular resistance. Normally, the pulmonary vascular resistance drops quickly after birth. Therefore, blood flows from the aorta into pulmonary
Correspondence to: Pavčnik Dušan, M.D., Ph.D., Professor of Radiology, Institute for Radiology, Clinical Medica! Centre, Zaloška 7, 61000 Ljubljana, Slovenia.
UDC: 616.131.3-007.22-089.819.1
arteries. 2 PDA is closed either surgically3 or by percutaneous transcatheter technique. First successful percutanous closure of PDA was reported by Postman in 1963.4 Since then numerous techniques have been developed over the years, but only the Rashkind double umbrella closure of PDA has been generally accepted (Figure 1).5-6
Case reports
Case 1
A 18-year-old woman presented with dyspnea on effort. A clinical diagnosis of PDA had been made at the age of 5, however, her parents refused surgical correction at that time. Chest radiograph showed increased pulmonary vascularity and a prominent aortic arch. Cardiac catheterisation showed conical shaped PDA 10 mm long and 5 mm in diameter without pulmonary hypertension. After diagnostic catheterisation, a 0.035 inch, 300cm long Amplatz
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in the ductus arteriosus. PA = pulmonary artery, A = aorta.
guide wire was introduced from the pulmonary aftery through the PDA into the thoracic aorta. The delivery catheter was advanced into the thoracic aorta and PDA was closed by 12 mm Rashkind double umbrela (Figure 2). During the 2-years follow-up, patient has been free of symptoms.
Case 2
A 30-years old woman was admitted to the hospital due to accidentally diagnosed PDA. She was symptoms free. On auscultation, a continous machinery murmur in the 2nd in 3rd left interspace was heard. She had no signs of heart failure. The 12-lead ECG showed normal sinus rhythm. The chest x-ray film showed no abnormalities. However, the transthoracic ec-hocardiogram in modified parasternal short axis view of the base of the heart revealed colour flow Doppler signal streaming into the main pulmonary artery. A continuous flow into the pulmonary artery was recorded by continuous were Doppler examination. Both findings are
A	B
Figure 2A. Lateral angiogram showing typical funnel shaped ductus (arrow). PA = pulmonary artery, A = aorta.
Figure 2B. Lateral angiogram showing device in position (arrow) with hinge point at the pulmonary artery (PA) end, distal limbs nicely flexed and no residual shunting. A = aorta.
characteristic for PDA without pulmonary hypertension. The diagnostic catheterisation was performed and 1 cm long conical shaped PDA was shown by aortography. At the pulmonary end it was 5 mm wide and at the aortic end 10mm. The pressures in the right heart and in the pulmonary circulation were in normal limits. After diagnostic catheterisation the PDA was closed by double Rashkind umbrella by trans-catheter technique. The typical murmur of PDA disappeared immediately after the procedure. Three days after transcatheter closure of the PDA the control echocardiogram was performed and there was no colour flow Doppler signal of PDA. The patient was examined two years after the procedure in six months intervals clinically and by echocardiography. She has been free of symptoms and echocardiogram has been in normal limits.
Discussion
PDA may escape clinical detection and persist into adulthood. If adults do not develop signi-
Transcatheter occlusion of patent ductus arteriosus in adults
11
ficant pulmonary vascular disease, they tend to have an unpredictable progression of left ventricular failure.7 Surgical or transcatheter occlusion of PDA is indicated in adulthood, too.
Although mortality of surgical correction of PDA is low, significant morbidity, including excessive bleeding, injury to the recurrent laryngeal or phrenic nerves, and complications of general anaesthesia, can occur in a small percentage of patients. To circumvent these problems, transcatheter closure of PDA was developed. Transcatheter occlusion is a successful mode of treatment for PDA with a low incidence of complications. Overal success rate is cca 96 % including reoclussions.8
Results reported by McManus (2) and McNa-mara (3), as well our data suggest that transcatheter closure of PDA with Rishkind double umbrella is a efficacious procedure in providing complete permanent ductus closure even in adult patients. The clinical course suggests that PDA closure is complete immediately after the procedure. After two years follow-up our patients have been free of symptoms and colour flow Doppler studies have been in normal limits.
References
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2.	McManus BM. Patent ductus arteriosus. In: Roberts WC; Adult Congenital Heart Disease. Philadelphia: FA Davis Company, 1987: 455-76.
3.	McNamara DG, Latson La. Long-term follow-up of patients with malformations for which definitive surgery has been available for 25 years or more. Am J Cardiol 1982; 50: 560-8.
4.	Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent duc-tus arteriosus; 62 cases treated without thoracotomy. Radiol Ciin North Am 1971; 9: 203-18.
5.	Rashkind W. Transcatheter treatment of congenital heart disease. Circulation 1983; 67: 711-6.
6.	Lock JE, Cockerham JT, Keane JF, Finely JP, Wakely PE, Fellows KE. Transcatheter umbrella closure of congenital cardiac defects. Circulation 1987; 75: 593-9.
7.	Marquis RM, Miller HC, McCormack RJM, Matthews MB, Kitchin AH. Persistence of ductus arte-riosus with left to right shunt in the older patient. Br Heart J 1982; 48: 469-84.
8.	Magee AG, Stumper O, Burns JE, Godman MJ. Medium-term follow-up residual shunting and potential complications after transcatheter occlusion of the ductus arteriosus. Br Heart J 1994; 71: 63-9.