1. PDA closureG AgnolettiCitta della Salutegagnoletti@cittadellasalute.to.itTorino, ItalyIPC 9th Milan, March 2013

2. Is PDA a congenital heartdisease? 3. PDA is not a congenital heart disease can be life saving can be unuseful can be dangerous WE WANT TO CLOSE IT can be lethal 4. EmbriologyAbsent oranomalous in PAtype III-IVAbsentpulmonaryvalveTruncusarteriosus 5. Prenatal circulationO2 saturation : 55% Cardiac output : 59% 6. At BirthPVR/SVR from 10 to 1/3 in few s.In the preterm infant:osystolic steal, reversed flow, pulmonarycongestionIn the newborn:ospontaneous constriction, due to increased PaO2,then fibrous occlusionPDA if the arterial duct is still patent after 1 month 7. Classification 8. What ONLY matters for clinicalimplications of ISOLATED DBP is its sizeWhat matters for percutaneous closure arepatient age and weight, PDA size, PDAshape (size of the aortic isthmus, size of theampulla, lenght of the PDA, size of LPA...) 9. Imaging in children and adult patients 10. PDASmall: no symptoms, sometimes systolicmurmur, low risk of endocarditisAttitude: varies in accordance with theinstitution policyLarge: ventricular overload, pulmonaryhypertension, congestive heart failureAttitude: percutaneous closure 11. Eisenmenger ? 12. PDA in preterm infantsAttitude: closureo medical treatmento surgical treatment (ligation - suture)medical - surgical implications, residual shunto percutaneous treatment (?????) few casesreported - technical implications 13. PDA in babies, children, adultsAttitude: closure if ventricular overload if PH if murmur to prevent endocarditis? to allow intense physical activity? 14. Endocarditis?Silent patent ductus arteriosus endarteritis. Heart 2000 15. All PDAs should be closed? 16. Is easy to close a PDA? 17. Devices and ideasHow shall I close a hole?Generally putting somethinginside....or simply covering it....coverocclude(dissection) 18. The beginningPercutaneous transfemoral closure of the the patentductus arteriosus - an alternative to surgeryPorstmann W Semin Roentgenol. 1981First percutaneous procedure: Rashkind 60s 19. Double umbrella Raskind deviceTo close a communication I want tocover both sidesDrawbacks: residual shunt, obstruction,migration, fracture, retrievability but norepositionability 20. Coils bare and hairy 21. CoilsoFrom venous or arterial sideoMultiple coils possibleoRetrievability and repositionabilityoBetter for small PDAoCheapDrawbacks: residual shunt (hemolysis),migration 22. Coilso Not too large..o Not tubular..o Not window like..o Not too smalloNo tortuous..Still I do use coils.. 23. ComplicationsSevere intravascular hemolysis.. J Invasive Cardiol 2005Residual shunt at 24 h 30-57% 24. Occluding devicesTo close a communication Iwant to stent it. 25. ADO I 26. Stenting the duct with an occlusivedeviceThe AGA systemADO I ADO II 27. AGA system : ADO IAdvantages From the venous side Retrievable Repositionable High rate immediateocclusion Occlusion of large PDADisadvantages Iatrogenic coarctation Absence of pulmonary disc Migration (aorta or PA) Difficult retrivability aftermigration Residual shunt andhaemolysis Bleeding ! 28. Complicationsmigration 29. Complicationsmigration 30. AGA system : ADO IVery large PDAs can be closed3yr-old african girl with heart failureLL OAD post 14-12.. 31. AGA system : ADO IVery large PDAs can be closedpost 16-14.. 32. AGA system : ADO ILarge PDAs in small babiesLL OAD large ampulla andisthmus 33. AGA system : ADO ILarge PDAs in small babies 34. AGA system : ADO ILarge PDAs in small childrenConcerns: Anatomy of the PDA, tricuspid angle,rigidity of the system, small aortic isthmus 35. AGA system : ADO ILarge PDAs in very small children ???Concerns: Anatomy of the PDA, tricuspid angle,rigidity of the system +++, small aortic isthmus,venous/arterial access.. (< 2Kg babies) 36. Peculiar casesSpasm of the arterial duct 37. Peculiar casesSpasm of the arterial ductHeart 2005Rev Esp Cardiol. 2012 38. The ADO II deviceADO II:fabric-free fine nitinol wire, 2 very low profiledisks, articulated connecting waist. Antegrade orretrograde approach.Advantages: reduced sheath sizes and softer shapeReports: protrusion into the aortic isthmus or pulmonaryartery 39. The ADO II device?easy to retrieve 40. ADO II ASFew preliminary reportsGood resultsEasy, premounted (generally..), navigability +++No obstruction, no migration, no residual shunt,variety of different anatomies Early clinical experience with a modified Amplatzer ductal Occluder for transcatheter arterial ductocclusion in infants and small children. Kenny D et al, Catheter Cardiovasc Interv 2012Closure of the patent ductus arteriosus with the new duct occluder II addotional sizes device.Agnoletti G et al Catheter Cardiovasc Interv 2012Closure of a large ductus arteriosus in a preterm infant using the ADO II AS device. Agnoletti G et al.Heart 2012 41. PDA closure in preterm babies? 42. Occlusion of a PDA in a 2 Kg baby withheart failure 43. Occlusion of a PDA in a 2 Kg baby withheart failure 44. Peculiar casesPDA and aortic coarctation 45. ADO II AS for different types of PDAs 46. ADO II AS for different types of PDAs 47. ADO II AS for different types of PDAs 48. ADO II ASfrom the venous side 49. ADO II ASfrom the arterial sideYou can inject in the sheath 50. PDAs in twins coils or ADO II AS?Enea and Jacopo 51. J Invasive Cardiol 2011Nit-Occlud PDA-R(Reverse) Device 52. Large PDA in small childrenAfter failed percutaneous closurePerventricular Device Closure of Patent Ductus Arteriosus:A Secondary ChanceAnn Thorac Surg 2012 53. PDA or APW?1800 g 54. ConclusionsAll PDAs can be closed percutaneously ?All PDAs should be closed percutaneously ?Almost always feasibleAlmost always successfulDifferent devices for different patientsComplications can occur 55. ConclusionsGood new: you recover from DA patency! 56. Also for our pet friends