Images of Pediatric and Congenital Heart Disease
Severe Aortic Regurgitation After Device Closure of Patent Ductus Arteriosus: An Unexpected Killjoy
World Journal for Pediatric and Congenital Heart Surgery 2015, Vol. 6(2) 346-347 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135115574009 pch.sagepub.com
Alban-Elouen Baruteau, MD1, and Mohamed-Salem Younsi, MD1 Keywords patent ductus arteriosus, cardiac catheterization/intervention, complications, aortic regurgitation, intensive care Submitted October 28, 2014; Accepted January 29, 2015.
A two-year-old, 12-kg boy with Down syndrome and frequent bronchopulmonary infections was referred for a symptomatic, hemodynamically significant patent ductus arteriosus. Echocardiography revealed an isolated restrictive patent ductus arteriosus (systolic velocity: 4.6 m/s, diastolic velocity: 3.6 m/s) with left ventricular enlargement (z score þ 1.74). Aortic valve was normal, tri-leaflet, and competent. Transcatheter ductus closure occurred under general anesthesia, without crossing the aortic valve during the procedure. Aortography in lateral and 30 right anterior oblique projections demonstrated a left-to-right shunt through a 2.5-mm conical, Krichenko Type A1 ductus (Panel A). Hemodynamic recordings confirmed significant shunting (Qp:Qs ¼ 2.8) and normal pulmonary arterial pressures. An 8 6 mm Amplatzer Duct Occluder 1 (Saint Jude Medical, Minnesota) was deployed under fluoroscopic guidance, through a 6F delivery sheath inserted transvenously. Pigtail aortic angiogram confirmed good position of the device and the lack of residual shunt (Panel B). Six hours later, echocardiography revealed an acute, severe aortic regurgitation, seen as a significant central jet on color flow mapping (Panel C) and holodiastolic reversal of flow in the descending aorta. Clinical examination found a 3/6 diastolic murmur in an asymptomatic child at rest. Aortic regurgitation regressed spontaneously, being
trivial the day after and having totally disappeared two days after the procedure. Although rare, trivial to mild aortic regurgitation has been reported after surgical ligation and device closure of a patent ductus, especially in small children with significant left-toright shunt,1,2 because of sudden termination of significant runoff from the aorta, together with a rise in the peripheral vascular resistance and the persistence of increased proximal vascular capacitance. Changes in the aortic root geometry following elimination of a significant shunting from the ductus that caused increased blood flow through the aortic valve and aortic root have also been proposed. Acquired severe aortic regurgitation following ductus closure remains exceptional.3 Clinicians must be aware of this potential consequence that may resolve spontaneously during follow-up. Postprocedure
1
Marie Lannelongue Hospital, Pediatric Cardiac Surgery, Paris-Sud University, France Corresponding Author: Alban-Elouen Baruteau, Centre Chirurgical Marie Lannelongue, 133 avenue de la Re´sistance, 92350 Le Plessis-Robinson, France. Email: [email protected]
Downloaded from pch.sagepub.com at UNIV NEBRASKA LIBRARIES on October 29, 2015
Baruteau and Younsi
347 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
temporary use of afterload reducing agent may be beneficial to reduce the risk of transient aortic regurgitation.
1. Bajic´ S, Berden P, Podnar T. Aortic valve regurgitation following percutaneous closure of patent ductus arteriosus. Catheter Cardiovasc Interv. 2011;77(3): 416-419. 2. Harrisberg JR, Govendrageloo K, Hunter V, Levin SE. Acquired aortic regurgitation following occlusion of the persistent arterial duct: an echocardiographic assessment. Heart. 1997;77(5): 404-406. 3. Baruteau AE, Hascoe¨t S, Baruteau J, et al. Transcatheter closure of patent ductus arteriosus: past, present and future. Arch Cardiovasc Dis. 2014;107(2): 122-132.
Downloaded from pch.sagepub.com at UNIV NEBRASKA LIBRARIES on October 29, 2015
Severe Aortic Regurgitation After Device Closure of Patent Ductus Arteriosus: An Unexpected Killjoy
World Journal for Pediatric and Congenital Heart Surgery 2015, Vol. 6(2) 346-347 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135115574009 pch.sagepub.com
Alban-Elouen Baruteau, MD1, and Mohamed-Salem Younsi, MD1 Keywords patent ductus arteriosus, cardiac catheterization/intervention, complications, aortic regurgitation, intensive care Submitted October 28, 2014; Accepted January 29, 2015.
A two-year-old, 12-kg boy with Down syndrome and frequent bronchopulmonary infections was referred for a symptomatic, hemodynamically significant patent ductus arteriosus. Echocardiography revealed an isolated restrictive patent ductus arteriosus (systolic velocity: 4.6 m/s, diastolic velocity: 3.6 m/s) with left ventricular enlargement (z score þ 1.74). Aortic valve was normal, tri-leaflet, and competent. Transcatheter ductus closure occurred under general anesthesia, without crossing the aortic valve during the procedure. Aortography in lateral and 30 right anterior oblique projections demonstrated a left-to-right shunt through a 2.5-mm conical, Krichenko Type A1 ductus (Panel A). Hemodynamic recordings confirmed significant shunting (Qp:Qs ¼ 2.8) and normal pulmonary arterial pressures. An 8 6 mm Amplatzer Duct Occluder 1 (Saint Jude Medical, Minnesota) was deployed under fluoroscopic guidance, through a 6F delivery sheath inserted transvenously. Pigtail aortic angiogram confirmed good position of the device and the lack of residual shunt (Panel B). Six hours later, echocardiography revealed an acute, severe aortic regurgitation, seen as a significant central jet on color flow mapping (Panel C) and holodiastolic reversal of flow in the descending aorta. Clinical examination found a 3/6 diastolic murmur in an asymptomatic child at rest. Aortic regurgitation regressed spontaneously, being
trivial the day after and having totally disappeared two days after the procedure. Although rare, trivial to mild aortic regurgitation has been reported after surgical ligation and device closure of a patent ductus, especially in small children with significant left-toright shunt,1,2 because of sudden termination of significant runoff from the aorta, together with a rise in the peripheral vascular resistance and the persistence of increased proximal vascular capacitance. Changes in the aortic root geometry following elimination of a significant shunting from the ductus that caused increased blood flow through the aortic valve and aortic root have also been proposed. Acquired severe aortic regurgitation following ductus closure remains exceptional.3 Clinicians must be aware of this potential consequence that may resolve spontaneously during follow-up. Postprocedure
1
Marie Lannelongue Hospital, Pediatric Cardiac Surgery, Paris-Sud University, France Corresponding Author: Alban-Elouen Baruteau, Centre Chirurgical Marie Lannelongue, 133 avenue de la Re´sistance, 92350 Le Plessis-Robinson, France. Email: [email protected]
Downloaded from pch.sagepub.com at UNIV NEBRASKA LIBRARIES on October 29, 2015
Baruteau and Younsi
347 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
temporary use of afterload reducing agent may be beneficial to reduce the risk of transient aortic regurgitation.
1. Bajic´ S, Berden P, Podnar T. Aortic valve regurgitation following percutaneous closure of patent ductus arteriosus. Catheter Cardiovasc Interv. 2011;77(3): 416-419. 2. Harrisberg JR, Govendrageloo K, Hunter V, Levin SE. Acquired aortic regurgitation following occlusion of the persistent arterial duct: an echocardiographic assessment. Heart. 1997;77(5): 404-406. 3. Baruteau AE, Hascoe¨t S, Baruteau J, et al. Transcatheter closure of patent ductus arteriosus: past, present and future. Arch Cardiovasc Dis. 2014;107(2): 122-132.
Downloaded from pch.sagepub.com at UNIV NEBRASKA LIBRARIES on October 29, 2015
