Catheterization and Cardiovascular Interventions 86:264–270 (2015)
Trans-Pulmonary Echocardiography as a Guide for Device Closure of Patent Ductus Arteriosus Yoshiyuki Kudo,1 MD, Kenji Suda,1* MD, Hironaga Yoshimoto,1 MD, Yozo Teramachi,2 MD, Shintaro Kishimoto,1 MD, Motofumi Iemura,2 MD, and Toyojiro Matsuishi,1 MD Objectives: The aim of this study was to develop trans-pulmonary echocardiography (TPE) to guide device closure of patent ductus arteriosus (DC-PDA). Background: Aortography requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy or residual shunt in patients with large PDA or dilated vessels and is precluded in patients with renal dysfunction. Practically, there is no imaging modality to monitor the entire procedure except for trans-esophageal echocardiography that requires general anesthesia. Methods: Subjects were seven patients with ages ranged from 6- to 77-years old and body weight > 15 kg. The size of the PDA ranged from 1.8 to 6.3 mm with pulmonary to systemic flow ratios from 1.2 to 2.2. During DC-PDA using Ampaltzer Duct Occluder or coil, an intra-cardiac echocardiographic (ICE) catheter was advanced into pulmonary arteries and standard views were developed to guide DC-PDA. Results: We have developed two standard views; the main pulmonary artery view (MPA view) and the left pulmonary artery view (LPA view). The MPA view provided aortic short axis view equivalent to that seen by trans-thoracic echocardiography in children. The LPA view, obtained by the echo probe in the LPA and turned it up upside down, provided long axis view of the PDA allowing more precise anatomical evaluation. TPE allowed us to monitor the entire procedure and determine residual shunts. Conclusions: TPE in the MPA and LPA view can be an effective guide for DC-PDA. This report leads to new application of this imaging device. VC 2015 Wiley Periodicals, Inc. Key words: intracardiac echocardiography; Amplatzer duct occluder; aortography; monitoring tool; residual shunt
INTRODUCTION
Device closure of patent ductus arteriosus (DCPDA) has become the standard treatment of this disease with acceptably high success rate and low complication rate [1,2]. Though aortography is the standard imaging modality to guide DC-PDA, aortography in patients with large PDA or dilated vessels requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy. In addition, aortography is precluded in patients with a history of contrast anaphylaxis or patients with renal dysfunction. Practically, there have been no imaging modalities except for trans-esophageal echocardiography (TEE) that allows us to monitor the entire procedure of DCPDA [3–5]. However, a major disadvantage of TEE is that it requires endotracheal intubation and general anesthesia. Overcoming this disadvantage of TEE, intracardiac echocardiography (ICE), especially using AcuNavTM (Biosense Webster Inc, Diamond Bar, CA, USA), has been developed and widely used in catheter intervention for inter-atrial septum, closure of atrial septal defect or perforation of inter-atrial septum, with C 2015 Wiley Periodicals, Inc. V
local anesthesia [6–9]. Recently ICE catheter has expanded its application and was used in the other types of catheter interventions including percutaneous pulmonary or aortic valve replacement and balloon valvuloplasty [9–13]. However, there is no report of the
1
Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan 2 Department of Pediatric Cardiology, St. Mary’s Hospital, Kurume, Japan Conflict of interest: Nothing to report. *Correspondence to: Kenji Suda, MD, Department of Pediatrics and Child Health, Kurume University School of Medicine, Asahi-Machi 67, Kurume, 830-0011, Japan. E-mail: [email protected] Received 29 October 2014; Revision accepted 31 January 2015 DOI: 10.1002/ccd.25879 Published online 25 February 2015 in Wiley Online Library (wileyonlinelibrary.com)
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TABLE I. Demographic Data of Study Patients
#
Age (years old)
Body weight (kg)
1 2 3 4 5 6 7
17 6.2 8.9 8.9 13.2 76.5 71.2
52.8 25.3 34 18.3 34 46.5 58.7
Body height (cm) 159 120 134 112 143 151 150
PDA size (mm) Sex F M F M F M F
Aortography or CCTa
Transpulmoanry echocardiography
Qp/Qs
mPAP (mm Hg)
1.8 2.2 2.2 3.8 4.0 4.2a 6.3a
1.8 2.2 2.3 3.6 3.9 4.0 –
1.3 1.2 1.2 1.7 1.8 2.2 1.9
18 17 16 29 17 18 26
Device Coil ADO-I ADO-I ADO-I ADO-I ADO-I ADO-I
6/4 6/4 8/6 8/6 8/6!10/8 14/12
Comorbidity
HT, MR, CHF CRF, Af, HT, CHF
Abbreviations Af, atrial fibrillation; ADO-I, Amplatzer Duct Occluder I; CCT, cardiac X-ray computed tomography; CHF, congestive heart failure; CRF, chronic renal failure; F, female; HT, hypertension; M, male; mPAP, mean pulmonary artery pressure; MR, mitral regurgitation; PDA, patent ductus arteriosus; Qp/Qs, pulmonary to systemic flow ratio. a Determined by cardiac X-ray computed tomography.
ICE catheter used in the pulmonary artery to guide DC-PDA. Therefore, the purpose of this study was to develop standard views of trans-pulmonary echocardiography (TPE) using AcuNavTM to guide DC-PDA. MATERIALS AND METHODS
Prospectively, we enrolled seven consecutive patients that weighed more than 15 kg and submitted to DCPDA in our institutions. Their demographics are described in Table I. After we obtained written informed consents from patients or patients’ guardians, patients underwent DC-PDA with local anesthesia using Amplatzer Duct Occluder–I (ADO-I, AGA Medical, Golden Valley, MN) with standard fashion via femoral vein [2] in 6 and a coil via femoral artery in 1. An ICE catheter, AcuNavTM, was inserted in the same sheath through which ADO-I was placed or in the separate sheath at the femoral vein. Then it was advanced into the pulmonary artery through a hand-shaped 9 French long sheath in the first patient and was advanced without a long sheath in the remaining six patients. In the first two patients, we placed the ICE catheter up to the main pulmonary artery (MPA) and, in the remaining five patients, we further advanced the ICE catheter into branch pulmonary arteries to look for the best view to evaluate PDA. In this series, the size of the device was selected primarily based on the measurements on aortography or cardiac X-ray computed tomography. After placed a device, we evaluated the residual leak primarily with ICE and determined if we replace the device or release it. When there was residual leak after we released the device, we followed the residual leak at least 10 minutes. The feasibility and image quality of TPE to guide DC-PDA was determined with the reference to aortography and fluoroscopy.
RESULTS
We have developed two standard views, the MPA view and the left pulmonary artery view (LPA view), of TPE to guide DC-PDA.
MPA View In our first patient with age of 71-years old (Patient 7), who had atrial fibrillation and chronic renal dysfunction and was on anti-coagulation therapy, cardiac X-ray computed tomography before the procedure showed type A PDA with 6.3 mm in diameter, calcification of PDA, and dilated pulmonary arteries. On the basis of these findings, we placed 14/12 ADO-I, far bigger device enough to prevent device migration, and confirmed the position and residual shunt using TPE without contrast aortography. After obtained home view [6,8,9], the ICE catheter was posteriorly deflected and advanced into the right ventricle where ICE can show the left ventricular long axis view. Once in the right ventricle, the ICE catheter was unlocked, straightened, and advanced into the right ventricular outflow tract. We advanced the ICE catheter further into the main pulmonary artery with mild anterior deflection and some clockwise rotation to obtain the MPA view (Fig. 1a). The MPA view clearly showed aortic short axis view including the device in the PDA, orifice of the left pulmonary artery, the right pulmonary artery, and the ascending aorta (Fig. 1b) equivalent to that in transthoracic echocardiography in small children. Patient 2 showed type A PDA on aortography (Fig. 2a). In this patient, we observed PDA before and after device placement in the MPA view. Again, the MPA view showed aortic short axis view with clear image of PDA on the color Doppler flow mapping (Fig. 2b) and
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Fig. 1. The position of the tip of ICE catheter (white arrow) to obtain the MPA view in relation to ADO-I (white triangle) on fluoroscopy with lateral projection (a) is shown in Patient 7. The MPA view showed aortic short axis view equivalent to that obtained by trans-thoracic echocardiography in children (b).
Fig. 2. Aortography in Patient 2 shows type A PDA (a). The MPA view showed aortic short axis view with clear image of PDA on the color Doppler flow mapping (b) and pulmonary end of 6/4 ADO-I after the device placement (c).
pulmonary end of 6/4 ADO-I after the device placement (Fig. 2c). LPA View To have stable position of ICE catheter, we further advanced the ICE catheter into the LPA. Once in the LPA, the ICE catheter was unlocked and straightened. Then, we rotated the ICE catheter and turned it upside down (Fig. 3a and b), because the scan plane faced downward when it reached LPA. By looking up PDA from the LPA, TPE showed the long axis of PDA because the left pulmonary artery runs parallel to the aorta. In patients 1, 3, 4, 5, and 6, the LPA view allowed us to precisely evaluate the anatomy of PDA, monitor the entire procedure, and determine the protruding part of device and any residual shunt. We show pictures of Patient 5 as the representation. Patient 5 had type A
PDA on aortography (Fig. 4a). In the LPA view, rotating right or left, advancing, or retreating the ICE catheter, we reviewed the anatomy of PDA in detail (Fig. 4b). The diameter of PDA measured 3.9 mm as the maximum diameter. Then, with fine adjustment of ICE catheter position, LPA view showed all steps of procedure; a 6 French long sheath was advanced through PDA (Fig. 4c), the aortic skirt of ADO-I was opened in the aorta and the long sheath and ADO-I was pulled back into PDA (Fig. 4d), and the body of ADO-I was deployed in the PDA (Fig. 4e). Determination of the Residual Shunt After the device placement and after release, the ICE catheter was rotated right and left to look for residual shunts. In patient 6, we chose 8/6 ADO-I based on the cardiac X-ray computed tomography (Table I), however, the LPA view showed a large amount of
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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residual shunt around the device (Fig. 5a), and therefore, we replaced the device with 10/8 ADO-I. After the release of this device, the LPA view showed a small central residual shunt (Fig. 5b) and this disappeared with time. Likewise, central residual shunt was observed and has disappeared within 10 minutes in Patient 2, 3, and 7. In addition, Patient 4 and 5 showed a small residual shunt around the device, but this residual shunt disappeared with time. In patient 1, we placed a coil because the size of PDA was small and the residual shunt beside coil disappeared with time.
Fig. 3. The position of the tip of ICE catheter (white arrow) to obtain the LPA view in relation to ADO-I (white triangle) on fluoroscopy with lateral projection is shown in Patient 5.
Fig. 4. A representative LPA view of TPE to monitor the procedure in Patient 5. The LPA view is shown in upside down for anatomical orientation. LPA view of TPE allowed us to monitor entire process of DC-PDA. An aortography in lateral projection showed type A PDA (a). TPE clearly showed the pulmonary orifice of PDA with a diameter of 3.9 mm (b). After
Comparison Between the MPA View and LPA View In terms of image direction, the MPA view provides axial view of PDA, but the LPA view provides long axis view of PDA, therefore the LPA view is better to delineate the configuration of PDA, but the MPA view should be better to determine the flow velocity though PDA or branch pulmonary arteries.
a long sheath was placed (c), ADO-I was advanced through it and the aortic skirt (white arrow) was opened, then ADO-I was pulled into PDA (d) and the body of device (white triangle) was deployed (e). A long sheath looked like tramlines in (c). Note the cable attached to the device in (d) and (e).
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Fig. 5. Residual central shunt detected by the LPA view. In Patient 6, when we placed 8/6 ADO-I (white triangle), the LPA view showed a large amount of residual shunt around the device (a). Composite picture shows two-dimensional echocardiography (5a left) and the colorDoppler mapping of the same picture (5a right). After we replaced the device with 10/8 ADOI, the LPA view showed a small central residual shunt (b) and this disappeared with time.
Measurement of the PDA Size
It looked that there was a reasonable agreement between the diameter determined by the TPE and that determined by the aortography or cardiac x-ray computed tomography (Table I). However, this topic was out of scope of this study and needs to be determined in the future study, because the number of subjects in this study was too small.
DISCUSSION
This study indicates that the MPA view and the LPA view can be standard views of TPE using an ICE catheter to effectively guide DC-PDA. For DC-PDA, there are several steps in the procedure; evaluation of anatomy including determination
of the diameter and length of PDA, monitoring device placement with recognizing the relationship between device and PDA, and evaluation of the residual shunt. Aortography in patients with a large PDA or enlarged vessels requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy because of contrast dilution or overlapping vessel shadows. Also, during the device placement, usually lateral projection of fluoroscopy has been used. However, there is no way to see the real relationship between device and surrounding vascular structures, aorta, PDA, and pulmonary artery on fluoroscopy. To guide DC-PDA, we have developed two standard imaging views of TPE, the MPA view and the LPA view. Indeed, these two views clearly showed the
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Trans-Pulmonary Echocardiography for PDA Closure
orifice of PDA in all patients examined, allowed us to determine the size of PDA, and also showed all steps of procedures; long sheath, opening aortic skirt, pulling back device and sheath, deploying body, and detaching device while showing the spatial relationship between the device and surrounding cardiac structures. Such information should be important to determine the risk of device migration or future development of vascular obstruction [8]. In addition, TPE allows us to monitor the residual shunt continuously until it disappears and decreases the number of aortography to determine residual shunt. On the basis of our experience with ADO-I, we think that usually the central shunt goes away with time, but shunt around the device may stay longer or indicate device replacement depending on the amount of residual shunt, though further experience is required. Though trans-aortic echocardiography was reported to guide DC-PDA [9,10], TPE has several advantages. Trans-aortic echocardiography needs to place an 8 French sheath into the femoral artery, and that is undesirable in patients on anti-coagulation therapy. Also trans-aortic echocardiography may show an inadequate image to determine the pulmonary orifice because it is away from the probe and has intrinsic problems, difficulty determining residual shunt because of the acoustic shadow once the device is placed. Also, TPE has an advantage over conventional transesophageal echocardiography in addition to local anesthesia. By placing the echo tip wherever we want, TPE gives us unique scan views such as LPA view, a long axis view of PDA that is never obtained by conventional trans-esophageal echocardiography. In this view, we can measure the pulmonary orifice of PDA most accurately because it parallels the echo beam and this must be especially important for device selection in patients with large PDA. One of the drawbacks of TPE might be the requirement of another sheath in femoral vein and the size of echo catheter. However, ICE has been already applied to many other types of catheter interventions [11–13]. Also ICE has been applied to guide closure of atrial septal defect even in small children less than 15 kg of body weight [14]. Also, there might be potential risks of TPE including arrhythmia and myocardial or vascular injury when we advance an ICE catheter into pulmonary artery via right ventricle. Obviously, careful manipulation of ICE catheter is mandatory and advancing ICE catheter through a pre-placed long sheath may minimize these risks. Further experience and accumulation of data are required.
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CONCLUSIONS
Trans-pulmonary echocardiography including the MPA view and the LPA view can be an effective guide for DC-PDA and may decrease the need for angiography and radiation. This report leads to new application of this imaging device.
ACKNOWLEDGMENT
The authors thank Dr Julien I. E. Hoffman, Professor of Pediatrics, University of California, San Francisco, for his kind assistance with the manuscript preparation. REFERENCES 1. Baruteau AE, Hasco€et S, Baruteau J, Boudjemline Y, Lambert V, Angel CY, Belli E, Petit J, Pass R. Transcatheter closure of patent ductus arteriosus: Past, present and future. Arch Cardiovasc Dis 2014;107:122–132. 2. Pass RH, Hijazi Z, Hsu DT, Lewis V, Hellenbr WE. Multicenter USA amplatzer patent ductus arteriosus occlusion device trial: Initial and one-year results. J Am Coll Cardiol 2004;44:513– 519. 3. Lam J, Tanke RB, van Oort A, Helbing WR, Ottenkamp J. The use of transesophageal echocardiography monitoring of transcatheter closure of a persistent ductus arteriosus. Echocardiography 2001;18:197–202. 4. Marek T Zelizko M, Kautzner J. Real-time 3-dimensional transesophageal echocardiography imaging: Adult patent ductus arteriosus before and after transcatheter closure. Circulation 2009; 120:e92–e93. 5. Chuang YC, Yin W-H, Hsiung MC, Tsai SK, Lee KC, Huang H-J, Ou C-H, Chang C-Y, Wei J, Chou Y-P. Successful transcatheter closure of a residual patent ductus arteriosus with complex anatomy after surgical ligation using an amplatzer ductral occluder guided by live three-dimensional transesophageal echocardiography. Echocardiography 2011;28:E101–E103. 6. Hijazi Z, Wang Z, Cao Q, Koenig P, Waight D, Lang R. Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: Feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv 2001;52:194–199. 7. Dello Russo A, Casella M, Pelargonio G, Bonelli F, Santangeli P, Fassini G, Riva S, Carbucicchio C, Giraldi F, De Iuliis P, Bartoletti S, Pintus F, Di Biase L, Pepi M, Natale A, Fiorentini C, Tondo C. Intracardiac echocardiography in electrophysiology. Miner Cardioangiol 2010;58:333–342. 8. Vaina S, Ligthart J, Vijayakumar M, Ten Cate FJ, Witsenburg M, Jordaens LJ, Sianos G, Thornton AS, Scholten MF, Jaegere D, Serruys PPW. Intracardiac echocardiography during interventional procedures. EuroIntervention 2006;1:454–464. 9. Bartel T, M€uller S, Biviano A, Hahn RT. Why is intracardiac echocardiography helpful? Benefits, costs, and how to learn. Eur Heart J 2014;35:69–76. 10. Bartel T, Gliech V, Muller S. Device closure of patent ductus arteriosus: Optimal guidance by transaortic phased-array imaging. Eur J Echocardiography 2011;12:E9. 11. Awad SM, Masood SA, Gonzalez I, Cao QL, Abdulla RI, Heitschmidt MG, Hijazi ZM. The use of intracardiac echocardiography during percutaneous pulmonary valve replacement. Pediatr Cardiol 2015;36:76–83.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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12. Bartel T, Bonaros N, Muller L, Friedrich G, Grimm M, VelikSalchner C, Feuchtner G, Pedross F, Muller S. Intracardiac echocardiography: A new guiding tool for transcatheter aortic valve replacement. J Am Soc Echocardiogr 2011;24:966–975. 13. Inohara T, Hayashida K, Fukuda K. Double balloon aortic valvuloplasty in TAVI era: Insight from intracardiac echocardiogra-
phy and multidetector computed tomography findings. J Invasive Cardiol 2014;26:E95–E97. 14. Patel A, Cao QL, Koenig PR, Hijazi ZM. Intracardiac echocardiography to guide closure of atrial septal defects in children less than 15 kilograms. Catheter Cardiovasc Interv 2006;68: 287–291.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Trans-Pulmonary Echocardiography as a Guide for Device Closure of Patent Ductus Arteriosus Yoshiyuki Kudo,1 MD, Kenji Suda,1* MD, Hironaga Yoshimoto,1 MD, Yozo Teramachi,2 MD, Shintaro Kishimoto,1 MD, Motofumi Iemura,2 MD, and Toyojiro Matsuishi,1 MD Objectives: The aim of this study was to develop trans-pulmonary echocardiography (TPE) to guide device closure of patent ductus arteriosus (DC-PDA). Background: Aortography requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy or residual shunt in patients with large PDA or dilated vessels and is precluded in patients with renal dysfunction. Practically, there is no imaging modality to monitor the entire procedure except for trans-esophageal echocardiography that requires general anesthesia. Methods: Subjects were seven patients with ages ranged from 6- to 77-years old and body weight > 15 kg. The size of the PDA ranged from 1.8 to 6.3 mm with pulmonary to systemic flow ratios from 1.2 to 2.2. During DC-PDA using Ampaltzer Duct Occluder or coil, an intra-cardiac echocardiographic (ICE) catheter was advanced into pulmonary arteries and standard views were developed to guide DC-PDA. Results: We have developed two standard views; the main pulmonary artery view (MPA view) and the left pulmonary artery view (LPA view). The MPA view provided aortic short axis view equivalent to that seen by trans-thoracic echocardiography in children. The LPA view, obtained by the echo probe in the LPA and turned it up upside down, provided long axis view of the PDA allowing more precise anatomical evaluation. TPE allowed us to monitor the entire procedure and determine residual shunts. Conclusions: TPE in the MPA and LPA view can be an effective guide for DC-PDA. This report leads to new application of this imaging device. VC 2015 Wiley Periodicals, Inc. Key words: intracardiac echocardiography; Amplatzer duct occluder; aortography; monitoring tool; residual shunt
INTRODUCTION
Device closure of patent ductus arteriosus (DCPDA) has become the standard treatment of this disease with acceptably high success rate and low complication rate [1,2]. Though aortography is the standard imaging modality to guide DC-PDA, aortography in patients with large PDA or dilated vessels requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy. In addition, aortography is precluded in patients with a history of contrast anaphylaxis or patients with renal dysfunction. Practically, there have been no imaging modalities except for trans-esophageal echocardiography (TEE) that allows us to monitor the entire procedure of DCPDA [3–5]. However, a major disadvantage of TEE is that it requires endotracheal intubation and general anesthesia. Overcoming this disadvantage of TEE, intracardiac echocardiography (ICE), especially using AcuNavTM (Biosense Webster Inc, Diamond Bar, CA, USA), has been developed and widely used in catheter intervention for inter-atrial septum, closure of atrial septal defect or perforation of inter-atrial septum, with C 2015 Wiley Periodicals, Inc. V
local anesthesia [6–9]. Recently ICE catheter has expanded its application and was used in the other types of catheter interventions including percutaneous pulmonary or aortic valve replacement and balloon valvuloplasty [9–13]. However, there is no report of the
1
Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan 2 Department of Pediatric Cardiology, St. Mary’s Hospital, Kurume, Japan Conflict of interest: Nothing to report. *Correspondence to: Kenji Suda, MD, Department of Pediatrics and Child Health, Kurume University School of Medicine, Asahi-Machi 67, Kurume, 830-0011, Japan. E-mail: [email protected] Received 29 October 2014; Revision accepted 31 January 2015 DOI: 10.1002/ccd.25879 Published online 25 February 2015 in Wiley Online Library (wileyonlinelibrary.com)
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TABLE I. Demographic Data of Study Patients
#
Age (years old)
Body weight (kg)
1 2 3 4 5 6 7
17 6.2 8.9 8.9 13.2 76.5 71.2
52.8 25.3 34 18.3 34 46.5 58.7
Body height (cm) 159 120 134 112 143 151 150
PDA size (mm) Sex F M F M F M F
Aortography or CCTa
Transpulmoanry echocardiography
Qp/Qs
mPAP (mm Hg)
1.8 2.2 2.2 3.8 4.0 4.2a 6.3a
1.8 2.2 2.3 3.6 3.9 4.0 –
1.3 1.2 1.2 1.7 1.8 2.2 1.9
18 17 16 29 17 18 26
Device Coil ADO-I ADO-I ADO-I ADO-I ADO-I ADO-I
6/4 6/4 8/6 8/6 8/6!10/8 14/12
Comorbidity
HT, MR, CHF CRF, Af, HT, CHF
Abbreviations Af, atrial fibrillation; ADO-I, Amplatzer Duct Occluder I; CCT, cardiac X-ray computed tomography; CHF, congestive heart failure; CRF, chronic renal failure; F, female; HT, hypertension; M, male; mPAP, mean pulmonary artery pressure; MR, mitral regurgitation; PDA, patent ductus arteriosus; Qp/Qs, pulmonary to systemic flow ratio. a Determined by cardiac X-ray computed tomography.
ICE catheter used in the pulmonary artery to guide DC-PDA. Therefore, the purpose of this study was to develop standard views of trans-pulmonary echocardiography (TPE) using AcuNavTM to guide DC-PDA. MATERIALS AND METHODS
Prospectively, we enrolled seven consecutive patients that weighed more than 15 kg and submitted to DCPDA in our institutions. Their demographics are described in Table I. After we obtained written informed consents from patients or patients’ guardians, patients underwent DC-PDA with local anesthesia using Amplatzer Duct Occluder–I (ADO-I, AGA Medical, Golden Valley, MN) with standard fashion via femoral vein [2] in 6 and a coil via femoral artery in 1. An ICE catheter, AcuNavTM, was inserted in the same sheath through which ADO-I was placed or in the separate sheath at the femoral vein. Then it was advanced into the pulmonary artery through a hand-shaped 9 French long sheath in the first patient and was advanced without a long sheath in the remaining six patients. In the first two patients, we placed the ICE catheter up to the main pulmonary artery (MPA) and, in the remaining five patients, we further advanced the ICE catheter into branch pulmonary arteries to look for the best view to evaluate PDA. In this series, the size of the device was selected primarily based on the measurements on aortography or cardiac X-ray computed tomography. After placed a device, we evaluated the residual leak primarily with ICE and determined if we replace the device or release it. When there was residual leak after we released the device, we followed the residual leak at least 10 minutes. The feasibility and image quality of TPE to guide DC-PDA was determined with the reference to aortography and fluoroscopy.
RESULTS
We have developed two standard views, the MPA view and the left pulmonary artery view (LPA view), of TPE to guide DC-PDA.
MPA View In our first patient with age of 71-years old (Patient 7), who had atrial fibrillation and chronic renal dysfunction and was on anti-coagulation therapy, cardiac X-ray computed tomography before the procedure showed type A PDA with 6.3 mm in diameter, calcification of PDA, and dilated pulmonary arteries. On the basis of these findings, we placed 14/12 ADO-I, far bigger device enough to prevent device migration, and confirmed the position and residual shunt using TPE without contrast aortography. After obtained home view [6,8,9], the ICE catheter was posteriorly deflected and advanced into the right ventricle where ICE can show the left ventricular long axis view. Once in the right ventricle, the ICE catheter was unlocked, straightened, and advanced into the right ventricular outflow tract. We advanced the ICE catheter further into the main pulmonary artery with mild anterior deflection and some clockwise rotation to obtain the MPA view (Fig. 1a). The MPA view clearly showed aortic short axis view including the device in the PDA, orifice of the left pulmonary artery, the right pulmonary artery, and the ascending aorta (Fig. 1b) equivalent to that in transthoracic echocardiography in small children. Patient 2 showed type A PDA on aortography (Fig. 2a). In this patient, we observed PDA before and after device placement in the MPA view. Again, the MPA view showed aortic short axis view with clear image of PDA on the color Doppler flow mapping (Fig. 2b) and
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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Kudo et al.
Fig. 1. The position of the tip of ICE catheter (white arrow) to obtain the MPA view in relation to ADO-I (white triangle) on fluoroscopy with lateral projection (a) is shown in Patient 7. The MPA view showed aortic short axis view equivalent to that obtained by trans-thoracic echocardiography in children (b).
Fig. 2. Aortography in Patient 2 shows type A PDA (a). The MPA view showed aortic short axis view with clear image of PDA on the color Doppler flow mapping (b) and pulmonary end of 6/4 ADO-I after the device placement (c).
pulmonary end of 6/4 ADO-I after the device placement (Fig. 2c). LPA View To have stable position of ICE catheter, we further advanced the ICE catheter into the LPA. Once in the LPA, the ICE catheter was unlocked and straightened. Then, we rotated the ICE catheter and turned it upside down (Fig. 3a and b), because the scan plane faced downward when it reached LPA. By looking up PDA from the LPA, TPE showed the long axis of PDA because the left pulmonary artery runs parallel to the aorta. In patients 1, 3, 4, 5, and 6, the LPA view allowed us to precisely evaluate the anatomy of PDA, monitor the entire procedure, and determine the protruding part of device and any residual shunt. We show pictures of Patient 5 as the representation. Patient 5 had type A
PDA on aortography (Fig. 4a). In the LPA view, rotating right or left, advancing, or retreating the ICE catheter, we reviewed the anatomy of PDA in detail (Fig. 4b). The diameter of PDA measured 3.9 mm as the maximum diameter. Then, with fine adjustment of ICE catheter position, LPA view showed all steps of procedure; a 6 French long sheath was advanced through PDA (Fig. 4c), the aortic skirt of ADO-I was opened in the aorta and the long sheath and ADO-I was pulled back into PDA (Fig. 4d), and the body of ADO-I was deployed in the PDA (Fig. 4e). Determination of the Residual Shunt After the device placement and after release, the ICE catheter was rotated right and left to look for residual shunts. In patient 6, we chose 8/6 ADO-I based on the cardiac X-ray computed tomography (Table I), however, the LPA view showed a large amount of
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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residual shunt around the device (Fig. 5a), and therefore, we replaced the device with 10/8 ADO-I. After the release of this device, the LPA view showed a small central residual shunt (Fig. 5b) and this disappeared with time. Likewise, central residual shunt was observed and has disappeared within 10 minutes in Patient 2, 3, and 7. In addition, Patient 4 and 5 showed a small residual shunt around the device, but this residual shunt disappeared with time. In patient 1, we placed a coil because the size of PDA was small and the residual shunt beside coil disappeared with time.
Fig. 3. The position of the tip of ICE catheter (white arrow) to obtain the LPA view in relation to ADO-I (white triangle) on fluoroscopy with lateral projection is shown in Patient 5.
Fig. 4. A representative LPA view of TPE to monitor the procedure in Patient 5. The LPA view is shown in upside down for anatomical orientation. LPA view of TPE allowed us to monitor entire process of DC-PDA. An aortography in lateral projection showed type A PDA (a). TPE clearly showed the pulmonary orifice of PDA with a diameter of 3.9 mm (b). After
Comparison Between the MPA View and LPA View In terms of image direction, the MPA view provides axial view of PDA, but the LPA view provides long axis view of PDA, therefore the LPA view is better to delineate the configuration of PDA, but the MPA view should be better to determine the flow velocity though PDA or branch pulmonary arteries.
a long sheath was placed (c), ADO-I was advanced through it and the aortic skirt (white arrow) was opened, then ADO-I was pulled into PDA (d) and the body of device (white triangle) was deployed (e). A long sheath looked like tramlines in (c). Note the cable attached to the device in (d) and (e).
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Fig. 5. Residual central shunt detected by the LPA view. In Patient 6, when we placed 8/6 ADO-I (white triangle), the LPA view showed a large amount of residual shunt around the device (a). Composite picture shows two-dimensional echocardiography (5a left) and the colorDoppler mapping of the same picture (5a right). After we replaced the device with 10/8 ADOI, the LPA view showed a small central residual shunt (b) and this disappeared with time.
Measurement of the PDA Size
It looked that there was a reasonable agreement between the diameter determined by the TPE and that determined by the aortography or cardiac x-ray computed tomography (Table I). However, this topic was out of scope of this study and needs to be determined in the future study, because the number of subjects in this study was too small.
DISCUSSION
This study indicates that the MPA view and the LPA view can be standard views of TPE using an ICE catheter to effectively guide DC-PDA. For DC-PDA, there are several steps in the procedure; evaluation of anatomy including determination
of the diameter and length of PDA, monitoring device placement with recognizing the relationship between device and PDA, and evaluation of the residual shunt. Aortography in patients with a large PDA or enlarged vessels requires a large amount of contrast yet may give us an inadequate image to evaluate anatomy because of contrast dilution or overlapping vessel shadows. Also, during the device placement, usually lateral projection of fluoroscopy has been used. However, there is no way to see the real relationship between device and surrounding vascular structures, aorta, PDA, and pulmonary artery on fluoroscopy. To guide DC-PDA, we have developed two standard imaging views of TPE, the MPA view and the LPA view. Indeed, these two views clearly showed the
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Trans-Pulmonary Echocardiography for PDA Closure
orifice of PDA in all patients examined, allowed us to determine the size of PDA, and also showed all steps of procedures; long sheath, opening aortic skirt, pulling back device and sheath, deploying body, and detaching device while showing the spatial relationship between the device and surrounding cardiac structures. Such information should be important to determine the risk of device migration or future development of vascular obstruction [8]. In addition, TPE allows us to monitor the residual shunt continuously until it disappears and decreases the number of aortography to determine residual shunt. On the basis of our experience with ADO-I, we think that usually the central shunt goes away with time, but shunt around the device may stay longer or indicate device replacement depending on the amount of residual shunt, though further experience is required. Though trans-aortic echocardiography was reported to guide DC-PDA [9,10], TPE has several advantages. Trans-aortic echocardiography needs to place an 8 French sheath into the femoral artery, and that is undesirable in patients on anti-coagulation therapy. Also trans-aortic echocardiography may show an inadequate image to determine the pulmonary orifice because it is away from the probe and has intrinsic problems, difficulty determining residual shunt because of the acoustic shadow once the device is placed. Also, TPE has an advantage over conventional transesophageal echocardiography in addition to local anesthesia. By placing the echo tip wherever we want, TPE gives us unique scan views such as LPA view, a long axis view of PDA that is never obtained by conventional trans-esophageal echocardiography. In this view, we can measure the pulmonary orifice of PDA most accurately because it parallels the echo beam and this must be especially important for device selection in patients with large PDA. One of the drawbacks of TPE might be the requirement of another sheath in femoral vein and the size of echo catheter. However, ICE has been already applied to many other types of catheter interventions [11–13]. Also ICE has been applied to guide closure of atrial septal defect even in small children less than 15 kg of body weight [14]. Also, there might be potential risks of TPE including arrhythmia and myocardial or vascular injury when we advance an ICE catheter into pulmonary artery via right ventricle. Obviously, careful manipulation of ICE catheter is mandatory and advancing ICE catheter through a pre-placed long sheath may minimize these risks. Further experience and accumulation of data are required.
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CONCLUSIONS
Trans-pulmonary echocardiography including the MPA view and the LPA view can be an effective guide for DC-PDA and may decrease the need for angiography and radiation. This report leads to new application of this imaging device.
ACKNOWLEDGMENT
The authors thank Dr Julien I. E. Hoffman, Professor of Pediatrics, University of California, San Francisco, for his kind assistance with the manuscript preparation. REFERENCES 1. Baruteau AE, Hasco€et S, Baruteau J, Boudjemline Y, Lambert V, Angel CY, Belli E, Petit J, Pass R. Transcatheter closure of patent ductus arteriosus: Past, present and future. Arch Cardiovasc Dis 2014;107:122–132. 2. Pass RH, Hijazi Z, Hsu DT, Lewis V, Hellenbr WE. Multicenter USA amplatzer patent ductus arteriosus occlusion device trial: Initial and one-year results. J Am Coll Cardiol 2004;44:513– 519. 3. Lam J, Tanke RB, van Oort A, Helbing WR, Ottenkamp J. The use of transesophageal echocardiography monitoring of transcatheter closure of a persistent ductus arteriosus. Echocardiography 2001;18:197–202. 4. Marek T Zelizko M, Kautzner J. Real-time 3-dimensional transesophageal echocardiography imaging: Adult patent ductus arteriosus before and after transcatheter closure. Circulation 2009; 120:e92–e93. 5. Chuang YC, Yin W-H, Hsiung MC, Tsai SK, Lee KC, Huang H-J, Ou C-H, Chang C-Y, Wei J, Chou Y-P. Successful transcatheter closure of a residual patent ductus arteriosus with complex anatomy after surgical ligation using an amplatzer ductral occluder guided by live three-dimensional transesophageal echocardiography. Echocardiography 2011;28:E101–E103. 6. Hijazi Z, Wang Z, Cao Q, Koenig P, Waight D, Lang R. Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: Feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv 2001;52:194–199. 7. Dello Russo A, Casella M, Pelargonio G, Bonelli F, Santangeli P, Fassini G, Riva S, Carbucicchio C, Giraldi F, De Iuliis P, Bartoletti S, Pintus F, Di Biase L, Pepi M, Natale A, Fiorentini C, Tondo C. Intracardiac echocardiography in electrophysiology. Miner Cardioangiol 2010;58:333–342. 8. Vaina S, Ligthart J, Vijayakumar M, Ten Cate FJ, Witsenburg M, Jordaens LJ, Sianos G, Thornton AS, Scholten MF, Jaegere D, Serruys PPW. Intracardiac echocardiography during interventional procedures. EuroIntervention 2006;1:454–464. 9. Bartel T, M€uller S, Biviano A, Hahn RT. Why is intracardiac echocardiography helpful? Benefits, costs, and how to learn. Eur Heart J 2014;35:69–76. 10. Bartel T, Gliech V, Muller S. Device closure of patent ductus arteriosus: Optimal guidance by transaortic phased-array imaging. Eur J Echocardiography 2011;12:E9. 11. Awad SM, Masood SA, Gonzalez I, Cao QL, Abdulla RI, Heitschmidt MG, Hijazi ZM. The use of intracardiac echocardiography during percutaneous pulmonary valve replacement. Pediatr Cardiol 2015;36:76–83.
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