Cardiovascular Journal of Africa: Vol 29 No 4 (July/August 2018)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018 AFRICA 203
The changing face of percutaneous closure of the patent
ductus arteriosus: advances over the last few years
Adele Greyling
Patent ductus arteriosus (PDA) closure is recommended for
patients with moderate-to-large PDAs with significant left-to-
right shunting, left-sided volume overload, reversible pulmonary
arterial hypertension (PAH) or aprevious episode of endocarditis.1
In patients with either a small or silent PDA, the decision to close
may be less clear. However, closure is still recommended in small,
audible PDAs and in selected small, silent PDAs, if so preferred
by the clinician and the family, due to the theoretically increased
risk for the development of endocarditis.1
Since the first transcatheter PDA closure over 50 years ago, it
has become the procedure of choice in infants over 5 kg as it is
less invasive and more cost effective than surgery and does not
leave a surgical scar.2 The Amplatzer duct occluders, ADO I and
ADO II, are widely used and have been shown to be safe and
effective to close moderate-to-large PDAs.3 They are probably
best suited to Krichenko type A or E PDAs. Similar in design to
the ADO I, but with flaring on the pulmonary side of the device,
the Occlutech PDA occluder has been proven to be safe and
effective, even in the low- to middle-income setting.4 With these
devices, use is limited in smaller infants due to the size of the
delivery system and the large aortic retention disc, which could
lead to vascular complications, iatrogenic pulmonary artery
stenosis or coarctation of the aorta.
In the ADO II AS device, the occlusive material has been
removed, making the device smaller and more flexible. Combined
with a lower-profile 4F delivery system, it can be delivered from
the aortic or pulmonary side. This makes it particularly well
suited for the closure of small- to moderate-sized elongated
PDAs (Krichenko type C and D PDAs) in small children. In
centres with experienced operators, the outcomes are similar to
surgical closure and it is more cost effective.5 In smaller PDAs,
Cook coils can be used, and although the cost is significantly
less, they are associated with increased procedure times and
radiation doses, higher risk of migration, residual leak and the
need for a redo procedure.5
A recent study suggested that a ‘foetal type PDA’, type F, be
added to the Krichenko classification and that the Amplatzer
vascular plug II (AVP-II) was the most effective device for
closure.6 They report that PDAs in pre-term infants are similar
to those seen during foetal life; typically wide in relation to the
descending aortic diameter, and long and tortuous without
significant stenosis. Type F PDAs are morphologically most
similar to type C PDAs; but they are longer and wider, with a
tortuous segment closest to the PA end. The shape resembles a
‘hockey stick’ with an initial mild cranial angulation, followed by
a caudal turn at the PA end. They are significantly larger, with
the minimal luminal ductal diameter:descending aortic diameter
ratio of 0.67 ± 0.12 and device diameter:descending aortic
diameter ratio of 1.04 ± 0.18, higher than in any other PDA type.
The biggest change in practice in recent years has been the
move to percutaneous closure in smaller and pre-term infants
with relatively larger PDAs, even in infants with a weight of
less than 2 kg. In centres with experienced operators, outcomes
comparable to surgical ligation can be achieved at a lower cost.
In this issue of the journal, Adams and co-workers discuss
the development of transcatheter closure of PDAs over a 15-year
period at Chris Hani Baragwanath Hospital in Johannesburg
(page 246). They found the procedure to be safe and effective in
this setting.
References
1. Doyle T, Kavanaugh-McHugh A, Soslow J, Hill K. Management of
patent ductus arteriosus in term infants, children, and adults. UpToDate
2018. (Accessed 1 July 2018.)
2. Rodríguez Ogando A, Planelles Asensio I, de la Blanca ARS, Ballesteros
Tejerizo F, Sánchez Luna M, Gil Jaurena JM, et al. Surgical ligation
versus percutaneous closure of patent ductus arteriosus in very low-
weight preterm infants: which are the real benefits of the percutaneous
approach? Pediatr Cardiol 2018; 39: 398–410.
3. Bass JL, Wilson N. Transcatheter occlusion of the patent ductus arterio-
sus in infants: Experimental testing of a new Amplatzer device. Catheter
Cardiovasc Interven 2014; 83(2): 250–255.
4. Pepeta L, Greyling A, Nxele MF, Makrexeni ZM. Patent ductus arte-
riosus closure using Occlutech® Duct Occluder, experience in Port
Elizabeth, South Africa. Ann Pediatr Card 2017; 10: 131–136.
5. Pamukcu O, Tuncay A, Narin N, Baykan A, Korkmaz L, Argun M, et
al. Patent ductus arteriosus closure in preterms less than 2 kg: surgery
versus transcatheter. Int J Cardiol 250; 2018 : 110–115.
6. Philip R, Waller BR, Agrawal V, Wright D, Arevalo A, Zurakowski D,
et al. Morphologic characterization of the patent ductus arteriosus in
the premature infant and the choice of transcatheter occlusion device.
Catheter Cardiovasc Interven 2016; 87: 310–317.
Division of Paediatric Cardiology, Department of Paediatrics,
Dora Nginza Hospital, Port Elizabeth, South Africa
Adele Greyling, MD,
Editorial