10 High spontaneous ductal closure even at the extreme of prematurity

Primary Subject area Neonatal-Perinatal Medicine Background Extremely preterm newborns are at risk of prolonged patency of the ductus arteriosus (PDA). Current literature has failed to indicate improvement in outcomes after exposure to strategies promoting ductal closure. As such, our center abandoned these practices in 2013. Objectives Describe the spontaneous PDA closure in premature infants, including those infants born at the extreme of gestational age (< 26 weeks). Design/Methods Retrospective study of newborns < 29 weeks, admitted within 24 hours after birth between 2015 and 2019 and without genetic or congenital anomalies. Newborns who were last known to be alive, with an available echocardiography, and who were not exposed to any intervention to accelerate PDA closure were included. Images were reviewed by experts blinded to the outcomes. Results 296 infants were analyzed. 37 (12%) did not survive their hospitalization, and 16 were exposed to interventions to accelerate ductal closure at some point during their lifetime (4 ligations, 4 catheter-closure, 5 ibuprofen and 3 acetaminophen). Out of the 243 remaining newborns, 214 had at least one echocardiography to ascertain ductal patency or closure (100% of those <26 weeks). The average gestational age was 26.3±1.5 weeks, with 84 (39%) being <26 weeks. PDA closed spontaneously in 194 (91%), with 60 having closure ascertainment after discharge (average age at closure ascertainment of 36.4 [IQR: 34.4 – 40.1] weeks). Of the 84 <26 weeks, 76 (90%) had confirmation of ductal closure. The 20 infants with an open PDA at the last evaluation were followed in an outpatient setting and considered small/restrictive. In our cohort, 92/243 (38%) were exposed to post-natal steroids. In the <26 weeks group, 74% were exposed to steroids, at a cumulative dose of 1.64 [0.89 – 2.44] mg/kg. BPD was found in 57% of the overall cohort and in 79% of <26 weeks. Conclusion The majority of newborns < 29 weeks, and even those at the extreme of gestational age (< 26 weeks) spontaneously closed their PDA before term-corrected age. While BPD rate was similar to previous cohorts, post-natal steroids use was high.

Trans-catheter closure of large PDA in adult patients with Amplatzer device: case series

Ductus arteriosus is a physiological structure if not closed after birth, may lead to many complications. Today, trans-catheter closure of patent ductus arteriosus with Occluder devices is the preferred method. Surgical ligation is used only in certain cases such as large symptomatic patent ductus arteriosus in very small infants and premature babies; unfavourable structure of the duct or economic considerations. In this article, we described haemodynamic and morphological characteristics of five patients with large patent ductus arteriosus which were occluded with Amplatzer device. From 23 January, 2010 to 31 July, 2018, five patients referred to our clinic with large patent ductus arteriosus and pulmonary arterial hypertension for further evaluation. After assessing them with various diagnostic methods, we decided to close defect with ventricular septal defect Occluder device. Patients aged 21–44 years and one of them was male. Ductus closure was successfully done with ventricular septal defect Occluder device. Closure was successful for all of them but in one case, whose device was embolized to pulmonary artery after 24 hr and he underwent surgery. Trans-catheter closure of large patent ductus arteriosus in adult patients with pulmonary hypertension is feasible. Despite the fact that complications may occur even with the most experienced hands, the ‘double disk’ Amplatzer ventricular septal defect muscular Occluder could be advantageous in this setting.

Case report of worsening of preexisting pericardial effusion after ASD device closure: is it calamitous?

Background Secundum-type atrial septal defects (ASD) constitute 8% to 10% of congenital heart defect. Secundum ASDs can be closed either percutaneously or surgically. However, ASD device closure has proven to be technically safe and feasible; it is not free of complications. These complications include device embolization/malposition which have been reported in 3.5% of cases, arrhythmia, and pericardial effusion in 2.6% and 0.5–1.5% respectively, device thrombus, residual shunting, and impingement of the device on the adjacent structures. Case presentation We introduce three patients with secundum ASD who had preexisting pericardial effusion, device closure was performed for them, and after the procedure, the effusion size progressed significantly. We used multimodality imaging to diagnose the cause of pericardial effusion (PE). Cardiac erosion was diagnosed in one of the patients that managed surgically. We did not found any specific procedure-related cause for worsening the pericardial effusion in the other two patients. Conclusion Several reasons include procedure-related complication and other systemic causes should be considered in patients who develop pericardial effusion after trans catheter closure of ASDs.

Does persistent (patent) foramen ovale closure reduce the risk of recurrent decompression sickness in scuba divers?

Introduction: Interatrial communication is associated with an increased risk of decompression sickness (DCS) in scuba diving. It has been proposed that there would be a decreased risk of DCS after closure of the interatrial communication, i.e., persistent (patent) foramen ovale (PFO). However, the clinical evidence supporting this is limited. Methods: Medical records were reviewed to identify Swedish scuba divers with a history of DCS and catheter closure of an interatrial communication. Thereafter, phone interviews were conducted with questions regarding diving and DCS. All Swedish divers who had had catheter-based PFO-closure because of DCS were followed up, assessing post-closure diving habits and recurrent DCS. Results: Nine divers, all with a PFO, were included. Eight were diving post-closure. These divers had performed 6,835 dives (median 410, range 140–2,200) before closure, and 4,708 dives (median 413, range 11–2,000) after closure. Seven cases with mild and 10 with serious DCS symptoms were reported before the PFO closure. One diver with a small residual shunt suffered serious DCS post-closure; however, that dive was performed with a provocative diving profile. Conclusion: Divers with PFO and DCS continue to dive after PFO closure and this seems to be fairly safe. Our study suggests a conservative diving profile when there is a residual shunt after PFO closure, to prevent recurrent DCS events.

Trans catheter device closure of a large azygos vein in adult patient with systemic venous collateral development after the bidirectional Glenn shunt

Superior cavopulmonary anastomosis is a type of palliative cardiac surgeries that usually done in children with cyanotic and complex congenital heart disease who have single ventricle profile. BDG shunt is staged palliation procedure for single ventricle patients who are candidates for total cavopulmonary connection (TCPC). Sometimes the surgeon misses ligating or intentionally leaves the azygos vein as a fenestration or emergency exit. This allows an abnormal flow from the superior vena cava (SVC into azygos vein). These patients can present progressive desaturation, chest tightness, progressive dyspnea, edema and shortness of breath. Therapeutic options include observation, surgical ligation and trans catheter closure. Because of high risks and extra traumas of surgery and greater chance for difficulties and the feasibility of trans catheter therapy, it is done in some centers as a method of choice.

Comparison of trans-catheter closure of paravalvular leak versus surgical approach-outcomes and cost analysis

Background The outcomes and costs of trans-catheter closure (TC) of paravalvular leak (PVL) compared with surgical closure (SC) are rarely described. Purpose The aim of the study was to assess the outcomes and hospital costs of patients who underwent TC or SC of PVL in our center. Methods Patients who underwent TC and SC of PVL between Jan. 2016 and Dec. 2019 were enrolled. Baseline characteristics, procedural, in-hospital and mid-term outcomes and hospital costs were compared. Results A total of 141 patients were studied (TC, n=65 and SC, n=76). The patients were elder in TC group (56.8±12.8 years vs. 50.1±12.8 years, p=0.002). Technical success was higher in SC group (83.1% vs. 98.7%, p<0.001). Procedure room time (93±38 min vs. 395±132 min, p<0.001), intensive care unit time (0 h vs. 25 h, p<0.001), length of stay from hospitalization to discharge (7 days vs. 21 days, p<0.001) and costs (¥45090±19343 vs. ¥164165±94300, p<0.001) were significantly less in TC group. After risk adjustment, there was no significant differences between in 30 days survival between TC group and SC group. However, the residual PVLs were less in SC group (43.1% vs. 12.0%, p=0.012). At a median follow-up of 21 months, there was a trend towards reduce all-cause death following TC versus SC (OR=0.054, 95% CI: 0.070 to 0.445, p=0.007). Conclusions SC for PVL is associated with higher technical rates and less residual shunt. But, the shorter length of stay and lower resources use with TC group significantly reduce hospital costs. In addition, TC achieve a better mid-term results in survival. Funding Acknowledgement Type of funding source: None