... page from the NHLBI on Twitter. What Is Patent Ductus Arteriosus? Patent ductus arteriosus (PDA) is a ... the lung arteries. Normal Heart and Heart With Patent Ductus Arteriosus Figure A shows the interior of ...
Green, Nicholas J; Rollason, Terence P
Fatal haemopericardium in a 27 year old pregnant woman was caused by rupture of a dissecting aneurysm of the pulmonary artery. She had an uncorrected patent ductus arteriosus and severe pulmonary hypertension. The wall of the pulmonary artery showed atherosclerosis and cystic medionecrosis. PMID:1467058
Maleki, Majid; Azizian, Nassrin; Esmaeilzadeh, Maryam; Moradi, Bahieh
We reported a case of patent ductus arteriosus (PDA) with congenital anomaly of coronary arteries as abnormal origin of right coronary artery (RCA) and left coronary artery (LCA) from a single ostium of the right coronary sinus. A 21-year-old man referred to our institution for evaluation of cardiac murmur. He has suffered from palpitation and atypical chest pain for three months. On physical examination, a continuous murmur was heard in the second left parasternal space. Transthoracic echocardiography showed normal left and right ventricular size and systolic function (LVEF = 55%). Main pulmonary artery (PA) and left pulmonary artery (LPA) branch were considerably dilated. Considering normal coronary flow, lack of clinical evidence of myocardial ischemia and echocardiography findings, patient underwent surgical closure of PDA via left thoracotomy and after five days discharged uneventfully. PMID:25478523
Maleki, Majid; Azizian, Nassrin; Esmaeilzadeh, Maryam; Moradi, Bahieh
We reported a case of patent ductus arteriosus (PDA) with congenital anomaly of coronary arteries as abnormal origin of right coronary artery (RCA) and left coronary artery (LCA) from a single ostium of the right coronary sinus. A 21-year-old man referred to our institution for evaluation of cardiac murmur. He has suffered from palpitation and atypical chest pain for three months. On physical examination, a continuous murmur was heard in the second left parasternal space. Transthoracic echocardiography showed normal left and right ventricular size and systolic function (LVEF = 55%). Main pulmonary artery (PA) and left pulmonary artery (LPA) branch were considerably dilated. Considering normal coronary flow, lack of clinical evidence of myocardial ischemia and echocardiography findings, patient underwent surgical closure of PDA via left thoracotomy and after five days discharged uneventfully.
Ghasemi, Abdolrahim; Serati, Ali Reza; Emami, Sepideh; Movahed, Mohammad Reza
Disconnection of the subclavian artery from the aortic arch, defined as isolation, is a rare aortic arch anomaly. In this anomaly, loss of continuity between one subclavian artery and the aorta with persistent connection to the homocollateral pulmonary artery through a patent or remnant ductus arteriosus is present. This isolation is almost always seen on the side contralateral to the aortic arch position. Complex cardiac and genetic anomalies are frequently associated with the isolation of a subclavian artery. We report a rare case of right subclavian artery originating from right pulmonary artery with bilateral patent ductus arteriosus in an otherwise normal infant.
Sehgal, A; Coombs, P; Tan, K; McNamara, P J
Patent ductus arteriosus in extremely premature babies is associated with major neonatal morbidities, such as necrotizing enterocolitis and intraventricular hemorrhage. This may be attributable, at least in part, to systemic hypoperfusion secondary to ductal steal. A hemodynamically significant ductus arteriosus (HSDA) is known to be associated with altered systemic blood flow and end-organ hypoperfusion. Although descending aorta blood flow profiles may show abnormal diastolic retrograde flow, Doppler studies of blood flow in the systemic arteries may help improve our understanding of the relationship of a HSDA with these morbidities. In this article, we discuss aspects of diastolic blood flow reversal in the systemic arteries in premature infants with a hemodynamically significant duct. Whether these hemodynamic effects are significant enough to form the basis for initiating treatment is still unclear; these should form the basis for prospective studies.
Bezgin, Tahir; Demircan, Hacer C; Kaymaz, Cihangir
Aneurysms involving the main pulmonary artery and its branches are rare. Clinical experience is limited, and their management is not well established. We present the case of a 35-year-old male patient with dyspnea and hemoptysis in whom subsequent imaging studies revealed a giant pulmonary artery aneurysm associated with an uncorrected patent ductus arteriosus and Eisenmenger’s syndrome. We chose to treat the patient conservatively with medical management due to the development of Eisenmenger’s physiology while waiting for heart-lung transplantation. PMID:25545802
Beker-Acay, Mehtap; Ozkececi, Gulay; Unlu, Ebru; Hocaoglu, Elif; Kacar, Emre; Onrat, Ersel
Unilateral absence of a pulmonary artery a very rare congenital disorder. We here present a case of a 22-year-old female patient with agenesis of the right pulmonary artery accompanying patent ductus arteriosus and Eisenmenger syndrome, diagnosed by chest X-ray and multidetector computed tomography 5 days after giving birth.
Kim, Sae Yun; Shin, Seung Han; Kim, Han-Suk; Jung, Young Hwa; Kim, Ee-Kyung; Choi, Jung-Hwan
To describe the clinical course and risk factors for pulmonary arterial hypertension (PAH) after ibuprofen treatment to close patent ductus arteriosus. All neonates weighing < 1500 g at birth who received ibuprofen to close patent ductus arteriosus and were admitted to Seoul National University Children's Hospital's neonatal intensive care unit in 2010-2014 were eligible for this study. The study population was divided into the PAH and non-PAH groups, and medical records were retrospectively reviewed. Of the 144 eligible infants, 10 developed PAH (6.9%). Relative to the non-PAH group, the PAH group exhibited greater respiratory severity and more frequent severe bronchopulmonary dysplasia or death before 36 weeks postmenstrual age. Multivariable analysis demonstrated that lower gestational age, birth weight in less than the third percentile for age, maternal hypertension of pregnancy, and oligohydramnios were risk factors for developing PAH after ibuprofen treatment. A high incidence of PAH after ibuprofen treatment was observed in the study population. Furthermore, younger gestational age and several prenatal conditions were identified as risk factors for developing PAH after ibuprofen treatment. Additional large cohort studies are necessary to confirm our results. Copyright © 2016 Elsevier Inc. All rights reserved.
Dubey, Gajendra; Gupta, Saurabh Kumar; Kothari, Shyam Sundar
We report a case of isolation of the left brachiocephalic artery with the right aortic arch in a 9-year-old male child masquerading as large patent ductus arteriosus with left-to-right shunt. We have emphasized the subtle clinical findings which served as clues to the diagnosis. PMID:28163435
Wong, S N; Lo, R N; Hui, P W
The flow velocity pattern in the descending aorta, renal arteries, and celiac and superior mesenteric arteries was studied with pulsed Doppler in eight premature babies with symptomatic ductus arteriosus before and after ductal closure, as compared to nine premature babies without ductus arteriosus. There was a decrease or reversal of flow in diastole in the above arteries in babies with ductus and diastolic flow reappeared after ductal closure. This diastolic steal phenomenon has not been previously demonstrated in the abdominal arteries. It may contribute to proneness to ischemic damage of abdominal organs in premature babies.
Korkmaz, Ozge; Beton, Osman; Goksel, Sabahattin; Kaya, Hakkı; Berkan, Ocal
Endovascular stent graft implantation is a favorable method for complex aortic coarctation accompanied by patent ductus arteriosus. Herein, an 18-year-old woman with complex aortic coarctation and patent ductus arteriosus was successfully treated by endovascular thoracic stent graft via retroperitoneal approach. The reason for retroperitoneal iliac approach was small sized common femoral arteries which were not suitable for stent graft passage. This case is the first aortic coarctation plus patent ductus arteriosus case described in the literature which is treated by endovascular thoracic stent graft via retroperitoneal approach. PMID:27242935
Güvenç, Osman; Ödemiş, Ender; Saygı, Murat; Demir, İbrahim Halil
Major aortopulmonary collateral arteries are abnormal vascular structures that may be seen in cyanotic diseases that progress with reduced pulmonary flow. They occur rather rarely in the absence of cyanotic congenital heart disease. Presently described is the case of an infant who underwent patent ductus arteriosus (PDA) and major aortopulmonary collateral artery occlusion in a single session, without presence of cyanotic congenital heart disease. To the best of our knowledge, this is the first case of congenital aortopulmonary collateral artery to be reported in a symptomatic infant with PDA.
Ecury-Goossen, Ginette M; Raets, Marlou M A; Camfferman, Fleur A; Vos, Rik H J; van Rosmalen, Joost; Reiss, Irwin K M; Govaert, Paul; Dudink, Jeroen
Little is known about cerebral artery resistive index values in infants born extremely preterm. To report resistive index values in various cerebral arteries in a prospective cohort of preterm infants born at <29 weeks' gestation, and to compare resistive index in these arteries and assess the relationship between resistive index and hemodynamically significant patent ductus arteriosus. Using Doppler imaging, we obtained resistive index values of internal carotid arteries, basilar artery, anterior cerebral artery, and pial and striatal arteries in the first 3 days of age and weekly thereafter until discharge or death. We analyzed paired observations using the Wilcoxon signed-rank test, between-group comparisons with the Mann-Whitney test. We performed 771 examinations in 235 infants. Resistive indices differed among arteries: vessels with larger diameters showed significantly higher resistive indices. Resistive index in infants without patent ductus arteriosus was lower than that in infants with hemodynamically significant patent ductus arteriosus (median in anterior cerebral artery: 0.75 and 0.82, respectively; P<0.001), though this was not statistically significant in all arteries. There was no difference in pre- and post-ligation resistive indices in infants who underwent patent ductus arteriosus ligation. For accurate follow-up and comparison of cerebral artery resistive index, the same artery should be examined on each occasion.
Wilcox, W D; Carrigan, T A; Dooley, K J; Giddens, D P; Dykes, F D; Lazzara, A; Ray, J L; Ahmann, P A
Range-gated pulsed Doppler (RGPD) ultrasonography was utilized to study the effect of a patent ductus arteriosus (PDA) on carotid arterial blood flow in small preterm infants. Carotid arterial flow velocity studies were performed on 23 preterm infants, sampling right and left carotid arteries. Studies on seven infants after PDA ligation and on seven who developed no evidence of PDA were used as controls. A strong relationship was demonstrated between diastolic reversal in the carotid arteries and PDA. The results of this study indicate that the RGPD flow velocity curve from the carotid artery is more sensitive than M-mode echocardiography or clinical examination in detecting PDA, and that PDA in small preterm infants is associated with a distinct abnormality in the carotid arterial flow pattern.
Tsuchiya, Takehiro; Tanaka, Makoto; Fukami, Takeshi
A 38-year-old woman was referred to our hospital because she presented with an abnormal shadow on a chest radiograph. A through examination showed an aberrant artery arising from the abdominal aorta and supplying the right basal segment and patent ductus arteriosus(PDA).Moreover the sequestrated lung was not recognized. Based on these findings we diagnosed the patient with anomalous systemic arterial supply to the basal segment of the right lung with PDA. Her pulmonary-to-systemic blood flow ratio was 1.10. Therefore we planned to treat the PDA someday afterwards. Right basal segmentectomy and transection of the aberrant artery by using only autosuturing device were performed. Five months later, three-dimensional computed tomography showed no aneurysm of the cut end of the abnormal vessel.
Celik, Murat; Celik, Turgay; Iyisoy, Atila; Guler, Adem
The heterotaxy syndrome is a rare and sporadic disorder. This syndrome presents with situs ambiguus, splenic malformations such as asplenia or polysplenia, and congenital heart disease. Congenital heart diseases associated with this syndrome include a broad variety of manifestations. Patent ductus arteriosus is one of them and percutaneous transcatheter closure can be challenging in the setting of this syndrome. Kommerell's diverticulum is a saccular aneurysmal dilation at the origin of an aberrant subclavian artery, and can be related with other congenital anomalies. However, there is no previous report of Kommerell's diverticulum being found together with patent ductus arteriosus and heterotaxy syndrome.
Dice, James E; Bhatia, Jatinder
Patent ductus arteriosus (PDA) is one of the most common congenital heart defects, accounting for 5%-10% of all congenital heart disease in term infants. The occurrence of PDA is inversely related to gestational age and weight, with an even greater incidence in preterm infants. The maintenance of ductal patency is essential for the normal development of the fetus. In the neonate, however, persistent patency of the ductus arteriosus (DA) is associated with significant morbidity and mortality. Normally, at birth, the DA constricts, resulting in intraluminal ischemic hypoxia, which eventually leads to closure and remodeling of the ductus. PDA in term infants is usually associated with a functional defect, whereas in preterm infants it is associated with immaturity. Normal physiologic mechanisms contributing to closure - oxygen tension and decreased prostaglandins-are altered in prematurity. Clinical signs of ductal patency include murmur, tachycardia, bounding peripheral pulses, and congestive heart failure and associated symptoms. Symptoms are not always present; therefore, diagnostic imaging is critical if a PDA is suspected on clinical grounds. Three management strategies are currently available for PDA: fluid restriction and diuretics (as clinically appropriate), medical intervention, and surgical ligation. Pharmacologic closure can be achieved via administration of intravenous indomethacin or ibuprofen lysine. While both agents have shown similar efficacy, ibuprofen lysine has demonstrated an improved safety profile, particularly in terms of renal effects, compared to indomethacin.
Wen, Bing; Yang, Junya; Liu, Huiruo; Jiao, Zhouyang; Zhao, Wenzeng
To document clinical experience of treating congenital heart disease combined with large patent ductus arteriosus with pulmonary artery closure in combination with patch technique. Thirty-six patients (8 males and 28 females) who suffered from congenital heart disease and underwent hybrid surgery in the First Affiliated Hospital of Zhengzhou University from October 2010 to February 2014 were selected for this study. They aged 14 to 39 years and weighed 32.20 to 61.50 kg. Diameter of arterial duct was between 10 mm and 13 mm; 28 cases were tube type, 4 cases were funnel type and four cases were window type. All patients had moderate or severe pulmonary arterial hypertension; besides, there were 28 cases of ventricular septal defect, 16 cases of atrial septal defect, eight cases of aortic insufficiency, four cases of mitral stenosis and insufficiency and four cases of infectious endocarditis. Cardz Pulmonary Bypass (CPB) was established after chest was opened along the middle line. With the help of Transesophageal echocardiography, large patent ductus arteriosus was blocked off through pulmonary artery. Pulmonary artery was cut apart after blocking of heart. Large patent ductus arteriosus on the side of pulmonary artery was strengthened with autologous pericardial patch. Of 36 patients, 32 patients had patent ductus arteriosus closure device and four patients had atrial septal defect closure device. Pulmonary arteries of 36 cases were all successfully closed. Systolic pressure declined after closure ((54.86±19.23) mmHg vs (96.05±23.07) mmHg, p<0.05); average pulmonary arterial pressure also declined after closure ((39.15±14.83) mmHg vs (72.88±15.76) mmHg, p<0.05). The patients were followed up for one to fifty one months (average 11.5 months). Compared to before surgery, left atrial diameter, left ventricular diameter and pulmonary artery diameter all narrowed after surgery. Besides, clinical symptoms were relieved and cardiac function of the patients also
Wen, Bing; Yang, Junya; Liu, Huiruo; Jiao, Zhouyang; Zhao, Wenzeng
Objective: To document clinical experience of treating congenital heart disease combined with large patent ductus arteriosus with pulmonary artery closure in combination with patch technique. Methods: Thirty-six patients (8 males and 28 females) who suffered from congenital heart disease and underwent hybrid surgery in the First Affiliated Hospital of Zhengzhou University from October 2010 to February 2014 were selected for this study. They aged 14 to 39 years and weighed 32.20 to 61.50 kg. Diameter of arterial duct was between 10 mm and 13 mm; 28 cases were tube type, 4 cases were funnel type and four cases were window type. All patients had moderate or severe pulmonary arterial hypertension; besides, there were 28 cases of ventricular septal defect, 16 cases of atrial septal defect, eight cases of aortic insufficiency, four cases of mitral stenosis and insufficiency and four cases of infectious endocarditis. Cardz Pulmonary Bypass (CPB) was established after chest was opened along the middle line. With the help of Transesophageal echocardiography, large patent ductus arteriosus was blocked off through pulmonary artery. Pulmonary artery was cut apart after blocking of heart. Large patent ductus arteriosus on the side of pulmonary artery was strengthened with autologous pericardial patch. Results: Of 36 patients, 32 patients had patent ductus arteriosus closure device and four patients had atrial septal defect closure device. Pulmonary arteries of 36 cases were all successfully closed. Systolic pressure declined after closure ((54.86±19.23) mmHg vs (96.05±23.07) mmHg, p<0.05); average pulmonary arterial pressure also declined after closure ((39.15±14.83) mmHg vs (72.88±15.76) mmHg, p<0.05). The patients were followed up for one to fifty one months (average 11.5 months). Compared to before surgery, left atrial diameter, left ventricular diameter and pulmonary artery diameter all narrowed after surgery. Besides, clinical symptoms were relieved and cardiac
Lipman, B; Serwer, G A; Brazy, J E
Blood flow patterns in the anterior cerebral arteries were studied in eight preterm infants with patent ductus arteriosus and left-to-right shunts. A noninvasive Doppler technique was used to obtain the blood flow patterns and to calculate a pulsatility index. Advancing diastolic blood flow was decreased in all eight infants, and two demonstrated retrograde anterior cerebral artery flow during diastole. Following ductal closure, the diastolic flow in the anterior cerebral arteries increased significantly, reaching levels seen in normal infants. These observations demonstrate that infants with patent ductus arteriosus and left-to-right shunts may have abnormal cerebral hemodynamics which return to normal following ductal closure.
Le, Jennifer; Gales, Mark A; Gales, Barry J
To evaluate the literature describing acetaminophen use in treatment of patent ductus arteriosus (PDA). Searches were conducted in MEDLINE with full text (EBSCOhost; 1946 to September 2014) using the search terms acetaminophen, paracetamol, and patent ductus arteriosus. The references of identified articles were reviewed to identify other relevant articles. Human clinical trials and case reports limited to the English language were reviewed. In all, 12 case reports and 2 randomized, controlled clinical trials explored the use of acetaminophen in treating PDA. The case reports described the use of oral or intravenous acetaminophen in patients with contraindications to or who had previously failed nonsteroidal anti-inflammatory drug therapy for PDA. More than 76% of patients achieved successful PDA closure in reported cases. The clinical trials compared the efficacy of oral acetaminophen versus oral ibuprofen in preterm infants. Acetaminophen was noninferior to ibuprofen, with closure rates from 72.5% to 81.2%. The acetaminophen dose used in most case series and trials was 15 mg/kg dose every 6 hours for 3 days. Acetaminophen therapy was well tolerated, with only a few incidents of elevated liver enzymes being reported. Oral acetaminophen is an alternative to PDA therapy in preterm infants when indomethacin/ibuprofen is not effective or is contraindicated, and it may be considered before surgical ligation. © The Author(s) 2014.
Bömelburg, T; Jorch, G
Blood flow velocities and pulsatory indices in both renal arteries (RAs) and in the internal carotid artery (CAI) were measured by pulsed Doppler ultrasonography in ten preterm infants with patent ductus arteriosus (PDA), before and after surgical ligation. The results obtained in the RAs were compared to those found in a reference group of 22 stable preterm infants. In the RAs the diastolic steal volume of the PDA led to a marked decrease in diastolic blood flow velocity (range 3 to -23 cm/s). Seven infants showed retrograde diastolic flow, whereas only three infants had these flow patterns in the CAI. In the RAs, the peak systolic blood flow velocities (range 56 to 135 cm/s) exceeded the values found in the reference group by 85% on average. The pulsatility indices reached values of above 1,00. In spite of the increase in systolic flow velocities before surgery, the time mean of maximum velocities was significantly lower than those measured after surgery and in the reference group. After PDA ligation, blood flow velocities normalized. The present study shows that a large PDA may induce abnormal flow patterns even in the RAs. These flow patterns may predispose to renal hypoperfusion and subsequent impairment of renal function.
Jafari Dehkordi, Afshin; Hoseini, Farzaneh
Patent ductus arteriosus (PDA) is a persistent patency of a vessel normally present in the fetus that connects the pulmonary arterial system to the aorta. The ductus arteriosus fails to close at birth when breathing commences and placental blood circulation is removed. Closure of the ductus arteriosus arises in response to decline pulmonary vascular resistance and increased systemic vascular resistance. This report describes a case of PDA in a two-month-old male lamb with clinical signs of machinery murmur, tachycardia, increase respiratory rate, weakness and ill thrift. Echocardiographic examination and necropsy finding confirmed PDA. PMID:27226893
Martínez-Guerra, M L; Fernández-Bonetti, P; Peraza, C; Lupi-Herrera, E
Eighteen patients with ventricular septal defect or patent ductus arteriosus were studied to investigate the effects of an increase of pulmonary hypertension. In general group II showed similar results as previously reported in patients with atrial septal defect without pulmonary hypertension. In group I, we found an increased frequency of functional abnormalities in the small airways. We do not have a definitive explanation for the origin of these differences.
Munoz, J.J. Urbaneja, A.; Gonzalez, N.; Martinez, J.L.
We present the case of a 63-year-old woman with a short patent ductus arteriosus and aneurysmal pulmonary arteries who was treated by placement of a stent-graft. The technique proved simple and safe. Further research is required to improve the design of stent-grafts and their release system for use of this technique in adult patients with this disorder.
Qu, Hong; Liu, Tianqi; Wang, Haiyan; Wang, Dong; Li, Quan
Left-ventricular diverticulum (LD) associated with patent ductus arteriosus (PDA) is extremely rare. We have not found any previous reports of the coexistence of these two malformations. Such an association presenting with chest pain mimicking an infarct aneurysm with angina or a takotsubo cardiomyopathy with chest pain is difficult to differentiate clinically. Here, we discuss several diseases characterized by left-ventricular apical protrusion with chest pain to familiarize clinicians with the differential diagnosis of these diseases. A 58-year-old woman was referred to our hospital because of complaints of chest pain and dyspnoea, mainly on exertion. An electrocardiograph on admission showed a q-wave in lead I, a Q-wave in lead aVL, and an abnormal T-wave in the limb leads and leads V4 to V6. A transthoracic echocardiograph revealed a PDA and a protrusion arising from the apex of the left ventricle. The diagnosis on admission was PDA and coronary artery disease with infarct aneurysm. To evaluate the source of the chest pain, further evaluations were performed. Coronary angiography showed no abnormal findings. Left ventriculography confirmed the presence of an apical contractile out-pouching. Based on these findings, we revised the diagnosis as LD associated with PDA. The patient underwent transcatheter occlusion of the PDA and was discharged 3 days later. Unexpectedly, transcatheter occlusion resolved the paroxysmal chest pain in this case. This is the first case report of LD combined with PDA. PDA should be considered in the list of differential diagnosis of chest pain. Several diseases characterized by left-ventricular apical protrusion with chest pain, such as LD, infarct aneurysm and takotsubo cardiomyopathy, can be misdiagnosed as one another. Therefore, it is important to familiarize clinicians with the differential diagnosis of these diseases.
Kuo, H.-Cg; Ko, Sheung-Fat; Wu, Yu-Tsun; Huang, Chien-Fu; Chien, Shao-Ju; Tiao, Mao-Meng; Liang, Chi-Di
We report an unusual case of simultaneous obstruction of the left pulmonary artery and descending thoracic aorta after Gianturco coil occlusion in a 15-month-old boy. The diagnosis was made by echocardiography and cardiac angiography. At surgery, thrombi coating on the protruded parts of the Gianturco coil in the pulmonary artery and aorta were found.
van Middendorp, Lars B; Maessen, Jos G; Sardari Nia, Peyman
We describe the case of a 59-year old male patient undergoing combined coronary artery bypass grafting and aortic valve replacement. Manipulation of the heart during cardiopulmonary bypass significantly decreased venous return. Several measures were necessary to improve venous return to a level at which continuation of the procedure was safe. Based on the initial troubles with venous return, we decided to selectively cross-clamp the aorta. This resulted in a large amount of backflow of oxygenated blood from the left ventricle, necessitating additional vents in the pulmonary artery and directly in the left ventricle. The procedure was continued uneventfully, and postoperative recovery was without significant complications. Postoperative 2D computed tomography did not show any signs of a shunt, but 3D reconstruction showed a small patent ductus arteriosus.
Fujii, Yoko; Aoki, Takuma; Takano, Hiroshi; Ishikawa, Ryokichi; Wakao, Yoshito
Three dogs presented for the evaluation of cardiac murmurs were diagnosed with aberrant arteriovenous shunts. All cases demonstrated the following findings: 1) relatively soft continuous murmur loudest at the left heart base resembling patent ductus arteriosus (PDA); 2) shunt flow signals in the pulmonary artery on echocardiography; and 3) no PDA on selective angiography, but evidence of anomalous shunting vessels from thoracic aorta to pulmonary vasculature. An aberrant arteriovenous shunt should be considered when a continuous murmur of relatively small intensity is heard.
Aggarwal, R; Bajpai, A; Deorari, A K; Paul, V K
Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.
Agarwal, Ramesh; Deorari, Ashok K; Paul, Vinod K
Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.
Setchi, Adriana; Mestel, A Jonathan; Siggers, Jennifer H; Parker, Kim H; Tan, Ming Wang; Wong, Kangwen
The ductus arteriosus is one of several shunts in the cardiovascular system. It is a small vessel connecting the aortic arch and pulmonary artery that allows blood to bypass the pulmonary circulation. It is open during foetal development because the foetal lungs cannot function and oxygenation of the blood occurs by exchange with the maternal blood in the placenta. Normally it closes a few days after birth; however, in a small number of people closure does not occur, leading to a condition known as patent ductus arteriosus. In this paper our aim is to investigate the resulting cardiovascular effects. We develop a mathematical model of the haemodynamics in three different idealised geometries by assuming that the entry flow is irrotational and remains so in the core until at least the shunt position. We argue that separation or diffusion of vorticity into the core flow is delayed due to the high frequency associated with the pulsatile component of the flow profile. The analysis uses complex potential theory, Schwarz-Christoffel transformations, conformal mappings and Fourier series. The main results are based on the assumption that the flow in patients with patent ductus arteriosus is similar to the flow in healthy adults, and we apply this assumption using boundary conditions that are representative of physiological values in healthy adults. The model suggests that the pressures in the aorta and pulmonary artery are likely to equalise, that the shear stress increases near the edges of the shunt and that backflow of large volumes may occur from the pulmonary artery into the aorta or towards the ventricles due to the presence of the patent shunt. Our results strongly suggest that an abnormal compensatory physiology develops in patients with patent ductus arteriosus.
Saunders, Ashley B; Winter, Randolph L; Griffin, Jay F; Thieman Mankin, Kelley M; Miller, Matthew W
An increase in the availability of advanced imaging modalities has led to improved recognition of cardiovascular anomalies. Computed tomography angiography (CTA) provides a non-invasive means of acquiring 3D images with a relatively short acquisition time thereby providing essential information in regards to patient anatomy and procedure planning. The dog in this report had a right aortic arch and abnormal branching with an aberrant left subclavian artery originating from the ampulla of a left patent ductus arteriosus (PDA) that was detected with CTA. The PDA was creating a volume overload to the left side of the heart as well as contributing to the vascular ring and compression of the esophagus. Therefore, ligation and transection instead of a minimally invasive catheter-based procedure was required. This aortic arch anomaly and surgical management have not been previously reported in dogs. Copyright © 2013 Elsevier B.V. All rights reserved.
Moore, J W; George, L; Kirkpatrick, S E; Mathewson, J W; Spicer, R L; Uzark, K; Rothman, A; Cambier, P A; Slack, M C; Kirby, W C
This report summarizes our experience with the use of occluding spring coils to close the small patent ductus arteriosus. Several patent ductus arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent ductus arteriosus in a small group of patients. This report describes our series of patients having patent ductus arteriosus closure with occluding spring coils. Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent ductus arteriosus closure by occluding spring coils. Selection criteria were age > 6 months and narrowest patent ductus arteriosus internal dimension < or = 3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent ductus arteriosus and into the aortic diverticulum. Patent ductus arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging. Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent ductus arteriosus. Average ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent ductus arteriosus noted on color flow imaging
Miraclin, Angel T; Perumalla, Susmitha K; Daniel, Jaifrin; Sathyendra, Sowmya
Endarteritis is a major complication in patients with patent ductus arteriosus, causing significant morbidity and mortality. We report an adult patient with asymptomatic patent ductus arteriosus and endarteritis involving the main pulmonary artery and secondary infective spondylodiscitis at the L5-S1 intervertebral disc caused by Abiotrophia defectivaA. defectiva, commonly referred to as nutritionally variant streptococci, cannot be identified easily by conventional blood culture techniques from clinical specimens. Its isolation was confirmed by 16S ribosomal RNA sequencing. The patient was successfully managed with a combination of penicillin G and gentamicin, pending surgical repair of the patent ductus arteriosus.
Wardle, Andrew J; Osman, Ahmed; Tulloh, Robert; Luyt, Karen
To compare differences in the management of the neonatal patent ductus arteriosus between neonatologists and paediatric cardiologists, physicians throughout the South-West were contacted. In treatment-refractory cases, neonatologists considered ligation less frequently than paediatric cardiologists (0% versus 40%; p<0.05) and held haemodynamic effects more important for ligation decisions [median: 5 (range 2-5) versus median: 4 (range 2-5); p<0.05]. Furthermore, 81% felt the current guidelines were insufficient.
Nagata, Hazumu; Ihara, Kenji; Yamamura, Kenichiro; Tanoue, Yoshihisa; Shiokawa, Yuichi; Tominaga, Ryuji; Hara, Toshiro
The purpose of this study was to evaluate the hemodynamic changes in left ventricular function before and after patent ductus arteriosus ligation in premature infants with regard to the energetic efficiency of left ventricular pumping. Thirty-five premature infants who underwent patent ductus arteriosus ligation were enrolled in this study. Left ventricular efficiency was evaluated at 4 points: within 24 hours before patent ductus arteriosus ligation, within 24 hours after patent ductus arteriosus ligation, between postoperative days 2 and 4, and on postoperative day 7. The indices of contractility (end-systolic elastance) and afterload (effective arterial elastance) were approximated on the basis of the systemic blood pressure and systolic or diastolic left ventricular volume. The ratio of stroke work and pressure-volume area, representing the ventricular efficiency, was estimated using the following theoretic formula: the ratio of stroke work and pressure-volume area = 1/(1 + 0.5 ventriculoarterial coupling). Left ventricular efficiency was transiently deteriorated within 24 hours after patent ductus arteriosus ligation because of the marked increase of the afterload and the slight increase of contraction, and then recovered to preoperation levels by 2 to 4 days after patent ductus arteriosus ligation. Analysis of indices representing the afterload, contractility, and energetic efficiency of the left ventricle may provide practical information for the management of premature infants during the postoperative period after patent ductus arteriosus ligation. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Buchanan, James W; Patterson, Donald F
Patent ductus arteriosus (PDA) is the most common congenital heart disease in dogs and usually causes heart failure and death unless corrected at a young age. Previous histologic studies in a line of dogs derived from Miniature Poodles with hereditary PDA identified varying degrees of hypoplasia and asymmetry of ductus-specific smooth muscle and the presence of aortalike elastic tissue in the ductus wall sufficient to cause patency. To determine if similar structural abnormalities cause PDA in other dogs, serial-section, 3-dimensional histology of ductal architecture was studied in 8 non-Poodle purebred dogs with PDA with no immediate family history of PDA. Morphologic abnormalities were observed in 7 of 8 dogs with PDA and essentially were the same as those in dogs known to have a hereditary form of PDA. These findings suggest that apparently sporadic PDA in these breeds is caused by a genetic defect in the structure of the ductus arteriosus that is similar or identical to that in the Poodle. The relatives of dogs with PDA, particularly parents, offspring, and siblings, should be screened for evidence of PDA. Dogs with PDA should not be used for breeding, regardless of breed.
Jiang, Hai-bin; Bai, Yuan; Zong, Gang-jun; Han, Lin; Li, Wei-ping; Lu, Yang; Qin, Yong-wen; Zhao, Xian-xian
The aim of this study was to evaluate a new type of occluder for patent ductus arteriosus. Patent ductus arteriosus was established in a canine model by anastomosing a length of autologous jugular vein to the descending aorta and the left pulmonary artery in an end-to-side fashion. Transcatheter closure of each patent ductus arteriosus was performed on 10 dogs, which were then monitored for as long as 6 months with aortography, echocardiography, and histologic evaluation. Transcatheter closure with use of the novel pan-nitinol device was successful in all canine models. Postoperative echocardiography showed that the location and shape of the occluders were normal, without any residual shunting. Further histologic evaluation confirmed that the occluder surface was completely endothelialized 3 months after implantation. Transcatheter patent ductus arteriosus closure with the pan-nitinol occluder can be performed safely and successfully in a canine model and shows good biological compatibility and low mortality rates. PMID:23466429
Pan, Xiangbin; Ouyang, Wenbin; Li, Shoujun; Guo, Gaili; Liu, Yao; Zhang, Dawei; Zhang, Fengwen; Pang, Kunjing; Fang, Nengxin; Hu, Shengshou
To avoid the radiation injuries and use of contrast agent, we assessed the safety and efficacy of percutaneous patent ductus arteriosus closure solely under thoracic echocardiography guidance. From June 2013 to June 2014, thirty patients (mean age: (6.3 ± 2.5) years, mean body weight:(22.5 ± 7.3) kg) with pure patent ductus arteriosus were continuously included in this study. The mean diameter of patent ductus arteriosus was (3.8 ± 0.9) mm. Patients were all treated by percutaneous patent ductus arteriosus closure via right femoral artery solely under thoracic echocardiography guidance. The efficacy of the procedure was evaluated by thoracic echocardiography. Follow-up was performed at one month after procedure. All 30 cases were successfully treated with percutaneous patent ductus arteriosus closure solely under thracic echocardiography guidance. The procedural time was (32.8 ± 5.7) minutes. The mean diameter of Amplatzer ADO II was (4.9 ± 1.0) mm. Postoperative trivial residual shunt occurred in six patients immediately after the procedure. All patients survived without peripheral vascular injury or complications such as cardiac perforation. Hospitalization time was (3.4 ± 0.7) days. At one-month follow-up, no complications such as residual shunt or pericardial effusion were observed. Echocardiography guided percutaneous patent ductus arteriosus closure by femoral artery approach is safe and effective, and can avoid X-ray and the use of contrast agents.
Yapakçı, Ece; Ecevit, Ayşe; Törer, Birgin; Ince, Deniz Anuk; Gökdemir, Mahmut; Gülcan, Hande; Tarcan, Aylin
This study aimed to examine the differences between arterial and inferior caval vein oxygen saturation, fractional oxygen extraction, and the shunt index, which were calculated in the diagnosis of patent ductus arteriosus. Twenty-seven preterm infants were included in this study and were divided into two groups according to patent ductus arteriosus. Among them, 11 (41%) infants had haemodynamically significant patent ductus arteriosus and 16 (59%) did not have significant patent ductus arteriosus. Synchronous arterial and venous blood gases were measured during the first post-natal hours after the insertion of umbilical catheters. The differences between arterial and inferior caval vein oxygen saturation, inferior body fractional oxygen extraction, and the shunt index were calculated. Echocardiography was performed before the 72nd hour of life in a selected group of patients who had haemodynamically significant patent ductus arteriosus. Ibuprofen treatment was administered to patients with patent ductus arteriosus. Echocardiography was performed on the 72nd hour of life in preterm infants without any clinical suspicion of patent ductus arteriosus. The early measured differences between arterial and inferior caval vein oxygen saturation and inferior body fractional oxygen extraction were found to be lower and the shunt index was found to be higher in the haemodynamically significant patent ductus arteriosus group than in the group without haemodynamically significant patent ductus arteriosus. We found that the shunt index, calculated in the first hours of life as ≥63%, predicted haemodynamically significant patent ductus arteriosus with a sensitivity of 78% and specificity of 82% in preterm newborns.
Bhatt, V; Nahata, M C
The incidence, pathophysiology, and clinical findings of symptomatic patent ductus arteriosus (PDA) are reviewed, and the pharmacologic management of symptomatic PDA is discussed. Spontaneous closure of the ductus arteriosus (DA) usually occurs within four days after birth in most premature and full-term infants. The incidence of PDA is related to birth weight in premature infants and has been shown to decrease with an increase in birth weight. Clinical findings are reviewed. Prophylactic treatment in the first few hours after birth may not be needed in most premature infants. Treatment should be considered only if the ductus becomes symptomatic. Medical management consists of respiratory support, fluid restriction, diuretics, digoxin, and indomethacin. Respiratory support, fluid restriction, and diuretics are used as first-line treatment of symptomatic PDA. Digoxin cannot be recommended as part of first-line therapy, since its risks seem to outweigh the benefits in preterm infants. Indomethacin should be used only if other standard measures including fluid restriction and diuretic treatment fail. The mechanism of action, pharmacokinetics, adverse effects, and drug interactions of indomethacin are discussed. Symptomatic PDA can increase morbidity and mortality, especially in very low birth weight infants. Treatment of symptomatic PDA may decrease the morbidity associated with this condition.
Walsh, M; Coleman, D; Murphy, J; Twomey, A
The aim of our study was to look at the amount of training required to accurately assess ductal patency in very low birth weight infants and to show that this service could be provided by non-cardiologists. Training consisted of an introductory echocardiography course, a CD package, and a total of 3 hours of teaching with a paediatric cardiologist. All of this was accomplished within the 3 months preceding our study. All newborn infants less than 1500 grams or less than 30 weeks gestation had an echocardiogram performed in the first 48 hours of life. A prediction was then made based on the echocardiogram findings as to whether the arterial duct would become a clinically significant one. We based our prediction on established echocardiography criteria for the prediction of ductal patency, namely a ductal diameter of greater than 1.5 millimetres, a left atrial-to-aortic ratio of greater than 1.4, and an abnormal pattern of flow in the distal aorta. In total, 20 very low birth weight infants were screened from March 2005 to June 2005. Fifteen infants did not develop any signs of an arterial duct and this was predicted correctly in 13 cases. Of the 5 infants who developed a clinically apparent duct 4 were predicted correctly, giving us a sensitivity and specificity of 80% and 87%. Our study shows that it is possible to predict ductal patency without extensive echocardiography training. It also shows us that a neonatology based screening programme for pre-symptomatic arterial ducts in very low birth weight infants would be feasible.
Kori, Mohamad Ikhwan; Jamalruhanordin, Fara Lyana; Taib, Ishkrizat; Mohammed, Akmal Nizam; Abdullah, Mohammad Kamil; Ariffin, Ahmad Mubarak Tajul; Osman, Kahar
A formation of thrombosis due to hemodynamic conditions after the implantation of stent in patent ductus arteriosus (PDA) will derived the development of re-stenosis. The phenomenon of thrombosis formation is significantly related to the distribution of wall shear stress (WSS) on the arterial wall. Thus, the aims of this study is to investigate the distribution of WSS on the arterial wall after the insertion of stent. Three dimensional model of patent ductus arteriosus inserted with different types of commercial stent are modelled. Computational modelling is used to calculate the distributions of WSS on the arterial stented PDA. The hemodynamic parameters such as high WSS and WSSlow are considered in this study. The result shows that the stented PDA with Type III stent has better hemodynamic performance as compared to others stent. This model has the lowest distributions of WSSlow and also the WSS value more than 20 dyne/cm2. From the observed, the stented PDA with stent Type II showed the highest distributions area of WSS more than 20 dyne/cm2. This situation revealed that the high possibility of atherosclerosis to be developed. However, the highest distribution of WSSlow for stented PDA with stent Type II indicated that high possibility of thrombosis to be formed. In conclusion, the stented PDA model calculated with the lowest distributions of WSSlow and WSS value more than 20dyne/cm2 are considered to be performed well in stent hemodynamic performance as compared to other stents.
Fugelseth, D; Satas, S; Steen, P A; Thoresen, M
To assess by Doppler echocardiography the effects of 24 hours of whole body mild hypothermia compared with normothermia on cardiac output (CO), pulmonary artery pressure (PAP), and the presence of a persistent ductus arteriosus (PDA) after a global hypoxic-ischaemic insult in unsedated newborn animals. Thirty five pigs (mean (SD) age 26.6 (12.1) hours and weight 1.6 (0.3) kg) were anaesthetised with halothane, mechanically ventilated, and subjected to a 45 minute global hypoxic-ischaemic insult. At the end of hypoxia, halothane was stopped; the pigs were randomised to either normathermia (39 degrees C) or hypothermia (35 degrees C) for 24 hours. Rewarming was carried out for 24-30 hours followed by 42 hours of normothermia. Unanaesthetised pigs were examined with a VingMed CFM 750 ultrasound scanner before and 3, 24, 30, and 48 hours after the hypoxic-ischaemic insult. Aortic valve diameter, forward peak flow velocities across the four valves, and the occurrence of a PDA were measured. Tricuspid regurgitation (TR) velocity was used to estimate the PAP. Stroke volume was calculated from the aortic flow. Twelve animals (seven normothermic, five hypothermic) had a PDA on one or more examinations, which showed no association with cooling or severity of insult. There were no differences in stroke volume or TR velocity between the hypothermic and normothermic animals at any time point after the insult. CO was, however, 45% lower at the end of cooling in the subgroup of hypothermic pigs that had received a severe insult compared with the pigs with mild and moderate insults. CO and TR velocity were transiently increased three hours after the insult: 0.38 (0.08) v 0.42 (0.08) litres/min/kg (p = 0.007) for CO; 3.0 (0.42) v 3.4 (0.43) m/s (p < 0.0001) for TR velocity (values are mean (SD)). The introduction of mild hypothermia while the pigs were unsedated did not affect the incidence of PDA nor did it lead to any changes in MABP or PAP. Stroke volume was also unaffected by
Zhang, Xiao-Tong; Liu, Ying-Long; Ruan, Ying-Mao; Yu, Cun-Tao; Liu, Lei
The development of pulmonary vascular bed is strongly flow-dependent. Abnormal pulmonary blood flow leads to pulmonary pathological changes. This study aimed to observe the pathological changes of small pulmonary arteries and alveoli in complex congenital heart defect with diminished pulmonary blood flow but without aortopulmonary collateral artery (APCA) and patent ductus arteriosus (PDA) in infants and young children. Autopsy pulmonary specimens obtained from 5 children who died of non-cardiovascular diseases were used as the control group (age: 4-18 months). Fifty-six children (age: 4-36 months) with complex congenital heart defect with diminished pulmonary blood flow but without APCA and PDA served as the study group, including 34 cases of tetralogy of Fallot, 7 cases of double outlet right ventricle with pulmonary stenosis, 9 cases of single ventricle with pulmonary stenosis, 4 cases of tricuspid atresia with pulmonary stenosis and 2 cases of complete atrioventricular septal defect with pulmonary stenosis. Pulmonary specimen sections were stained by hematoxylin-eosin and Weigert-Van Gieson. Percentage of media thickness (MT%), percentage of media section area (MS%), number of small arterial per square centimeter (APSC), mean alveolar number (MAN), mean linear intercept (MLI), proportion of parenchyma area in total area (PPA%) and alveolar to small arterial ratio per unit area (AAR) were measured by morphologic quantitative analysis. MT% (10.93+/-2.87% vs 15.08+/-2.51%), MS% (18.97+/-5.56% vs 25.04+/-3.87%) and APSC (202.43+/-67.45 vs 441.69+/-65.29) decreased significantly in the study group compared with the control group (P<0.01). The internal diameter of small pulmonary artery (80.26+/-21.57 microm vs 58.53+/-10.29 microm; P<0.05), AAR (46.59+/-14.43 vs 34.46+/-4.98; P<0.01) and MLI (144.98+/-44.87 microm vs 108.39+/-20.76 microm; P<0.05) increased significantly compared with the control group. The media of small pulmonary arteries becomes thinner, the
Das, S; Yool, D A; French, A T; Self, I A; del-Pozo, J
A 12-week old, entire female Border terrier weighing 3·5 kg was presented for investigation of a continuous left heart base murmur. The clinical presentation and preoperative echocardiogram were consistent with a standard morphology of patent ductus arteriosus (PDA) but a discrete ductal vessel was not identified during surgical dissection. Surgery had to be abandoned due to deterioration of the patient's condition under general anaesthesia which led to cardiorespiratory arrest and death despite attempts at resuscitation. Necropsy identified a recess within the wall of the aorta communicating with the pulmonary artery via an ostium at the heart base which determined this structure as an intramural PDA. This morphology of PDA is previously unreported. This report demonstrates that an intramural PDA is not readily identifiable surgically because of the absence of a discrete ductal vessel and it is important to appreciate that unusual morphologies of PDA may occur.
Reiter, Gert; Reiter, Ursula; Kovacs, Gabor; Adelsmayr, Gabriel; Greiser, Andreas; Stalder, Aurelien F; Olschewski, Horst; Fuchsjäger, Michael
In patients with pulmonary hypertension (PH), duration of vortical blood flow along the main pulmonary artery enables estimation of the mean pulmonary arterial pressure (mPAP) non-invasively. It remains to date not known, if this method is applicable in patients with pulmonary arterial hypertension (PAH) and abnormal aortic-to-pulmonary shunting. The present case analyzes the effect of a patent ductus arteriosus (PDA) on pulmonary artery flow patterns in PAH (mPAP from right heart catheterization, 75 mmHg). PH-associated vortical blood flow, which is typically observed rotating in a clockwise direction when viewed in right ventricular outflow tract orientation, was found nested in PDA left-to-right shunting. Even though rotating counter-clockwise, duration of vortical flow translated into correct non-invasive mPAP estimate. This case indicates that PH-associated vortex rotation is not restricted to clockwise direction, and that vortex-based estimation of elevated mPAP might also be feasible in patients with PAH and PDA.
De Monte, Valentina; Staffieri, Francesco; Caivano, Domenico; Nannarone, Sara; Birettoni, Francesco; Porciello, Francesco; Di Meo, Antonio; Bufalari, Antonello
The objective of the study was to retrospectively analyse the cardiovascular effects that occurs following the transvascular occlusion of patent ductus arteriosus in dogs. Sixteen anaesthesia records were included. Variables were recorded at the time of placing the arterial introducer, occlusion of the ductus, and from 5 to 60min thereafter, including, among the other, heart rate, systolic, diastolic and mean arterial blood pressure. The maximal percentage variation of the aforementioned physiological parameters within 60min of occlusion, compared with the values recorded at the introducer placing, was calculated. The time at which maximal variation occurred was also computed. Correlations between maximal percentage variation of physiological parameters and the diameter of the ductus and systolic and diastolic flow velocity through it were evaluated with linear regression analysis. Heart rate decreased after occlusion of the ductus with a mean maximal percentage variation of 41.0±14.8% after 21.2±13.7min. Mean and diastolic arterial blood pressure increased after occlusion with a mean maximal percentage variation of 30.6±18.1 and 55.4±27.1% after 19.6±12.1 and 15.7±10.8min, respectively. Mean arterial blood pressure variation had a significant and moderate inverse correlation with diastolic and systolic flow velocity through the ductus. Transvascular patent ductus arteriosus occlusion in anaesthetised dogs causes a significant reduction in heart rate and an increase in diastolic and mean blood arterial pressure within 20min of closure of the ductus. Copyright © 2017 Elsevier Ltd. All rights reserved.
Jiang, Hai-bin; Bai, Yuan; Zong, Gang-jun; Han, Lin; Li, Wei-ping; Lu, Yang; Qin, Yong-wen; Zhao, Xian-xian
The aim of this study was to evaluate a new type of occluder for patent ductus arteriosus. Patent ductus arteriosus was established in a canine model by anastomosing a length of autologous jugular vein to the descending aorta and the left pulmonary artery in an end-to-side fashion. Transcatheter closure of each patent ductus arteriosus was performed on 10 dogs, which were then monitored for as long as 6 months with aortography, echocardiography, and histologic evaluation. Transcatheter closure with use of the novel pan-nitinol device was successful in all canine models. Postoperative echocardiography showed that the location and shape of the occluders were normal, without any residual shunting. Further histologic evaluation confirmed that the occluder surface was completely endothelialized 3 months after implantation. Transcatheter patent ductus arteriosus closure with the pan-nitinol occluder can be performed safely and successfully in a canine model and shows good biological compatibility and low mortality rates.
Sabzi, Feridoun; Faraji, Reza
An adult with a large patent ductus arteriosus may present with fatigue, dyspnea or palpitations or in rare presentation with endocarditis. The case illustrated unique role of vegetation of endocarditis in hemolytic anemia in adult with patent ductus arteriosus (PDA). Despite treatment of endocarditis with complete course of appropriate antibiotic therapy and normality of C- reactive protein, erythrocyte sedimentation rate and leukocytosis and wellness of general condition, transthoracic echocardiography revealed large vegetation in PDA lumen, surgical closure of PDA completely relieved hemolysis, and fragmented red cell disappeared from peripheral blood smear. The 3-month follow-up revealed complete occlusion of PDA and abolishment of hemolytic anemia confirmed by clinical and laboratory examination.
Aslan, Eyüp; Tanıdır, İbrahim Cansaran; Saygı, Murat; Onan, Sertaç Hanedan; Güzeltaş, Alper
Scimitar syndrome is a rare disease associated with a right lung sequestration vascularised by arteries arising from the abdominal aorta and abnormal venous drainage into the inferior vena cava. The infantile form is generally presented with severe heart failure, pulmonary hypertension and respiratory distress. It may be associated with various intracardiac defects, including atrial septal defects, ventricular septal defects, patent ductus arteriosus or more complicated structural congenital heart defects. Here, we present a 2-month-old girl with Scimitar syndrome whose pulmonary arterial pressure decreased after transcatheter patent ductus arteriosus closure and embolization of the anomalous systemic arterial supply.
Panagopoulos, Ph. G.; Tatooles, C. J.; Aberdeen, Eoin; Waterston, D. J.; Carter, R. E. Bonham
Nine hundred and thirty-six consecutive cases of closure of a patent ductus arteriosus in infants and children are reported. Among 789 without any other cardiac anomalies there were 11 deaths, seven of these with severe congenital anomalies other than cardiovascular. There was one incomplete closure. The deaths in this series were mostly associated with additional congenital cardiac anomalies. Forty-eight of the 59 who died had additional cardiac anomalies. Forty-seven of the deaths were in infants. For 691 patients over the age of 1 year the hospital mortality rate was less than 0·5%. Ligation of the ductus using two ligatures of thick plaited silk (1·2 mm diameter) was the technique used in 99% of these cases. There were four cases of recanalization or inadequate ligation but all four survived. This technique seems an acceptable one for the closure of a patent ductus arteriosus. Images PMID:5576528
Abstract A 2.5-year-old dog with signs of weight loss, vomiting, and hepatic encephalopathy was diagnosed with a patent ductus venosus, based on serum biochemical analysis, jejunal portography, and biopsies, and treated with lactulose, antibiotics, and a reduced protein diet. Two years after initial presentation, the dog is still being managed medically. PMID:15943124
Azhar, I O; Anas, R
We report a case of two babies with absence of pericardium and patent ductus arteriosus (PDA). The absence of pericardium was found coincidentally during PDA ligation. The PDA was successfully ligated but the pericardium was not reconstructed. Postoperatively, the agenesis of the pericardium did not interfere with cardiac function.
Page, G G
This article has reviewed current thought on the pathophysiology, medical management, and nursing implications of PDA in the premature newborn. The ductus arteriosus is a normal vascular channel that provides a route for blood flow to the descending aorta in the fetus; and it is an abnormal channel in the newborn that allows additional pulmonary blood flow to be shunted from the higher pressured aorta. Left heart volume overload and additional insults in connection with concurrent RDS and BPD were discussed. Current management for closure advocates indomethacin administration, and ligation, should indomethacin fail or be contraindicated. Continued patency with prostaglandin administration is the objective in cyanotic neonates with congenital heart disease and diminished pulmonary blood flow and in acyanotic neonates with aortic arch abnormalities that lead to decreased descending aortic flow. Nursing responsibilities encompass the well-being of the newborn as well as the family. The neonate must be assessed frequently for signs of cardiopulmonary deterioration. The neonate's responses to drug administration must be monitored for their effect on the ductus and the minimization of side effects. Care of the parents regarding support and information was discussed.
Qasim, Amna; Jain, Sunil K.; Jiwani, Amyn K.
Surgical ligation of a patent ductus arteriosus (PDA) is a commonly performed procedure. Complications are infrequent and most commonly include recurrent laryngeal nerve injury and rarely ligation of left pulmonary artery. We report a case of accidental ligation of the descending thoracic aorta leading to a clinically significant coarctation. PMID:28386503
Lista, Gianluca; Bianchi, Silvia; Mannarino, Savina; Schena, Federico; Castoldi, Francesca; Stronati, Mauro; Mosca, Fabio
Early diagnosis of significant patent ductus arteriosus reduces the risk of clinical worsening in very low birth weight infants. Echocardiographic patent ductus arteriosus shunt flow pattern can be used to predict significant patent ductus arteriosus. Pulmonary venous flow, expressed as vein velocity time integral, is correlated to ductus arteriosus closure. The aim of this study is to investigate the relationship between significant reductions in vein velocity time integral and non-significant patent ductus arteriosus in the first week of life. A multicenter, prospective, observational study was conducted to evaluate very low birth weight infants (<1500 g) on respiratory support. Echocardiography was used to evaluate vein velocity time integral on days 1 and 4 of life. The relationship between vein velocity time integral and other parameters was studied. In total, 98 very low birth weight infants on respiratory support were studied. On day 1 of life, vein velocity time integral was similar in patients with open or closed ductus. The mean vein velocity time integral significantly reduced in the first four days of life. On the fourth day of life, there was less of a reduction in patients with patent ductus compared to those with closed patent ductus arteriosus and the difference was significant. A significant reduction in vein velocity time integral in the first days of life is associated with ductus closure. This parameter correlates well with other echocardiographic parameters and may aid in the diagnosis and management of patent ductus arteriosus.
Lista, Gianluca; Bianchi, Silvia; Mannarino, Savina; Schena, Federico; Castoldi, Francesca; Stronati, Mauro; Mosca, Fabio
OBJECTIVE: Early diagnosis of significant patent ductus arteriosus reduces the risk of clinical worsening in very low birth weight infants. Echocardiographic patent ductus arteriosus shunt flow pattern can be used to predict significant patent ductus arteriosus. Pulmonary venous flow, expressed as vein velocity time integral, is correlated to ductus arteriosus closure. The aim of this study is to investigate the relationship between significant reductions in vein velocity time integral and non-significant patent ductus arteriosus in the first week of life. METHODS: A multicenter, prospective, observational study was conducted to evaluate very low birth weight infants (<1500 g) on respiratory support. Echocardiography was used to evaluate vein velocity time integral on days 1 and 4 of life. The relationship between vein velocity time integral and other parameters was studied. RESULTS: In total, 98 very low birth weight infants on respiratory support were studied. On day 1 of life, vein velocity time integral was similar in patients with open or closed ductus. The mean vein velocity time integral significantly reduced in the first four days of life. On the fourth day of life, there was less of a reduction in patients with patent ductus compared to those with closed patent ductus arteriosus and the difference was significant. CONCLUSIONS: A significant reduction in vein velocity time integral in the first days of life is associated with ductus closure. This parameter correlates well with other echocardiographic parameters and may aid in the diagnosis and management of patent ductus arteriosus. PMID:27759846
Onji, Keiichi; Matsuura, Wataru
A 49-year-old man without heart murmur was admitted with fever because of bacteremia following a tooth extraction. Antibiotics rapidly alleviated the fever; however, a small nodule in the pulmonary artery was identified on computed tomography (CT). When the patient experienced chest discomfort with fever, CT demonstrated the absence of the nodule and the appearance of an abnormal lung opacity, and echocardiography showed turbulent retrograde flow in the pulmonary artery. We had the rare opportunity to follow a case of pulmonary bacterial endarteritis and subsequent pulmonary embolism with clinically silent patent ductus arteriosus (PDA) that was confirmed by 3-dimensional CT.
Patel, Priti M; Momany, Allison M; Schaa, Kendra L; Romitti, Paul A; Druschel, Charlotte; Cooper, Margaret E; Marazita, Mary L; Murray, Jeffrey C; Dagle, John M
To identify single-nucleotide polymorphisms (SNPs) in specific candidate genes associated with patent ductus arteriosus in term infants. We conducted an initial family-based, candidate gene study to analyze genotype data from DNA samples obtained from 171 term infants and their parents enrolled in the National Birth Defects Prevention Study (NBDPS). We performed transmission disequilibrium testing (TDT) using a panel of 55 SNPs in 17 genes. Replication of SNPs with P < .1 in the NBDPS trios was performed with a case-control strategy in an independent population. TDT analysis of the NBDPS trios resulted in 6 SNPs reaching the predetermined cutoff (P < .1) to be included in the replication study. These 6 SNPs were genotyped in the independent case-control population. A SNP in TGFBR2 was found to be associated with term patent ductus arteriosus in both populations after we corrected for multiple comparisons. (rs934328, TDT P = 2 × 10(-4), case-control P = 6.6 × 10(-5)). These findings confirm the importance of the transforming growth factor-beta pathway in the closure of the term ductus arteriosus and may suggest new therapeutic targets. Published by Elsevier Inc.
Patent ductus arteriosus (PDA) is part of the typical morbidity profile of the preterm infant, with a high incidence of 80–90% in extremely low birth weight infants born before 26 weeks of gestation. Whereas spontaneous closure of the ductus arteriosus (DA) is likely in term infants, it is less so in preterm ones. PDA is associated with increased mortality and various comorbidities including cardiac failure, need for respiratory support, bronchopulmonary dysplasia, pulmonary or intracranial hemorrhage, and necrotizing enterocolitis; however, there is no proven causality between these morbidities and the presence of DA. Thus, the indication to close PDA remains highly controversial. This paper focuses on echocardiographic evaluation of PDA in the preterm infant and particularly on the echocardiographic signs of hemodynamic significance. PMID:28680875
McNamara, Patrick J; Stewart, Lilian; Shivananda, Sandesh P; Stephens, Derek; Sehgal, Arvind
Patent ductus arteriosus ligation is often complicated by systemic hypotension and oxygenation failure. The ability of the immature myocardium to compensate for altered afterload is poorly understood. The aim of this study was to characterize the effects of patent ductus arteriosus ligation on myocardial performance in preterm infants. Serial echocardiographic analysis was performed before and after patent ductus arteriosus ligation. Characteristics of the patent ductus arteriosus, myocardial performance (fractional shortening, mean velocity of circumferential fiber shortening, and left ventricular output) and left ventricular afterload (end-systolic wall stress) were assessed. The stress-velocity relationship was measured as a preload-independent, afterload-adjusted measure of myocardial contractility. Forty-six preterm infants were assessed at 28.5 +/- 11.3 days and a weight of 1058 +/- 272 g. Patent ductus arteriosus ligation was followed by increased left ventricular exposed vascular resistance temporally coinciding with reduced left ventricular preload, decreased left ventricular contractility, and low left ventricular output. Neonates weighing 1000 g or less had a higher rate of low fractional shortening (<25%) or low left ventricular output (<170 mL x kg(-1) x h(-1)) and increased need for cardiotropes and demonstrated a trend toward an impaired stress-velocity relationship. Neonates with impaired left ventricular systolic performance were more likely to require cardiotropes and have low systolic arterial pressure, increased heart rate, and abnormal base deficit. Patent ductus arteriosus ligation is sometimes associated with impaired left ventricular systolic performance, which is most likely attributable to altered loading conditions. Neonates weighing 1000 g or less are at increased risk of impaired left ventricular systolic performance, which might relate to maturational differences and decreased tolerance to altered loading conditions. Crown Copyright
Parikh, Ravikumar; Negrine, Robert J S; Chikermane, Ashish; Rasiah, Shree Vishna; Ewer, Andrew K
To assess myocardial function in preterm infants with different degrees of ductal patency in the first week of life using tissue Doppler imaging. Infants <30 weeks of gestation underwent echocardiography on day 3. A total of 72 infants were recruited into the study and categorised into three groups (i) haemodyamically significant ductus arteriosus, (ii) patent ductus arteriosus and (iii) no patent ductus arteriosus. Those with haemodynamically significant ductus arteriosus were treated with indometacin and echocardiography was repeated after 48-72 hours following treatment. Peak systolic and diastolic myocardial velocities were obtained using tissue Doppler imaging, and myocardial performance index was calculated. Initial myocardial velocities were significantly lower and myocardial performance index significantly higher in the haemodynamically significant ductus arteriosus group compared with other groups. For the haemodynamically significant ductus arteriosus group, post-treatment myocardial velocities were higher and myocardial performance index lower than pre-treatment. Preterm infants with haemodynamically significant ductus arteriosus had lower myocardial velocities and higher myocardial performance index, suggesting relative systolic and diastolic myocardial dysfunction. Babies whose patent ductus arteriosus remained open despite indometacin had lower pre-treatment myocardial velocities and higher myocardial performance index than those babies whose patent ductus arteriosus closed, suggesting worse myocardial function in this group. Measurement of myocardial function using tissue Doppler imaging in preterm infants is feasible and may prove to be helpful in the management of babies with patent ductus arteriosus.
Hoffman, Julien I E
As closing a patent arterial duct is relatively simple, safe, and successful, most children with a patent arterial duct have it closed soon after diagnosis. The larger ducts are closed to prevent congestive heart failure, pulmonary vascular disease, or aneurysmal dilatation of the ductus, and smaller ducts are closed to prevent infective endocarditis. Consequently, there is no opportunity to determine whether spontaneous closure or diminution in size of the patent arterial duct is common. If the duct does become smaller, flow through it may be so low that no murmur is produced - the silent ductus. The frequency and best management of the silent patent arterial duct are unknown, and we do not know whether these tiny ducts are the last stage before spontaneous closure.
Abrams, Herbert L.; Robinson, Saul J.
Patent ductus arteriosus and coarctation of the aorta are among the commonest causes of congestive heart failure early in life. When medical therapy fails to control heart failure in these cases, surgical division of the ductus or excision of the coarcted segment can be performed. But the recognition of these anomalies in infancy is more difficult than in childhood or adult life. Retrograde thoracic aortography is a technique which permits positive identification. In the presence of patent ductus arteriosus, opacification of the pulmonary arteries from the descending aorta will be clearly shown; if coarctation is present, its position, severity, and the length of the involved segment can usually be demonstrated. Properly employed, retrograde brachial aortography is a relatively safe and effective diagnostic procedure. ImagesFigure 1.Figure 2.Figure 3.Figure 4.Figure 5. PMID:13404515
Puig, Isabel; Champeval, Delphine; Kumasaka, Mayuko; Belloir, Elodie; Bonaventure, Jacky; Mark, Manuel; Yamamoto, Hiroaki; Taketo, Mark M.; Choquet, Philippe; Etchevers, Heather C.; Beermann, Friedrich; Delmas, Véronique; Monassier, Laurent; Larue, Lionel
Background Patent ductus arteriosus is a life-threatening condition frequent in premature newborns but also present in some term infants. Current mouse models of this malformation generally lead to perinatal death, not reproducing the full phenotypic spectrum in humans, in whom genetic inheritance appears complex. The ductus arteriosus (DA), a temporary fetal vessel that bypasses the lungs by shunting the aortic arch to the pulmonary artery, is constituted by smooth muscle cells of distinct origins (SMC1 and SMC2) and many fewer melanocytes. To understand novel mechanisms preventing DA closure at birth, we evaluated the importance of cell fate specification in SMC that form the DA during embryonic development. Upon specific Tyr::Cre-driven activation of Wnt/β-catenin signaling at the time of cell fate specification, melanocytes replaced the SMC2 population of the DA, suggesting that SMC2 and melanocytes have a common precursor. The number of SMC1 in the DA remained similar to that in controls, but insufficient to allow full DA closure at birth. Thus, there was no cellular compensation by SMC1 for the loss of SMC2. Mice in which only melanocytes were genetically ablated after specification from their potential common precursor with SMC2, demonstrated that differentiated melanocytes themselves do not affect DA closure. Loss of the SMC2 population, independent of the presence of melanocytes, is therefore a cause of patent ductus arteriosus and premature death in the first months of life. Our results indicate that patent ductus arteriosus can result from the insufficient differentiation, proliferation, or contractility of a specific smooth muscle subpopulation that shares a common neural crest precursor with cardiovascular melanocytes. PMID:23382837
Parra-Bravo, José Rafael; Apolonio-Martínez, Adriana; Estrada-Loza, María de Jesús; Beirana-Palencia, Luisa Gracia; Ramírez-Portillo, César Iván
The closure of patent ductus arteriosus with multiple devices has been associated with a reduction in lung perfusion. We evaluated the pulmonary perfusion after percutaneous closure of patent ductus arteriosus with the Amplatzer Duct Occluder device using perfusion lung scan. Thirty patients underwent successful percutaneous patent ductus arteriosus occlusions using the Amplatzer Duct Occluder device were included in this study. Lung perfusion scans were preformed 6 months after the procedure. Peak flow velocities and protrusion of the device were analyzed by Doppler echocardiography. A left lung perfusion<40% was considered abnormal. The device implantation was successful in all patients. Average perfusion of left lung was 44.7±4.9% (37.8-61.4). Five patients (16.6%) showed decreased perfusion of the left lung. Age, low weight, the length of the ductus arteriosus and the minimum and maximum diameter/length of the ductus arteriosus ratio were statistically significant in patients with abnormalities of lung perfusion. It was observed protrusion the device in 6 patients with a higher maximum flow rate in the left pulmonary artery. The left lung perfusion may be compromised after percutaneous closure of patent ductus arteriosus with the Amplatzer Duct Occluder. The increased flow velocity in the origin of the left pulmonary artery can be a poor indicator of reduction in pulmonary perfusion and can occur in the absence of protrusion of the device. Copyright © 2014 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.
Ishibashi, Hiroyuki; Sugimoto, Ikuo; Yamada, Tetsuya; Maruyama, Yuki; Hagihara, Makiyo; Ishiguchi, Tsuneo
The patient described herein was a 75-year-old female. Echocardiography showed patent ductus arteriosus (PDA). Heart failure symptoms gradually appeared, and she was referred to our department for treatment. Contrast-enhanced computed tomography (CT) revealed a tubular structure communicating between the aortic arch and pulmonary artery trunk, suggesting adult PDA. Thoracic endovascular aortic repair (TEVAR) was performed to close PDA. Completion angiography confirmed the disappearance of PDA. Post-TEVAR CT revealed no endoleak. The patient was discharged from the hospital on the 11th day after surgery. TEVAR is more useful and less invasive for adult PDA than conventional open surgery. PMID:28018507
This is the case of a young female who was seen at our adult congenital heart disease and pulmonary hypertension service (Royal Brompton Hospital, London, UK) at the age of 17 years. She initially presented at the age of 4 years with increasing shortness of breath. At that time, there was differential cyanosis with clubbing and lower oxygen saturations in the toes (82%) compared with her fingers (95%). On echocardiography there was evidence of severe pulmonary hypertension and a large patent ductus arteriosus (PDA) with low velocity bidirectional shunting. She underwent cardiac catheterisation at the time which showed a pulmonary arterial pressure equal to that of the aorta.
Fernando, Rajeev; Koranne, Ketan; Loyalka, Pranav; Kar, Biswajit; Gregoric, Igor
The ductus arteriosus originates from the persistence of the distal portion of the left sixth aortic arch. It connects the descending aorta (immediately distal to the left subclavian artery) to the roof of the main pulmonary artery, near the origin of the left pulmonary artery. Persistence of the duct beyond 48 h after birth is abnormal and results in patent ductus arteriosus (PDA). PDA is rare in adults because it is usually discovered and treated in childhood. Mechanical closure remains the definitive therapy because the patency of ductus arteriosus may lead to multiple complications, depending on the size and flow through the ductus. PDA closure is indicated in patients with symptoms and evidence of left heart enlargement, and in patients with elevated pulmonary pressures when reversal is possible. Transcatheter closure is the preferred technique in adults because it avoids sternotomy, reduces the length of hospital stay and is associated with fewer complications compared with surgery. First demonstrated in 1967, both the technique and the occluder devices used have since evolved. However, designing an ideal PDA occluder has been a challenge due to the variability in size, shape and orientation of PDAs. The present article describes a case involving a 35-year-old woman who presented to the Center for Advanced Heart Failure (Houston, USA) with congestive heart failure due to a large PDA, which was successfully occluded using an Amplatzer (St Jude Medical, USA) muscular ventricular septal defect closure device. The wider waist and dual-retention discs of these ventricular septal defect closure devices may be important factors to consider in the future development of devices for the occlusion of large PDAs.
Fernando, Rajeev; Koranne, Ketan; Loyalka, Pranav; Kar, Biswajit; Gregoric, Igor
The ductus arteriosus originates from the persistence of the distal portion of the left sixth aortic arch. It connects the descending aorta (immediately distal to the left subclavian artery) to the roof of the main pulmonary artery, near the origin of the left pulmonary artery. Persistence of the duct beyond 48 h after birth is abnormal and results in patent ductus arteriosus (PDA). PDA is rare in adults because it is usually discovered and treated in childhood. Mechanical closure remains the definitive therapy because the patency of ductus arteriosus may lead to multiple complications, depending on the size and flow through the ductus. PDA closure is indicated in patients with symptoms and evidence of left heart enlargement, and in patients with elevated pulmonary pressures when reversal is possible. Transcatheter closure is the preferred technique in adults because it avoids sternotomy, reduces the length of hospital stay and is associated with fewer complications compared with surgery. First demonstrated in 1967, both the technique and the occluder devices used have since evolved. However, designing an ideal PDA occluder has been a challenge due to the variability in size, shape and orientation of PDAs. The present article describes a case involving a 35-year-old woman who presented to the Center for Advanced Heart Failure (Houston, USA) with congestive heart failure due to a large PDA, which was successfully occluded using an Amplatzer (St Jude Medical, USA) muscular ventricular septal defect closure device. The wider waist and dual-retention discs of these ventricular septal defect closure devices may be important factors to consider in the future development of devices for the occlusion of large PDAs. PMID:24294051
Elsayed, Yasser N; Fraser, Debbie
The clinical guidelines for treating patent ductus arteriosus (PDA) have significantly evolved over the last decades from treating any ductal shunt to more conservative management where only the hemodynamically significant patent ductus arteriosus (HSPDA) is treated. This shift has resulted largely from a lack of evidence from randomized controlled trials supporting a relationship between treating a PDA and improving long-term neonatal outcomes. However, there are many unresolved issues. There is no consensus on the precise definition of HSPDA requiring treatment or a clear understanding of when to treat HSPDA. Moreover, the current evidence shows worsening of the long-term neurodevelopmental outcome for infants undergoing surgical PDA ligation.
The presence of physiologic variability among preterm infants, and the presence of different compensatory mechanisms may make it difficult to establish a link between pathophysiology and long-term outcomes. That is, the physiologic variability cannot be simply assessed by randomly assigning infants into two arms of a study. Relying on research from animal and human studies, this article explains the link between the pathophysiology of a PDA and neonatal outcomes.
Barefield, E S; Dwyer, M D; Cassady, G
To determine the relationship of phototherapy and patent ductus arteriosus, we analyzed prospectively collected data on 295 infants with birth weight of 501 to 999 gm admitted from 1984 through 1988. Seventy-four percent were evaluated by an imaging study to aid in the detection of a silent patent ductus arteriosus. Overall incidence of patent ductus arteriosus in the study population was 63%. Infants who received phototherapy (n = 128) had an increased incidence of patent ductus arteriosus compared with those who did not receive phototherapy (76% vs 53%). There was an association of patent ductus arteriosus and phototherapy (p < 0.05) when we analyzed the data with a stepwise regression model that controlled for the effects of gestational age, birth weight, gender, race, diagnosis of hyaline membrane disease, mechanical ventilation, patent ductus arteriosus imaging studies, prophylactic indomethacin, peak total and indirect bilirubin values, and the occurrence of abnormal serum sodium values. We conclude that the use of phototherapy is associated with an increased incidence of patent ductus arteriosus in extremely low birth weight infants.
Gray, Margaret A; Graham, Eric M; Atz, Andrew M; Bradley, Scott M; Kavarana, Minoo N; Chowdhury, Shahryar M
Preoperative risk factors associated with poor outcomes after patent ductus arteriosus ligation in preterm infants have not been well defined. The aim of this study was to determine the association between preoperative echocardiographic measures of left ventricular mechanics and postoperative clinical outcomes after patent ductus arteriosus ligation. Preterm infants less than 90 days of age with no other significant congenital anomalies who underwent patent ductus arteriosus ligation between 2007 and 2015 were considered for retrospective analysis. The primary outcome was peak postoperative vasoactive inotropic score. Conventional echocardiographic measures of ventricular size, function, and patent ductus arteriosus size were performed. Echocardiographic single-beat, pressure-volume loop analysis estimates of contractility (end-systolic elastance) and afterload (arterial elastance) were calculated. Ventriculoarterial coupling was assessed using the arterial elastance/end-systolic elastance ratio. Multivariable linear regression was performed using clinical and echocardiographic data. Echocardiograms from 101 patients (42.5% male) were analyzed. We found a statistically significant association between vasoactive inotropic score and both end-systolic elastance and arterial elastance. No patient with arterial elastance/end-systolic elastance greater than 0.78 (n = 32) had a vasoactive inotropic score 20 or greater. Analysis of our secondary outcomes found associations between preoperative end-systolic elastance and postoperative urine output less than 1 mL/kg/h at 24 hours, creatinine change greater than 0.5 mg/dL, and time to first extubation. End-systolic elastance and arterial elastance were the only predictors of postoperative vasoactive inotropic score after patent ductus arteriosus ligation in preterm infants. Those neonates with increased contractility and low afterload were at highest risk for elevated inotropic support. These findings suggest a role
Kebba, Naomi; Mwambu, Tom; Oketcho, Michael; Izudi, Jonathan; Obuku, Ekwaro A
There is clinical equipoise regarding post-operative management of patients with patent ductus arteriosus (PDA) without insertion of a chest drain. This study evaluated post operative outcomes of chest closure with or without a drain following Patent Ductus Arteriosus ligation among childen at Uganda Heart Instritute (UHI). This was an open label randomized controlled trial of 62 children 12 years of age and below diagnosed with patent ductus arteriosus at Mulago National Teaching and Referral Hospital, Uganda. Participants were randomized in the ratio of 1:1 with surgical ligation of patent ductus arteriosus to either thoracotomy closure with a chest tube or without a chest tube. All participants received standard care and were monitored hourly for 24 hours then until hospital discharge. The combined primary endpoint consisted of significant pleural space accumulation of fluid or air, higher oxygen need or infection of the surgical site. Analysis was conducted by multivariable logistic regression analysis at 5 % significance level. We enrolled 62 participants, 46 (74 %) of whom were females. Their median age was 12 months (IQR: 8-36). Participants in the no-drain arm significantly had less post-operative complications compared to the drain arm (Unadjusted odds ratio [uOR]: 0.21, 95 % CI: 0.06-0.73, p = 0.015). This "protective effect" remained without statistical significance in the multivariable regression model (Adjusted odds ratio [aOR]: 0.07, 95 % CI: 0.00-2.50, p = 0.144). Children aged below 6 years with patent ductus arterious can safely and effectively have thoracotomy closure without using a drain in uncomplicated surgical ligation of the PDA. Chest drain was associated with post-operative complications. The trial was registered in the Pan African Clinical Trials registry on 1st/July/2012, retrospectively registered. Identifier number PACTR201207000395469 .
Bardanzellu, Flaminia; Neroni, Paola; Fanos, Vassilios
In preterm infants, failure or delay in spontaneous closure of Ductus Arteriosus (DA), resulting in the condition of Patent Ductus Arteriosus (PDA), represents a significant issue. A prolonged situation of PDA can be associated with several short- and long-term complications. Despite years of researches and clinical experience on PDA management, unresolved questions about the treatment and heterogeneity of clinical practices in different centers still remain, in particular regarding timing and modality of intervention. Nowadays, the most reasonable strategy seems to be reserving the treatment only to hemodynamically significant PDA. The first-line therapy is medical, and ibuprofen, related to several side effects especially in terms of nephrotoxicity, is the drug of choice. Administration of oral or intravenous paracetamol (acetaminophen) recently gained attention, appearing effective as traditional nonsteroidal anti-inflammatory drugs (NSAIDs) in PDA closure, with lower toxicity. The results of the studies analyzed in this review mostly support paracetamol efficacy in ductal closure, with inconstant low and transient elevation of liver enzymes as reported side effect. However, more studies are needed to confirm if this therapy shows a real safety profile and to evaluate its long-term outcomes, before considering paracetamol as first-choice drug in PDA treatment. PMID:28828381
Marino, Bruno; Chiariello, Luigi; Mercanti, Corrado; Bosman, Cesare; Colloridi, Vicenzo; Reale, Attilio; Marino, Benedetto
Thirty-one hearts with aortic arch obstruction and patent ductus arteriosus were examined with special reference to associated cardiac anomalies. Six presented with complete interruption of the aortic arch, four with atretic isthmus, twelve with coarctation, and three with tubular hypoplasia. Associated cardiac anomalies were divided into two main groups: (1) septal defect with left-to-right shunt, and (2) left ventricular inflow and/or outflow obstruction. A high incidence (9/19=47.4%) of ventriculo-infundibular malalignment type of ventricular septal defect with subaortic stenosis was observed. Associated cardiac lesions that reduce blood flow in the aortic arch during fetal life may be responsible for poor development of this structure. Images PMID:15216214
Clyman, R I; Roman, C; Heymann, M A; Mauray, F
A model of patent ductus arteriosus in premature lambs was created to examine the lamb's ability to handle the volume load imposed by a patent ductus arteriosus and to determine the lamb's ability to handle any additional volume load. Fifteen preterm lambs [133 +/- 2 (+/- SD) days gestation, term 145 days], whose ductal diameter could be regulated with a mechanical occluder, were studied to determine the independent effects of ductus patency and a saline volume load (50 ml/kg over 3 min) on left ventricular output and its distribution. During a saline infusion, preterm lambs with a closed ductus could only increase their stroke volume by 40% above baseline stroke volume. When challenged with a saline infusion, lambs with an open ductus still were able to increase their stroke volume significantly; the maximal increase in stroke volume during the saline load with the ductus open was 70% above baseline stroke volume. We hypothesize that the associated reduced left ventricular afterload plays a significant role in the preterm lamb's ability to increase its stroke volume when challenged with a patent ductus arteriosus. Even with a patent ductus arteriosus, the lamb still has the ability to handle additional volume loads.
Yamaguchi, Hiroshi; Kosugiyama, Kiyotaka; Honda, Shohei; Tadao, Okada; Taketomi, Akinobu; Iwata, Seido
The association between Down syndrome and congenital portosystemic shunts, most commonly caused by patent ductus venosus, remains relatively unknown. The authors present a girl with Down syndrome with patent ductus venosus, pancreaticobiliary maljunction and paucity of interlobular bile ducts, presenting with neonatal cholestasis and transient abnormal myeloproliferative disorder. To the best of authors' knowledge, no report of the concurrent presence of the above in Down syndrome has been published.
Zulqarnain, Arif; Younas, Muhammad; Waqar, Tariq; Beg, Ahsan; Asma, Touseef; Baig, Mirza Ahmad Raza
Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus (PDA) with surgical ligation of PDA. This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus (PDA) closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant. There were one hundred and twenty (120) patients who underwent transcatheter occlusion of PDA using SHSMA occluder (PDA Device Group) and one hundred and thirty (130) patients who underwent surgical ligation of PDA (Surgical Group). Incidence of residual shunting was two (1.5%) in surgical group and 0 (0.0%) in PDA Device group for one month follow up period. There were 4 (3.1%) major complications in surgical group. The rate of blood transfusions were high in surgical group (p-value 0.04). Hospital stay time was significantly less in PDA Device group (P-value <0.001). Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group (p-value <0.001). The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA. There was no operative mortality. The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation.
Zulqarnain, Arif; Younas, Muhammad; Waqar, Tariq; Beg, Ahsan; Asma, Touseef; Baig, Mirza Ahmad Raza
Objectives: Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus (PDA) with surgical ligation of PDA. Methods: This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus (PDA) closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant. Results: There were one hundred and twenty (120) patients who underwent transcatheter occlusion of PDA using SHSMA occluder (PDA Device Group) and one hundred and thirty (130) patients who underwent surgical ligation of PDA (Surgical Group). Incidence of residual shunting was two (1.5%) in surgical group and 0 (0.0%) in PDA Device group for one month follow up period. There were 4 (3.1%) major complications in surgical group. The rate of blood transfusions were high in surgical group (p-value 0.04). Hospital stay time was significantly less in PDA Device group (P-value <0.001). Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group (p-value <0.001). The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA. There was no operative mortality. Conclusion: The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation. PMID:27648051
Weinberg, Jacqueline G; Evans, Frank J; Burns, Kristin M; Pearson, Gail D; Kaltman, Jonathan R
We sought to analyse the variation in the incidence of patent ductus arteriosus over three recent time points and characterise ductal ligation practices in preterm infants in the United States, adjusting for demographic and morbidity factors. Using the Kids' Inpatient Database from 2003, 2006, and 2009, we identified infants born at ⩽32 weeks of gestation with International Classification of Diseases, Ninth Revision diagnosis of patent ductus arteriosus and ligation code. We examined patient and hospital characteristics and identified patient and hospital variables associated with ligation. Of 182,610 preterm births, 30,714 discharges included a patent ductus arteriosus diagnosis. The rate of patent ductus arteriosus diagnosis increased from 14% in 2003 to 21% in 2009 (p<0.001). A total of 4181 ligations were performed, with an overall ligation rate of 14%. Ligation rate in infants born at ⩽28 weeks of gestation was 20% overall, increasing from 18% in 2003 to 21% in 2009 (p<0.001). The ligation rate varied by state (4-28%), and ligation was associated with earlier gestational age, associated diagnoses, hospital type, teaching hospital status, and region (p<0.001). The rates of patent ductus arteriosus diagnosis and ligation have increased in the recent years. Variation exists in the practice of patent ductus arteriosus ligation and is influenced by patient and non-patient factors.
Background Diagnosis of extracardiac intrathoracic vascular anomalies is of clinical importance, but remains challenging. Traditional imaging modalities, such as radiography, echocardiography, and angiography, are inherently limited by the difficulties of a 2-dimensional approach to a 3-dimensional object. We postulated that accurate characterization of malformations of the aorta would benefit from 3-dimensional assessment. Therefore, multidetector-row computed tomography (MDCT) was chosen as a 3-dimensional, new, and noninvasive imaging technique. The purpose of this study was to evaluate patients with 2 common diseases of the intrathoracic aorta, either patent ductus arteriosus or vascular ring anomaly, by contrast-enhanced 64-row computed tomography. Results Electrocardiography (ECG)-gated and thoracic nongated MDCT images were reviewed in identified cases of either a patent ductus arteriosus or vascular ring anomaly. Ductal size and morphology were determined in 6 dogs that underwent ECG-gated MDCT. Vascular ring anomalies were characterized in 7 dogs and 3 cats by ECG-gated MDCT or by a nongated thoracic standard protocol. Cardiac ECG-gated MDCT clearly displayed the morphology, length, and caliber of the patent ductus arteriosus in 6 affected dogs. Persistent right aortic arch was identified in 10 animals, 8 of which showed a coexisting aberrant left subclavian artery. A mild dilation of the proximal portion of the aberrant subclavian artery near its origin of the aorta was present in 4 dogs, and a diverticulum analogous to the human Kommerell's diverticulum was present in 2 cats. Conclusions Contrast-enhanced MDCT imaging of thoracic anomalies gives valuable information about the exact aortic arch configuration. Furthermore, MDCT was able to characterize the vascular branching patterns in dogs and cats with a persistent right aortic arch and the morphology and size of the patent ductus arteriosus in affected dogs. This additional information can be of help
Meinarde, Leonardo; Hillman, Macarena; Rizzotti, Alina; Basquiera, Ana Lisa; Tabares, Aldo; Cuestas, Eduardo
The association between inflammation, platelets, and patent ductus arteriosus (PDA) has not been studied so far. The purpose of this study was to evaluate whether C-reactive protein (CRP) is related to low platelet count and PDA. This was a retrospective study of 88 infants with a birth weight ≤1500 g and a gestational age ≤30 weeks. Platelet count, CRP, and an echocardiogram were assessed in all infants. The subjects were matched by sex, gestational age, and birth weight. Differences were compared using the χ(2), t-test, or Mann-Whitney U-test, as appropriate. Significant variables were entered into a logistic regression model. The association between CRP and platelets was evaluated by correlation and regression analysis. Platelet count (167 000 vs. 213 000 µl(-1), p = 0.015) was lower and the CRP (0.45 vs. 0.20 mg/dl, p = 0.002) was higher, and the platelet count correlated inversely with CRP (r = -0.145, p = 0.049) in the infants with vs. without PDA. Only CRP was independently associated with PDA in a logistic regression model (OR 64.1, 95% confidence interval 1.4-2941, p = 0.033).
Cassidy, Harvey D; Cassidy, Lynsey A; Blackshear, Joseph L
Patent ductus arteriosus (PDA) is an uncommon clinical finding in adult primary care patients. However, with improved survival of premature infants at risk for PDA and an increase in cases discovered incidentally on echocardiograms performed for other purposes, the incidence of PDA is rising. Thus, primary care physicians need to be alert to the clinical situations suggesting a previously undiagnosed PDA. It is estimated that the incidence of PDA is approximately 0.02% to 0.04% in term infants and slightly higher in premature infants. PDA accounts for 6% to 11% of all congenital heart defects. Although most cases of PDA would seem to occur sporadically, multifactorial inheritance is believed to underlie many cases. These people are thought to possess a genetic predisposition acted on by an environmental trigger that occurs at an unknown but vulnerable time during the pregnancy. The clinical spectrum of presentation of a PDA may range from a "silent" PDA, one with no clinical manifestations but which is incidentally discovered on echocardiogram for other purposes, to patients who present with congestive heart failure, pulmonary hypertension, signs of volume overload, endocarditis, atrial fibrillation, or "recurrent pneumonia." We describe 2 cases that illustrate the discovery of an asymptomatic PDA during routine physical examination of adult patients.
López Sousa, M; Pérez Feal, A; Soto, A; Fraga, J M; Couce, M L
Patent ductus arteriosus (PDA) is a common problem in preterm newborns. Left vocal cord paralysis (LVCP) can complicate surgical closure if the recurrent nerve is damaged. A retrospective case series study was conducted on preterm babies diagnosed with PDA in our unit from 1999 to 2013. Their clinical features and treatment complications were reviewed. In those patients that received surgical treatment a telephone questionnaire on the symptoms of LVCP symptoms was completed, and laryncoscopy examination offered. A total of 88 subjects diagnosed with PDA were found, of whom 13.64% (12/88) needed surgery. These patients had a lower gestational age and birth weight. They required mechanical ventilation more frequently, and they had more complications such as, diaphragmatic paralysis, bronchopulmonary dysplasia and intraventricular hemorrhage. One third (3/9) of the surgically treated patients had LVCP, and all of them had dysphonia (100% vs. 16.7%, p=.05). LVCP is a common complication of PDA surgery. Further studies are needed to determine its risk factors and its short and long-term consequences. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.
Pac, Aysenur; Polat, Tugcin Bora; Vural, Kerem; Pac, Mustafa
We report a case of a 6-year-old boy with fixed severe pulmonary artery hypertension secondary to a ventricular septal defect (VSD) together with a patent ductus arteriosus (PDA). As a preliminary step, PDA embolization was performed following therapy with inhaled prostacyclin over a period of 6 months. Further, the patient underwent successful surgical VSD closure. We postulate that a staged procedure with long-term prostaglandin therapy might be capable of reducing pulmonary artery resistance and permitting total correction in a patient once considered to have inoperable pulmonary arteriopathy.
Garg, Naveen; Madan, Bevunahalli Kantharaj
Sometimes, it is difficult to visualize a patent ductus arteriosus and deploy a device in the standard lateral view because of an end-on orientation. The right anterior oblique view may be helpful by separating the ductus arteriosus from the aorta. This study was undertaken to evaluate the incidence of end-on patent ductus arteriosus and the utility of the right anterior oblique view during device closure. Aortography was performed in lateral and right anterior oblique views before, during, and after successful device deployment in 117 consecutive patients. When a ductus arteriosus was not clearly visible in the lateral view due to overlapping by the aorta, it was termed "right anterior oblique view useful". The types of patent ductus arteriosus were A, B, C, and E in 86 (73.5%), 20 (17.1%), 4 (3.4%), and 7 (6.0%) patients, respectively. An end-on ductus arteriosus was present in 24 (20.5%) patients (14 type B, 10 type A). The right anterior oblique view was useful during device closure in 15 (12.8%) cases (all end-on type). Among all cases of end-on patent ductus arteriosus, it was useful in 62.5% (most type B and a few type A). In all of these, the device appeared obliquely oriented and foreshortened in the lateral view but fully profiled in the right anterior oblique view. Recognizing an end-on patent ductus arteriosus and utilizing the right anterior oblique view simplified device closure. For ducts well-profiled in the lateral view, the right anterior oblique view is unnecessary and avoidable. © The Author(s) 2016.
Butera, Gianfranco; Lovin, Nicusor; Basile, Domenica Paola
Patent ductus arteriosus (PDA) transcatheter closure is a widespread procedure. However in some cases PDA measurements may be unclear and choice of the proper device could be quite difficult. This may happen in large PDA and in particular in adults. We have developed a new technique using an ASD sizing balloon to measure the PDA in order to better understand PDA anatomy and size. The first step is to create an artero-venous circuit across the PDA. A 24 or a 34 mm Amplatzer balloon sizing for ASD closure is placed over the wire from the venous access in the descending aorta. Then, the balloon is inflated and gently pulled back across the PDA toward the pulmonary artery. The frame where the balloon is exactly across the PDA is chosen and measurements performed. In conclusion, a new method for PDA measurement in large PDA is reported. The procedure is safe and reliable. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
Oxnard, S C; McGough, C; Jung, A L; Ruttenberg, H D
During a two-year period, 21 premature infants (weight at birth, 680 to 2,340 gm) had operative closure of patent ductus arteriosus (PDA). The first 6 infants had ligation performed in the operating room (OR); the subsequent 15 had ligation in the Newborn Intensive Care Unit. There were no immediate postoperative deaths. Two infants died from problems presnet preoperatively within 30 days postoperatively. There were no infections. Technique in the unit utilizes an open warmer with local anesthesia and a paralyzing agent. By eliminating transportation to the OR one avoids problems with thermoregulation, loss of lines, malfunction of monitors, poorly controlled ventilation, and fluid overload. Additional advantages to ligation in the unit are that the infant is already monitored, intubated, and on a respirator, and that venous and usually umbilical arterial lines are in place. At the conclusion of operation, management is returned to the neonatologists for optimal continuity of care.
Akar, Melek; Yildirim, Tulin G; Sandal, Gonca; Bozdag, Senol; Erdeve, Omer; Altug, Nahide; Uras, Nurdan; Oguz, Serife S; Dilmen, Ugur
Introduction Ibuprofen is used widely to close patent ductus arteriosus in preterm infants. The anti-inflammatory activity of ibuprofen may also be partly due to its ability to scavenge reactive oxygen species and reactive nitrogen species. We evaluated the interaction between oxidative status and the medical treatment of patent ductus arteriosus with two forms of ibuprofen. Materials and methods This study enrolled newborns of gestational age ⩽32 weeks, birth weight ⩽1500 g, and postnatal age 48-96 hours, who received either intravenous or oral ibuprofen to treat patent ductus arteriosus. Venous blood was sampled before ibuprofen treatment from each patient to determine antioxidant and oxidant concentrations. Secondary samples were collected 24 hours after the end of the treatment. Total oxidant status and total antioxidant capacity were measured using Erel's method. This prospective randomised study enrolled 102 preterm infants with patent ductus arteriosus. The patent ductus arteriosus closure rate was significantly higher in the oral ibuprofen group (84.6 versus 62%) after the first course of treatment (p=0.011). No significant difference was found between the pre- and post-treatment total oxidant status and total antioxidant capacity in the groups. Discussion Ibuprofen treatment does not change the total oxidant status or total antioxidant capacity. We believe that the effect of ibuprofen treatment in inducing ischaemia overcomes the scavenging effect of ibuprofen.
Bin-Nun, Alona; Mimouni, Francis B; Fink, Daniel; Sela, Hen; Hammerman, Cathy
We hypothesized that postnatal absolute nucleated red blood cell (aNRBC) counts would be elevated in premature infants with hemodynamically significant patent ductus arteriosus (PDA), reflecting intrauterine hypoxia. PDA severity was assessed and categorized echocardiographically. aNRBC counts were significantly correlated with ductal severity (Pearson correlation: P = .007). At the extremes, aNRBC levels were 3770 (728, 6015) hemodynamically significant PDA vs 865 (483, 2528) closed ductus. Copyright © 2016 Elsevier Inc. All rights reserved.
Wierzbicki, Mark A; Bryant, Jesse; Miller, Matthew W; Keller, Brandis; Maitland, Duncan J
Patent ductus arteriosus (PDA) is a congenital cardiovascular malformation in which a fetal connection between the aorta and pulmonary artery remains patent after birth. This defect commonly results in clinical complications, even death, necessitating closure. Surgical ligation is the most common treatment but requires a thoracotomy and is therefore invasive. A minimally invasive option is preferable. A prototype device for PDA occlusion which utilizes shape memory polymer foams has been developed and evaluated using mechanical and in vitro experiments. Removal force and radial pressure measurements show that the prototype device exhibited a lower removal force and radial pressure than a commercially available device. The in vitro experiments conducted within simplified and physiological PDA models showed that the prototype does not migrate out of position into the pulmonary artery at either physiological or elevated pressures in multiple model configurations. While the radial pressure and removal force were lower than commercial devices, the device performed acceptably in the in vitro benchtop experiments warranting further prototype development. Copyright © 2016. Published by Elsevier Ltd.
Sanatani, Shubhayan; Potts, James E.; Ryan, Angela; Sandor, George G.S.; Human, Derek G.; Culham, J.A. Gordon
Purpose: To review the clinical outcomes of catheter-directed coil occlusion (coil occlusion) of persistently patent ductus arteriosus (PDA) at a pediatric tertiary care hospital.Methods: A retrospective review of all patients referred to the Cardiac Catheterization Laboratory for coil occlusion at our institution was performed. Twenty-one consecutive patients (12 female) underwent coil occlusion and follow-up between May 1995 and December 1997. We undertook PDA occlusion if: (a) the PDA narrowed to less than 4 mm on echocardiogram and (b) the minimum body weight was approximately 10 kg. Standard right and retrograde left heart catheterization was performed, followed by coil occlusion. Color-flow mapping (CFM) was used intra-procedurally to confirm occlusion of the PDA with a follow-up study several weeks later.Results: The median age and weight of the patients were 33 months and 13.2 kg, respectively. Fourteen patients received one coil, with six requiring a second coil and one requiring multiple coils. Initial follow-up was at a median of 2.4 months. At latest follow-up, 2 patients still have persistent flow at the ductal level. The coils were deployed without complication or embolization.Conclusions: A review of our first 21 cases demonstrated three important lessons: (1) the maximum diameter of the PDA suitable for coil occlusion is approximately 3 mm; (2) CFM must show complete obliteration of flow in the catheterization lab in order to ensure occlusion of the PDA at follow-up; and (3) the Jackson detachable system allows for precise placement of the coil, often within another coil.
Schwartz, Matthew C; Nykanen, David; Winner, Lawrence H; Perez, Jose; McMahan, Michael; Munro, Hamish M; Suguna Narasimhulu, Sukumar
Transcatheter patent ductus arteriosus (PDA) occlusion is feasible in small infants and may improve lung function in symptomatic patients. We aimed to describe transcatheter PDA closure in small infants including predictors of technical success and rate of complication and to identify factors associated with improved respiratory status after closure. All patients in the NICU at our center who were referred for transcatheter PDA occlusion between 1/2010 and 11/2014 were retrospectively identified. Relevant details were extracted. Additionally, a modification of the respiratory severity score (RSS) (FiO2 × mean airway pressure) was used to characterize degree of pulmonary support before and at intervals after catheterization. Twenty patients were identified with median age of 96 days (13-247) and weight of 3.1 kg (1.7-4.7). The PDA was type F morphology in 14 (70%) patients. The PDA was successfully occluded in 16 (80%) patients. Ratio of minimum PDA diameter/length was >0.5 in all unsuccessful attempts and <0.4 in all successful cases (P = .01). Of the 16 cases of occlusion, Amplatzer Vascular Plug II was used in 15 (94%). No deaths or pulse loss occurred. Five (25%) patients required blood transfusion and transfusion was associated with lower hemoglobin (P = .049), lower weight (P = .008), and lower aortic pressure (P = .04). Excluding 1 patient with significant congenital heart disease, the RSS improved at 3 days in 9 (60%) patients and at 7 days in 12 (80%) compared with preintervention value. Patient factors were not associated with improved RSS at 3 or 7 days. In our cohort of symptomatic infants, transcatheter PDA occlusion was successful in most and a ratio of minimum PDA diameter/length of <0.4 was predictive of technical success. Using a surrogate for pulmonary support, the majority of patients were on less support 7 days after closure. © 2016 Wiley Periodicals, Inc.
Lee, C S; Hwang, B; Lu, J H; Soong, W J; Chen, S J
Premature neonatal survival rates have increased significantly. The diagnosis of patent ductus arteriosus (PDA) has also increased. In this paper, we present our experience of incidence, clinical features and outcome of the treatment of symptomatic PDA in very low birth weight infants. From January 1990 to December 1995, 181 premature infants with birth weight less than 1,500 g were admitted to the Neonatal Intensive Care Unit (NICU) of Veterans General Hospital-Taipei. Thirty-seven were diagnosed to have symptomatic PDA. By reviewing hospital records, the clinical features and outcome of treatment of these infants were analyzed retrospectively. The incidence of symptomatic PDA was 20.9% and 21.4% in infants with birth weight less than or equal to 1,000 g, 1,001-1,500 g, respectively. The mean age at diagnosis of infants with symptomatic PDA was significantly less than those without symptoms (3.6 +/- 2.9 days vs 9.6 +/- 17.2 days, p = 0.044, 95% CI = 0.2-11.8). With fluid restriction and diuretic therapy, asymptomatic patients had a higher spontaneous ductal closure rate than symptomatic patients (58.3% vs 10.8%, p < 0.001, 95% CI = 17.9-77.1%). Thirty-two (97.0%) infants with symptomatic PDA responded to indomethacin therapy. However, four infants (12.1%) had recurrence. These four infants and a nonresponder received surgical ligation of the PDA and survived. There were four deaths. The reasons for death were respiratory failure in two, sepsis in one and necrotizing enterocolitis with intestinal perforation in one. Conservative medical management such as fluid restriction and diuretics are often adequate for asymptomatic PDA. However, since symptomatic PDA tends not to close spontaneously, patients should be treated with indomethacin if ductal shunting compromises cardiopulmonary function.
Arat, Nurcan; Akyıldız, Murat; Tellioğlu, Gürkan; Tokat, Yaman
Primary hyperoxaluria is a rare hereditary metabolic disorder resulting in accumulation of calcium oxalate in visceral organs, including the heart. We report a 19-year-old male with non- compaction cardiomyopathy combined with patent ductus arteriosus awaiting combined liver-kidney transplantation for primary hyperoxaluria. After surgical closure of the patent ductus arteriosus, the patient underwent a successful renal and subsequent liver transplantation. The presence of hypertrophic cardiomyopathy in hyperoxaluria patients has been reported before, but this is the first report of non-compaction myocardium with patent ductus arteriosus in a patient with primary hyperoxaluria. At the third month after combined liver and renal transplantation, improvement in cardiac functions were observed. Primary hyperoxaluria is a clinical entity to be taken into consideration in differential diagnosis of hypertrophied myocardium with high myocardial echocardiographic intensity. In cases of hyperoxaluria, additional congenital abnormalities may complicate the clinical picture.
Martin, C G; Snider, A R; Katz, S M; Peabody, J L; Brady, J P
To determine whether there are significant alterations in cerebral blood flow patterns in infants with a patent ductus arteriosus and whether these alterations correlate with alterations in aortic blood flow, we performed range-gated pulsed-Doppler examinations of the aorta and cerebral arteries in 20 infants. Ten infants had a PDA and ten control infants did not. We analyzed these flow patterns quantitatively by calculating the pulsatility index (peak systolic frequency minus trough diastolic frequency)/peak systolic frequency. In the ten control infants and in three infants with a small PDA, there was no significant diastolic flow in the descending aorta; flow in the cerebral arteries was antegrade throughout systole and diastole (PI = 0.75 +/- 0.03 for control infants and 0.73 +/- 0.07 for small PDA infants). In seven infants with a large PDA, there was retrograde diastolic flow in the descending aorta. This pattern was not seen after PDA closure. In the cerebral arteries of the seven infants with a large PDA, diastolic flow was retrograde in three and decreased or absent in four, and PI was significantly higher (PI = 0.96 +/- 0.06. P less than 0.001 vs controls). After PDA closure, cerebral diastolic flow was antegrade in all seven infants (PI = 0.74 +/- 0.04). We conclude that a large PDA can cause abnormal flow patterns in the descending aorta and cerebral arteries. These flow patterns may predispose these infants to CNS ischemia or intraventricular hemorrhage.
Subramanian, Venkateshwaran; Kavassery Mahadevan, Krishnamoorthy; Sivasubramonian, Sivasankaran
A 7-month-old boy was admitted for the device closure of symptomatic patent ductus arteriosus (PDA) with moderate pulmonary hypertension. The PDA measured 4.2 mm with adequate ampulla. It was closed with an 8-6 mm Heart R device from pulmonary artery (PA) end. Post extubation, the device embolized to proximal descending thoracic aorta just distal to PDA ampulla. While attempting to snare from the venous side, the device self-repositioned to PDA. It was stable thereafter and patient was discharged after 2 days. We report a complication, which got self-corrected.
Weir, E K; Obreztchikova, M; Vargese, A; Cabrera, J A; Peterson, D A; Hong, Z
Specialized tissues that sense acute changes in the local oxygen tension include type 1 cells of the carotid body, neuroepithelial bodies in the lungs, and smooth muscle cells of the resistance pulmonary arteries and the ductus arteriosus (DA). Hypoxia inhibits outward potassium current in carotid body type 1 cells, leading to depolarization and calcium entry through L-type calcium channels. Increased intracellular calcium concentration ([Ca++]i) leads to exocytosis of neurotransmitters, thus stimulating the carotid sinus nerve and respiration. The same K+ channel inhibition occurs with hypoxia in pulmonary artery smooth muscle cells (PASMCs), causing contraction and providing part of the mechanism of hypoxic pulmonary vasoconstriction (HPV). In the SMCs of the DA, the mechanism works in reverse. It is the shift from hypoxia to normoxia that inhibits K+ channels and causes normoxic ductal contraction. In both PA and DA, the contraction is augmented by release of Ca++ from the sarcoplasmic reticulum, entry of Ca++ through store-operated channels (SOC) and by Ca++ sensitization. The same three ‘executive' mechanisms are partly responsible for idiopathic pulmonary arterial hypertension (IPAH). While vasoconstrictor mediators constrict both PA and DA and vasodilators dilate both vessels, only redox changes mimic oxygen by having directly opposite effects on the K+ channels, membrane potential, [Ca++]i and tone in the PA and DA. There are several different hypotheses as to how redox might alter tone, which remain to be resolved. However, understanding the mechanism will facilitate drug development for pulmonary hypertension and patent DA. PMID:18641675
Harth, W; Linse, R
Keratosis follicularis spinulosa decalvans (KFSD) appeared sporadically in an Asian boy, who also presented with naevus teleangiectaticus lateralis, patent ductus arteriosus (Botalli) and hypospadia. The association of these findings raises the question of a new syndrome. In addition, this is the first report of KFSD in a patient of Asian origin.
Toib, Amir; Goldstein, Seth B; Khanna, Geetika; Canter, Charles E; Lee, Caroline K; Balzer, David T; Singh, Gautam K
We describe a case of an infant with a single ventricle physiology, who presented with spontaneous microbubbles originating from her inferior vena cava. Imaging revealed a persistent patent ductus venosus, leading to a portosystemic shunt, streaming the microbubbles into the heart. We discuss the possible mechanisms for this rare phenomenon in a child. © 2011 Wiley Periodicals, Inc.
Kessel, Irena; Waisman, Dan; Lavie-Nevo, Karen; Golzman, Marcelo; Lorber, Avraham; Rotschild, Avi
Paracetamol was reported to be effective for patent ductus arteriosus (PDA) closure. We present a case series of PDA closure by paracetamol in seven premature infants. During the treatment, paracetamol blood levels did not exceed the recommended levels for analgesia and hyperthermia in six tested infants. None of the patients demonstrated significant disturbances of liver function.
Abstract A 9-day old Grant’s zebra with a 3-day history of lethargy, weight loss, inappetance, and diarrhea was treated with ampicillin, vitamin E and selenium, and tetanus antitoxin without effect in 24 h. On transfer to the local veterinary clinic, a grade IV/VI continuous heart murmur was detected and a patent ductus arteriosus found at necropsy. PMID:16152724
Soares, Andressa M; Aiello, Vera D; Andrade, José L; Kajita, Luis J; Soares, José; Morhy, Samira S; Mathias, Wilson; Lopes, Antonio A B; Ramires, José A F
Coil protrusion into the left pulmonary artery (LPA) has been described after transcatheter closure of the patent ductus arteriosus (PDA). The possible impact of such a finding in lung perfusion has not been completely clarified. We evaluated Doppler flow velocities and lung perfusion in patients submitted to that procedure. After transcatheter closure of PDA with coils, 70 patients (mean age 8.6+/-3.4 years) were followed for a period of 3.6+/-0.9 years (range 2.1-5.9) and compared to 22 controls. Peak flow velocities and coil protrusion were assessed by Doppler echocardiography. A Doppler velocity index (DVI) was calculated by the difference between the LPA and right pulmonary artery (RPA) peak flow velocities relative to the pulmonary trunk (PT) expressed in percentage, as follows: DVI=(LPA velocity - RPA velocity)/PT velocity x 100. Lung scintigraphy was performed using (99m)Tc-labelled macro-aggregated albumin. Device protrusion was observed in 94% of the patients, 10% of whom presented abnormal left lung perfusion. Peak LPA velocity and DVI were significantly greater in patients (p=0.001) and correlated negatively with left lung perfusion values (R(2)=0.21 and R(2)=0.65, respectively). A cut-off value of 50% for the DVI showed high sensitivity and specificity for reduced lung perfusion. Impaired left lung perfusion may appear following transcatheter closure of PDA with coils and the determination of DVI may anticipate such alteration.
Lee, Youngjae; Jung, Jaihyun; Park, Junyong; Jeong, Jiyoon; Jeon, Seokho; Park, Sunyoung; Chang, Jinhwa; Kang, Ji-Houn; Lee, Chulhyun; Chang, Dongwoo
Patent ductus arteriosus (PDA) is the most common congenital cardiovascular disorder in dogs and requires an accurate diagnosis for an appropriate treatment. Cardiac MRI (cMRI) has been reported as a method for characterization of canine thoracic vasculature. However, to the authors' knowledge, no published studies describe evaluation of canine PDA through cMRI. Three dogs were selected for this exploratory study. Electrocardiogram gating and breath-hold techniques were performed using a 3T MR scanner. Both black blood imaging and bright blood cine acquisitions were performed. Quantification of stroke volume (SV) and shunting volume were calculated using a stack of short-axis cine images. Additional 4D (three-spatial dimensions plus time)-TRAK (time-resolved MR angiography with keyhole) sequences were conducted in patient 2 to verify other vasculature abnormality. Black blood images clearly depicted the course of the ductus from the descending aorta to the pulmonary artery in all three dogs. Morphological evaluation of PDA classified patients 1 and 2 as Type 2a and patient 3 as Type 1. Patient 2 was confirmed to have a concurrent persistent left cranial vena cava. Left ventricular SV, right ventricular SV, and left-to-right SV ratio were 12.4 ml, 3.36 ml, and 3.704, respectively, in patient 1; 6.85 ml, 1.22 ml, and 5.60 in the patient 2; and 3.67 ml, 2.14 ml, and 1.702 in patient 3. Findings indicated that cMRI is a feasible method for characterizing the morphology of PDA and extracardiac vasculature anomalies in dogs. © 2016 American College of Veterinary Radiology.
Matsui, H; McCarthy, Kp; Ho, Sy
Patent ductus arteriosus (PDA), one of the most common congenital heart defects, is an abnormal persistence of a patent lumen in the arterial duct due to an arrest of the natural process of closure after it has served its function as a vital channel in fetal circulation. The histological feature of the arterial duct is entirely different from its adjoining arteries and many intrinsic substances mediate in the process of its normal closure. When existing in isolation, catheter or surgical intervention is usually used for its treatment. Ductal aneurysm is a rare type of PDA. The PDA associated with other congenital heart disease has variable morphology and closing it naturally or by intervention may produce critical symptoms. The PDA and its ligament which represents a closed arterial duct can be part of a vascular ring with abnormal aortic arch formation. It is important to understand the morphological features of PDA so as to choose the optimal strategy for treatment.
Bharmanee, Apinya; Gowda, Srinath; Singh, Harinder R
Limb ischaemia is a rare but catastrophic complication related to cardiac catheterisation. We report an infant weighing 3 kg with unrepaired tricuspid atresia type 1b, small patent ductus arteriosus, and ventricular septal defect presenting with cardiogenic shock owing to progressively reduced pulmonary blood flow from closing ventricular septal defect and patent ductus arteriosus. An emergency palliative ductal stent was successfully placed with marked clinical improvement. However, acute limb ischaemia developed necessitating above-knee amputation, despite medical management and vascular surgery. The cause of limb loss in our patient was catheterisation-related vascular injury causing arterial dissection-arterial thrombosis in the presence of shock and coagulopathy. This report emphasises the complexity in managing limb ischaemia associated with coagulopathy and highlights the importance of early recognition of reduced pulmonary flow in a single ventricle patient. Timely elective placement of a surgical systemic to pulmonary shunt would prevent catastrophic clinical presentation of compromised pulmonary flow and avoid the need for an emergent life-saving intervention and its associated complications.
De Decker, Rik; Comitis, George; Thomas, Jenny; van der Merwe, Elmarie; Lawrenson, John
Ductal spasm is a rare yet important complication of device occlusions of patent ductus arteriosus. Spasm may result in failure of the procedure, under-sizing of the device, or embolisation of the implanted device as the spasm resolves after the procedure. We describe a novel protocol that rapidly and completely reversed the spasm in eight prematurely born infants who experienced ductal spasm during cardiac catheterisations for patent ductus arteriosus occlusion. In total, eight infants born between 25 and 34 weeks of gestation presented for transcatheter patent ductus arteriosus occlusion between 13 and 87 months of age. All eight patients experienced ductal spasm either immediately before, during, or soon after induction of anaesthesia or only after entering the ductus arteriosus with a catheter. After detection of the spasm, the anaesthetist, in each case, changed the mode of anaesthesia from inhaled sevoflurane to total intravenous anaesthesia with propofol, reduced the inhaled oxygen fraction to 21%, and initiated a continuous intravenous infusion of prostaglandin E1. The first two steps (total intravenous anaesthesia and FiO2 0.21) resulted in only partial relaxation of the spasm. Complete relaxation was attained after intravenous prostaglandin E1 infusions of only 10-15 minutes' duration. While maintaining this protocol, six ducti were successfully occluded and two were considered to be unsuitable for device occlusion and were referred for surgery. Ductal spasm during transcatheter occlusion may be reliably resolved and the procedure safely completed by a simple anaesthetic protocol, including the continuous infusion of intravenous prostaglandin E1.
Patent ductus arteriosus (PDA) affects approximately 31% of infants whose birth weight is between 501 and 1500 g. The ductus arteriosus is a blood vessel that allows blood to bypass the pulmonary vasculature in utero. Oxygen delivery and elimination of prostaglandins are essential for the closure of the ductus after birth. For years, indomethacin has been the drug of choice for the treatment of PDA in the USA. Undesirable adverse effects prompted researchers to seek alternative agents. In April 2006, the US Food and Drug Administration approved the use of ibuprofen lysine (NeoProfen) for closure of clinically significant PDA in premature neonates. Ibuprofen's mechanism of action for closure of PDA is believed to be through the inhibition of prostaglandins. Clinical studies have shown ibuprofen to be as effective as indomethacin with fewer adverse effects. PMID:17256050
Kalavrouziotis, Georgios; Kourtesis, Antonios; Paphitis, Christodoulos; Azariades, Prodromos
Surgical closure of a patent ductus arteriosus (PDA) in cases with pulmonary hypertension, a short and wide PDA, and/or calcification of the wall of the vessel can be a hazardous procedure. The use of extracorporeal circulation provides the necessary safety for effective closure. Four patients (one male), aged 7, 22, 54 and 60 years old, underwent PDA closure. All had pulmonary hypertension (pulmonary artery pressure, PAP 55-85 mmHg, PAP-to-systemic pressure ratio 0.6-0.8) and a wide, short PDA (diameter 9-12 mm) with a calcified wall in 2 cases. The surgical technique involved transpulmonary PDA closure with a synthetic patch under extracorporeal circulation and mild hypothermia (n=2); or double ligation and purse-string suture of the PDA with extracorporeal circulation and normothermia on a beating heart (n=1), or with heart-lung machine on standby (n=1). Mortality was nil. The postoperative course was mild in all cases. Follow up 3 to 8 years post surgery showed effective PDA closure, PAP within normal (n=3) or at upper normal limits (n=1), and no other sequelae. The use of extracorporeal circulation allows safe and uncomplicated surgical closure of a PDA in "difficult" cases.
Yap, Norah; Bharucha, Tara
Clinical signs alone are unreliable in the diagnosis of patent ductus arteriosus (PDA) in preterm infants, and therefore echocardiography remains the mainstay of diagnosis of this common condition. Echocardiography also facilitates understanding of the hemodynamic effects of a PDA, and thus aids in management decisions. Several echocardiographic parameters, including duct size, maximum ductal velocity, left atrial: aorta ratio, mitral inflow E:A ratio, and isovolumic relaxation time, have been utilized in the assessment of PDA, but no single measurement can be used in isolation to inform clinical judgement. Therefore, it is important that echocardiographers on the neonatal unit have a comprehensive understanding of available methods and their limitations. Newer echocardiographic techniques, such as 3 Dimensional echocardiography, tissue Doppler imaging and strain imaging, are now providing insights into myocardial function in the adaptation of preterm infants to extra-uterine life, and into the effects of a PDA causing systemic-to-pulmonary artery shunting. Magnetic resonance imaging delivers excellent diagnostic information and accurate hemodynamic evaluation; however this modality is not easily accessible for most preterm infants, in comparison to echocardiography, which is readily available at the cotside in most neonatal units. Further developments in echocardiography may further refine the contribution it makes to individualized clinical decisionmaking in the management of premature infants with PDA.
Wu, J R; Huang, T Y
Twenty-seven patients, aged 2 months to 3 years, underwent thoracic aorta angiography with balloon inflation during right heart catheterization and cineangiography. The balloon-tipped catheter was manipulated either from the right ventricle to main pulmonary artery and then through patent ductus arteriosus (PDA) or from the right ventricle through ventricular septal defect (VSD) to ascending aorta and to mid-thoracic aorta where the balloon was fully inflated with carbon dioxide. After satisfactory positioning of the inflated balloon, contrast medium was administrated via power injector with a volume of 1.5 ml/kg and a flow rate of 10 ml/sec. Cineangiograms of left lateral projection were obtained. The blood was seen clearly from the thoracic aorta to aortic arch, and also through the PDA to pulmonary vessels. On the late films, left heart chambers were also opacified. Areas of anatomic interest were well visualized in 20 cases of isolated PDA, three of PDA with VSD, two of infantile coarctation of aorta with PDA and VSD, two of tetralogy of Fallot with severe pulmonic stenosis and PDA. This procedure is simple and effective in visualizing the PDA and also, in many occasions, other associated cardiac anomalies. Conventional left heart catheterization and cineangiography could thus be omitted in some cases of congenital heart diseases. There were no untoward complications observed during and after the procedure. This technique is useful especially in critically ill infants.
Kheiwa, Ahmed; Ross, Robert D; Kobayashi, Daisuke
We report a critically ill premature infant with severe mitral valve regurgitation associated with pulmonary hypertension and a severely dilated left atrium from a large patent ductus arteriosus. The mitral valve regurgitation improved significantly with normalisation of left atrial size 4 weeks after percutaneous closure of the patent ductus arteriosus. This case highlights the potential reversibility of severe mitral valve regurgitation with treatment of an underlying cardiac shunt.
Laborde, F; Folliguet, T; Batisse, A; Dibie, A; da Cruz, E; Carbognani, D
Closure of patent ductus arteriosus by video thoracoscopy is a standardised procedure. The authors report their experience of closure of patent ductus arteriosus by video-thoracoscopy from May 1991 to December 1995. The series included 282 patients divided into 3 groups according to age: under 6 months (78 patients, 27.6%), from 6 months to 4 years (135 patients, 42.88%) and over 4 years of age (69 patients, 24.6%) with an average weight of 12.6 kg (range: 1.2 to 65 kg). Symptomatic pulmonary hypertension was observed in 39 cases and 9 children had associated intracardiac malformations (ostium secundum: 3; ventricular septal defect: 5; abnormal pulmonary venous drainage: 1) which were not corrected. The technique consisted of placing two titanium clips in position under video-thoracoscopy to close the ductus. An echo performed immediately afterwards confirmed closure of the ductus. The main complications were: persistence of a shunt (4 cases) at the beginning of our experience requiring immediate reoperation by video-thoracoscopy in 3 cases and by thoracotomy in one case; left recurrent laryngeal nerve palsy in 6 cases (2.1%) with regression in 5 and persistence in one case; one case of postoperative chylothorax which regressed rapidly. There were no fatalities or haemorrhages and no blood transfusions were required in this series. The average operating time was 20 +/- 15 minutes and the duration of hospital stay around 48 hours when the patients were over 6 months old and 72 hours when less than 6 months of age. Video-thoracoscopic closure of patent ductus arteriosus is rapid, safe, economical, it provides excellent results and may be used in children of all ages.
Lee, M L; Chaou, W T; Wang, J K
We wish to present the preliminary result of transarterial occlusion of patent ductus arteriosus (PDA) with Gianturco coils in pediatric patients in central Taiwan. We attempted occlusion of PDA with Gianturco coils in a total of 26 consecutive patients, 13 infants and 13 children, 23 female and three male, between July 1 1997 to September 30 1998. Median patient age was 2.57 years (from 0.25 to 14.02 years old). Median patient weight was 10.8 kg (4.0 to 36.0 kg). Premature babies with PDA, full-term babies who were less than three months old and patients who had other congenital heart disease were not included in this study. All PDAs were approached transarterially from the femoral artery. Coils were selected to provide a helical diameter that was twice or more the minimum ductus diameter and a length approximating five loops. In five patients who had a PDA diameter > or =3.5 mm, we used a snare technique to assist coil delivery beforehand, and to test coil stability, or to retrieve coil that had migrated to the pulmonary artery afterwards. Physical auscultation, chest radiographs and echocardiography with color Doppler were done in all patients within 24 h, and one, two, three, six and 12 months after coil occlusion. The median ductus minimum diameter was 2.3 mm (range, 1.0 to 4.7 mm). Fifteen patients had the megaphone type (type A), four had the window type (type B), five had the tubular type (type C), one had the aneurysmal type (type D) and one had the elongated conical type (type E). Twenty-one patients underwent single coil occlusion and five had multiple coils occlusion. Twenty-one patients had immediate angiographic closure of the ductus and disappearance of heart murmur at 15 min after the procedure. Dark-brown urine (hemoglobinuria) was found in one patient, 10 h after the first procedure, due to a mild residual ductal shunt. Two more coils were implanted in a second procedure that was performed within 24 h, and the ductus was completely occluded. The
Douay, Guillaume; Drut, Amandine; Ribas, Thibault; Gomis, David; Graille, Mélanie; Lemberger, Karin; Bublot, Isabelle
A clinically healthy 16-yr-old female leopard (Panthera pardus orientalis) was diagnosed with a patent ductus arteriosus on echocardiography and later confirmed on necropsy A murmur was heard on auscultation during a routine examination, and the congenital defect was an incidental finding. The animal had been asymptomatic its entire life. This deformity is rarely observed in nondomestic felids and may be asymptomatic, as has been described in domestic cats.
Bussadori, Claudio; Domenech, Oriol; Longo, Antonio; Pradelli, Danitza; Bussadori, Roberto
A 6-months old female German shepherd dog was referred for management of congenital heart disease. A diagnosis of pulmonic stenosis (PS) and patent ductus arteriosus (PDA) was confirmed by Doppler echocardiography and cardiac catheterisation. The conditions were treated during a single cardiac catheterisation procedure using percutaneous techniques. Gianturco coil embolisation was used to close the PDA, and the PS was relieved using a balloon valvuloplasty technique.
Lee, LLeona CL; Tillett, Angela; Tulloh, Robert; Yates, Robert; Kelsall, Wilf
Background The patent ductus arteriosus (PDA) is an important problem in premature infants. Surgical PDA ligation is usually only be considered when medical treatment has either failed or was contraindicated. The aims of our study were to determine the mortality and morbidity following patent ductus arteriosus ligation in premature infants, and whether prostaglandin synthetase inhibitor (PSI) use prior to ligation affects outcome. Methods A retrospective case note review study to determine the outcome of premature infants undergoing patent ductus arteriosus ligation in one tertiary neonatal intensive care unit and two paediatric cardiothoracic centres. Results We had follow-up data on 87 infants. Cumulative mortality rates at 7 days, 30 days and at hospital discharge were 2%, 8% and 20% respectively. The incidence of chronic lung disease, intraventricular haemorrhage, necrotising enterocolitis and retinopathy of prematurity were 77%, 39%, 26% and 28% respectively. There was no difference in mortality, incidence of chronic lung disease or duration of oxygen dependence between those who had and those who had not received a PSI prior to surgical ligation. In those who had received 2 or more courses of PSI prior to surgical ligation, there was a trend to increase in the duration of oxygen therapy and chronic lung disease, but no difference in mortality. Conclusion This study shows that patent ductus arteriosus ligation is a relatively safe procedure (30 day survival 92%) but there is substantial late mortality and a high incidence of morbidity in the survivors. 2 or more courses of PSI prior to surgical ligation trends to increased oxygen dependence and chronic lung disease. This high risk population requires careful follow-up. A definitive prospective cohort study is lacking. PMID:16689986
Kang, Sok-Leng; Samsudin, Salehuddin; Kuruvilla, Minju; Dhelaria, Anshoo; Kent, Sue; Kelsall, Wilfred A
Surgical ligation of patent ductus arteriosus is considered when medical treatment fails or is contraindicated. This study aims to determine the mortality and morbidity of preterm neonates referred for patent ductus arteriosus ligation. A prospective study was conducted in the East of England to follow the outcome of premature infants under 37 weeks’ gestation undergoing patent ductus arteriosus ligation. A standardised proforma was used to collect information before and after the procedure. A total of 102 premature infants were recruited, and patent ductus arteriosus ligation was performed in 92. Surgical complications occurred in 8.7% (8/92), which included pneumothorax (5/8), recurrent laryngeal nerve palsy (2/8), and chylothorax (1/8). Morbidity outcome data were not available for all infants. The incidence of chronic lung disease was 88% (88/99); intraventricular haemorrhage was 49% (49/100); necrotising enterocolitis 39% (39/99), and retinopathy of prematurity 42% (41/97). The overall mortality rate in our study was 7.8% (8/102). Mortality rate in infants who had patent ductus arteriosus ligation was 4.3% (4/92). The 30-day survival rate after ligation was 99% (91/92). Beyond 30 days post-ligation, three infants died from other causes that were not directly related to surgery. Patent ductus arteriosus ligation in premature infants is associated with low mortality and complication rates; however, there is a high incidence of neonatal morbidity. Surgical capacity for patent ductus arteriosus ligation needs to be carefully planned nationally as the duration of ‘‘waiting time’’ and transport to another surgical centre could adversely affect outcomes in this high-risk population.
Ghosh, P K; Lubliner, J; Mogilnar, M; Yakirevich, V; Vidne, B A
The results of ligation of a patent ductus arteriosus in 30 premature neonates with a very low birth weight were analysed. The mean gestational age at birth was 27 weeks and the mean weight 811 g. Attempted closure of the ductus with indomethacin in 19 infants failed, though there was temporary closure in nine. Congestive heart failure was present in 29 and respiratory distress in 22 patients. Endotracheal intubation with assisted ventilation was necessary in all cases. The mean age at operation was 13.5 days and ductal ligation was performed in the intensive care unit under local anaesthesia supplemented with pancuronium and pethidine. There were no intraoperative deaths, but five infants died in hospital. There were seven late deaths. Eighteen survivors have been followed for a mean of 26.5 months. Early ligation of a patent ductus arteriosus in premature infants with a very low birth weight improved the cardiorespiratory state. Long term follow up showed good clinical progress in two thirds of the surviving group. PMID:4035621
Gruenstein, Daniel H; Ebeid, Makram; Radtke, Wolfgang; Moore, Phillip; Holzer, Ralf; Justino, Henri
The study purpose is to evaluate the safety and efficacy of the ADO II device for closure of patent ductus arteriosus (PDA) in children. Transcatheter treatment of PDA has been evolving for 40+ years and is the treatment of choice. The AMPLATZER™ Duct Occluder (ADO) device was developed for larger diameter ducts and is not ideal in all PDAs. ADO II was developed for small to moderate-sized ducts. This is a single-arm, multicenter study evaluating safety and efficacy of the ADO II device. Patients <18 years were screened for a PDA ≤5.5 mm in diameter and 3-12 mm in length. Right and left heart catheterization was performed, and hemodynamic data were obtained at the time of implant. The diameter of the left pulmonary artery (LPA) and descending aorta, and the presence of any pre-existing pressure gradients across the LPA or aortic arch were assessed at baseline and 6 months post-implant. A total of 192 patients were enrolled. The median implant time was 74 min. Median fluoroscopy time was 12 min. A retrograde (aortic) approach was used in 33% of procedures and demonstrated a statistically significant reduction in fluoroscopy time (P value = 0.0018) compared to an antegrade approach. The device was successfully implanted in 93% of patients, with complete closure in 98% of successful implantations. In this prospective study, the ADO II was safe and effective for closure of small to moderate PDAs. Implantation is simple and the ability for retrograde aortic delivery reduces procedure-related radiation exposure. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.
Olsen, Dennis; Harkin, Kenneth R; Banwell, Max N; Andrews, Gordon A
To describe an unusual case of fatal aortic aneurysm rupture after standard ligation of a left-to-right shunting patent ductus arteriosus (PDA) and review the literature concerning the causes of aneurysm and applicable medical physics of blood flow that may contribute to mural failure. Clinical case report. An 11-month-old female Brittany spaniel. A PDA was diagnosed in the dog after referral for a grade IV/IV cardiac murmur. Diagnostic tests performed included a minimum database, thoracic radiography, and echocardiography. Conventional surgical ligation of the PDA was performed. The postoperative recovery from anesthesia was uneventful. Approximately 5 hours after surgery, the dog vocalized once and collapsed. All resuscitative efforts failed. Necropsy showed a large, spiral rupture of the cranial and dorsal wall of the aorta that extended from the left subclavian artery to 2 cm distal to the PDA-aorta junction. No evidence of intramural, perianeurysmal hemorrhage or inflammation was noted. Histopathologic examination of the ruptured aneurysm showed that the wall lacked a defined tunica intima and endothelial cell layer. A distinct separation of the thinned tunica media parallel to the elastic fibers was noted. Dilatation of the aorta near the area of a PDA is one of the recognized abnormalities associated with the condition. Aneurysmal dilatation results from and contributes to abnormal blood flow dynamics and increased aortic wall tension, which promotes expansion. Although an unusual and previously unreported sequela, rupture of the aneurysm should be considered a possible complication when ligation of a PDA with a conspicuous aortic aneurysmal dilation is performed. Copyright 2002 by The American College of Veterinary Surgeons
Cordero, L; Nankervis, C A; Delooze, D; Giannone, P J
Indomethacin prophylaxis or expectant treatment are common strategies for the prevention or management of symptomatic patent ductus arteriosus (sPDA). To compare the clinical responses of extremely low birth weight (ELBW) infants to indomethacin prophylaxis with that of other infants who were managed expectantly by being treated with indomethacin or surgically only after an sPDA was detected. Retrospective cohort investigation of 167 ELBW infants who received indomethacin prophylaxis (study) and 167 ELBW infants (control) treated expectantly who were matched by year of birth (1999 to 2006), birth weight, gestational age (GA) and gender. Mothers of the two groups of infants were comparable demographically and on the history of preterm labor, pre-eclampsia, antepartum steroids and cesarean delivery. Study and control infants were similar in birth weight, GA, low 5 min Apgar scores, surfactant administration, the need for arterial blood pressure control, bronchopulmonary dysplasia and neonatal mortality. Necrotizing enterocolitis, spontaneous intestinal perforations, intraventricular hemorrhage grade III to IV, periventricular leukomalacia and stage 3 to 5 retinopathy of prematurity occurred also with similar frequency in both groups of infants. In the indomethacin prophylaxis group, 29% of the infants developed sPDA, and of them 38% responded to indomethacin treatment. In the expectantly treated group, 37% developed sPDA, and of them 59% responded to indomethacin treatment. Overall, surgical ligation rate for sPDA was similar between both groups of patients. In our experience, indomethacin prophylaxis does not show any advantages over expectant early treatment on the management of sPDA in ELBW infants. Although no deleterious effects were observed, prophylaxis exposed a significant number of infants who may have never developed sPDA, to potential indomethacin-related complications.
Lazim, Zulfaqih; Ismail, Al Emran; Taib, Ishkrizat; Atan, Bainun Akmal Mohd
This paper presents a review of stent’s failure on patent ductus arteriosus (PDA). Ductus arteriosus (DA) is an opening for newborn babies and some patient that experienced cynotic congenital heart disease (CCHD) should maintain the duct opening for survival. To date, there are no specific research on mechanical stent failure study at DA. The challenging of the stent implantation on PDA is the PDA morphology. The failure of stent in term of stent fracture have been reported and reviewed in this paper. Furthermore, the failure prediction of stent is important for further stent design development. The morphology of PDA, stent type and material used in PDA and method for accessing the failure of stent is reviewed.
Clyman, Ronald I.
A persistent left-to right shunt through a patent ductus arteriosus (PDA) increases the rate of hydrostatic fluid filtration into the lung’s interstitium, impairs pulmonary mechanics, and prolongs the need for mechanical ventilation. In preclinical trials, pharmacologic PDA closure leads to improved alveolarization and minimizes the impaired postnatal alveolar development that is the pathologic hallmark of the “new bronchopulmonary dysplasia (BPD)”. Although early pharmacologic closure of the PDA decreases the incidence of pulmonary hemorrhage, intraventricular hemorrhage, and the need for PDA ligation, there is little evidence from controlled, clinical trials to support or refute a causal role for the PDA in the development of BPD. On the other hand, evidence from epidemiologic, preclinical, and randomized controlled clinical trials demonstrate that early ductus ligation is an independent risk factor for the development of BPD and may directly contribute to the neonatal morbidities it is trying to prevent. PMID:23582964
Magal, C; Wright, K C; Duprat, G; Wallace, S; Gianturco, C
A new device for transcatheter closure of the patent ductus arteriosus was developed and initially evaluated in the vasculature of adult mongrel dogs. The device consists of a nylon sack that can be made in various sizes and shapes. A small flexible crossbar attached to the distal end maintains the position of the sack while it is filled with a segment of modified guide wire. The device is delivered coaxially through a 10-Fr Teflon catheter and is easily repositioned or retrieved before release. The expansile force of the sack against the vessel wall can be varied, and its stability is easily checked prior to detachment. The device produced immediate and permanent vascular occlusion without inflammation or erosion. Over time, the entire unit became incorporated into the vessel wall by neointimal encasement. Nylon sacks offer a simple, unique method of closing virtually any ductus arteriosus without general anesthesia and major surgery.
Fanos, Vassilios; Pusceddu, Michele; Dessì, Angelica; Marcialis, Maria Antonietta
Although the prophylactic administration of indomethacin in extremely low-birth weight infants reduces the frequency of patent ductus arteriosus and severe intraventricular hemorrhage, it does not appear to provide any long-term benefit in terms of survival without neurosensory and cognitive outcomes. Considering the increased drug-induced reduction in renal, intestinal, and cerebral blood flow, the use of prophylaxis cannot be routinely recommended in preterm neonates. However, a better understanding of the genetic background of each infant may allow for individualized prophylaxis using NSAIDs and metabolomics. PMID:22189742
White, Robert N; Murphy, Kate; Renfrew, Helen; Shales, Chris
A 3 mo old male German shepherd dog presented with a 2 wk history of diarrhea with possible melena followed by inappetence and progressive abdominal distension. Clinical findings, serum biochemical analysis, and abdominal ultrasound were highly suggestive of an extrahepatic abdominal arteriovenous fistula and concurrent patent ductus venosus, which were confirmed during an abdominal exploratory surgery. Renal biopsies taken at the time of surgery confirmed a chronic glomerulopathy. The dog made a good initial recovery from the procedure but was euthanatized 6 wk postoperatively for medically unresponsive renal disease.
Wesselowski, S; Saunders, A B; Gordon, S G
Deployment of the Amplatz Canine Duct Occluder (ACDO) is the preferred method for minimally invasive occlusion of patent ductus arteriosus (PDA) in dogs, with appropriate device sizing crucial to successful closure. Dogs of any body weight can be affected by PDA. To describe the range of ACDO sizes deployed in dogs of various body weights for improved procedural planning and inventory selection and to investigate for correlation between minimal ductal diameter (MDD) and body weight. A total of 152 dogs undergoing ACDO deployment between 2008 and 2016. Body weight, age, breed, sex, and MDD obtained by angiography (MDD-A), MDD obtained by transesophageal echocardiography (MDD-TEE), and ACDO size deployed were retrospectively evaluated. Correlation between body weight and ACDO size, MDD-A and MDD-TEE was poor, with R-squared values of 0.4, 0.36, and 0.3, respectively. Femoral artery diameter in the smallest population of dogs placed inherent limitations on the use of larger device sizes, with no limitations on the wide range of device sizes required as patient size increased. The most commonly used ACDO devices were size 3 through 6, representing 57% of the devices deployed within the entire study population. Patent ductus arteriosus anatomy varies on an individual basis, with poor correlation between MDD and body weight. Weight-based assumptions about expected ACDO device size for a given patient are not recommended. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.
Mądry, Wojciech; Karolczak, Maciej A
Authors discuss methods of echocardiographic diagnosis of the pulmonary sling with stenosis and hypoplasia of the left pulmonary artery and patent arterial duct with massive left-to-right shunt, based on a case of the newborn with resistant to treatment heart failure, with initial diagnosis of patent ductus arteriosus, referred to surgical treatment. The optimal echocardiographic views permitting establish diagnosis of the pulmonary sling were suggested. The special attention was paid to high parasternal and suprasternal views visualizing vessels of the upper mediastinum as well as characteristic differences between the normal and pathologic picture. The typical features of the echocardiogram suggesting pulmonary sling, like the lack of the left pulmonary artery in its expected position, and the abnormal branching pattern of the right pulmonary artery were indicated. The greatest diagnostic difficulties in visualization of the abnormal route of the left pulmonary artery were related to the presence of air-containing tissues, like lungs and central airways between the ultrasound probe and area of interest. The other was the masking influence of the large patent arterial duct, that may mimic the left pulmonary artery arising from the pulmonary trunk. The other entities requiring differentiation with sling, like aplasia of the left lung, the direct or indirect aortic origin of the left pulmonary artery, were discussed. The role of other visualization technics, like computed 3D tomography, and magnetic nuclear resonance, as well as direct visualization of central airways with bronchoscopy in establishing precise diagnosis were stressed.
Munayer Calderón, J; Aldana Pérez, T; San Luis Miranda, R; Maza Juárez, G; Lázaro Castillo, J L; Ramírez Reyes, H; Quintero, L R; Arias Monroy, L; Campos Gómez, A
We present the initial experience of closing of patent ductus arteriosus (PDA) with a new device; Gianturco-Grifka, at the General Hospital of The Medical Center "La Raza". The patient was a 4 year's old girl, in whom we detected continuous murmur in the second intercostal space, echocardiography showed a long conical patent ductus arteriosus 4.9 mm of diameter, systolic pressure of the pulmonary artery was 35 mm Hg with QP/QS 1.6:1. Hemodynamic study revealed a long conical ductus arteriosus 5 mm of diameter, type A1 from Krichenko classification. We proceeded to occlude the PDA with a Gianturco-Grifka device of 7 mm. Immediately after the PDA occlusion the shunt disappeared, there were no complications during the procedure. More cases are needed to determine long term benefits and limitations, of this procedure. However we conclude that technically it is easy to use. There is greater decrease of residual shunt that the one reported with other devices.
Lee, Jan Hau; Greenberg, Rachel G; Quek, Bin H; Clark, Reese H; Laughon, Matthew M; Smith, P Brian; Hornik, Christoph P
In very low birth weight infants, persistence of a patent ductus arteriosus results in morbidity and mortality. Therapies to close the ductus are effective, but clinical outcomes may depend on the accuracy of diagnosis and the timing of administration. The objective of the present study was to characterise the association between early echocardiography, therapy for patent ductus arteriosus, and outcomes in very low birth weight infants. This retrospective cohort study used electronic health record data on inborn infants of gestational age ⩽28 weeks and birth weight <1500 g who were discharged after day of life 7 from 362 neonatal ICU from 1997 to 2013. The primary outcome was death between day of life 7 and discharge. Secondary outcomes included bronchopulmonary dysplasia, necrotising enterocolitis, and grade 3 or 4 intraventricular haemorrhage. This study included a total of 48,551 infants with a median gestational age of 27 weeks (interquartile range 25, 28) and birth weight 870 g (706, 1050). Early echocardiography - that is, performed during days of life 2 to 6 - was performed in 15,971/48,551 (33%) infants, and patent ductus arteriosus was diagnosed in 31,712/48,551 (65%). The diagnosis was more common in infants who had undergone early echocardiography (14,549/15,971 [91%] versus 17,163/32,580 [53%], p<0.001). In multivariable analysis, early echocardiography was not associated with reduced mortality (odds ratio 0.97, 95% CI 0.89-1.05). Results were similar in the subset of infants who received therapy for patent ductus arteriosus (odds ratio 1.01, 95% CI 0.90-1.15). Early echocardiography was associated with an increased diagnosis of patent ductus arteriosus, but not with decreased mortality.
Godart, F; Rey, C; Francart, C; Vaksmann, G; Brevière, G M
The authors report their experience of percutaneous closure of large patent ductus arteriosus with the Amplatzer duct occluder. The age of the patients ranged from 3 months to 72 years (average 24 months) with body weights of 3.9 to 74 Kg (average 16 Kg). The smallest angiographic diameter of the ductus was 4.0 +/- 1.3 mm at angiography (range 1.8 to 6 mm). The occluder was inserted under local anaesthetic with control aortography in all but one case who required general anaesthesia. In two small babies, the implantation was performed after venous puncture alone with transthoracic echocardiographic monitoring. The implantation was successful in all but one case in which there was a distensible duct. Early angiographic control showed suppression of the shunt in 61% of patients. Secondary haemolysis was observed in one case and was corrected by a second catheterisation 4 days later, with occlusion of the duct with a balloon catheter. The patients were followed up clinically, radiologically and echocardiographically. Doppler echocardiography showed absence of a residual shunt in 24 patients (86%) one month after the procedure, in 25 patients (89%) 3 months after the procedure and in 26 patients (93%) one year after the procedure. Two patients were left with mild or moderate shunts 12 and 16 months after the attempted occlusion. No cases of aortic or pulmonary obstruction were observed. The authors conclude that the Amplatzer duct occluder is a reliable device for closing large patent ductus arteriosus. It may be proposed in young symptomatic children over 4 Kg in body weight. A high rate of occlusion is obtained with a minimal risk of complications.
Tefera, Endale; Teodori, Michael
Congenital or acquired aneurysm of the pulmonary artery (PA) is rare. Although aneurysms are described following surgical treatment of patent ductus arteriosus (PDA), occurrence of this lesion in association with PDA without previous surgery is extremely uncommon. An eight-year-old patient with PDA and aneurysm of the main PA is described in this report. Clinical diagnosis of PDA was made upon presentation. Diagnosis of PA aneurysm was suspected on chest x-ray and was confirmed on transthoracic echocardiography. Successful surgical resection of the aneurysm and division of the duct were performed under cardiopulmonary bypass. The patient did well on follow-up both from clinical and echocardiographic point of view.
Prescott, Stephanie; Keim-Malpass, Jessica
The incidence of hemodynamically significant patent ductus arteriosus (hsPDA) increases with decreasing gestational age and is associated with many common morbidities of extreme prematurity. Controversies remain surrounding the definition of hsPDA, the population of infants requiring treatment, the appropriate timing and method of treatment, and the outcomes associated with PDA and its therapies. This integrative literature review focuses on diagnostic and treatment recommendations derived from the highest levels of evidence. PubMed and CINAHL were searched using key words "neonatal" and "patent ductus arteriosus" to discover the highest levels of evidence surrounding diagnosis, treatment methods, and outcomes. The lack of consensus surrounding the diagnosis and clinical significance of PDA hinders meta-analysis across studies and confounds understanding of appropriate management strategies. Novel biomarkers, pharmaceutical choices, and transcatheter closure methods are expanding diagnostic and treatment options. Infants weighing less than 1000 g are at highest risk. Prophylactic closure is no longer recommended, although early asymptomatic therapy is still preferred by some to avoid prolonged pulmonary overcirculation or decreased renal and gut perfusion. Conservative treatment measures such as fluid restriction and diuretic administration have not consistently proven effective and are in some instances detrimental. Cyclooxygenase inhibitors are effective but have adverse renal and mesenteric effects. Oral ibuprofen is associated with lower instance of necrotizing enterocolitis. Well-defined staging criteria would aid in comparison and meta-analysis. Trials that include a control group that receives no therapy may help separate the outcomes associated with prematurity from those associated with PDA.
A rare case of acyanotic congenital heart disease, large patent ductus arteriosus with pre-ductal coarctation of descending thoracic aorta with patent ductus arteriosus closure and extra anatomical bypass grafting.
Wani, Zara; Tiwari, Deepak; Gehlot, Rajeev; Kumar, Deepak; Chhabra, Sushil; Sharma, Meenaxi
We report a case of 18-year-old female patient with large patent ductus arteriosus (PDA)-preductal coarctation of descending thoracic aorta. She underwent large PDA closure with a prosthetic graft from ascending aorta to descending thoracic aorta by mid-sternotomy on cardiopulmonary bypass machine under total hypothermic circulatory arrest.
Dornelles, Laura Vargas; Corso, Andréa Lúcia; Silveira, Rita de Cássia; Procianoy, Renato Soibelmann
To compare the efficacy of intravenous ibuprofen at high (20-10-10mg/kg/dose) and low doses (10-5-5mg/kg/dose) the closure of patent ductus arteriosus in preterm newborns. A cohort study with historical control of newborns that received high- and low-dose intravenous ibuprofen, from 2010 to 2013 in a neonatal intensive care unit, for closure of the patent ductus arteriosus, documented by echocardiography. Secondary outcomes included the number of ibuprofen cycles, incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, changes in renal function, and death. Seventy-seven patients received three doses of ibuprofen for the treatment of patent ductus arteriosus, with 33 receiving high-dose and 44 low-dose therapy. The ductus closed after the first cycle in 25 (56.8%) low-dose patients and in 17 (51.5%) high-dose patients (p>0.99). Sixteen patients received a second cycle of ibuprofen, and the ductus closed in 50% after low-dose and in 60% after high-dose therapy (p>0.99). Seven patients required surgery for ductus closure, 13.6% in the low-dose group and 3% in the high-dose group (p=0.22). Thirty-nine patients developed bronchopulmonary dysplasia, 50% in the low-dose group and 51.5% in the high-dose group (p>0.99). Twenty-two (50%) low-dose patients died vs. 15 (45.5%) high-dose patients (p=0.86). There was no difference in closure of the ductus arteriosus or occurrence of adverse effects between the two dose regimens. Copyright © 2016 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.
Bilici, Meki; Demir, Fikri; Akın, Alper; Türe, Mehmet; Balık, Hasan; Kuyumcu, Mahir
The aim of this study was to evaluate the feasibility, efficacy and safety of transcatheter closure of patent ductus arteriosus (PDA) with the Occlutech duct occluder (ODO) in children. We reviewed the clinical records of 71 patients who underwent percutaneous closure of PDA with an ODO between September 2014 and August 2016. The Occlutech duct occluder was applied to 71 patients during the study period (September 2014-August 2016), and the results were analyzed in this study. Forty-two of the patients were female and 29 male. The median age was 20.5 months (range, 6-194 months) and median weight was 16 kg (range, 6-68 kg). The PDA was classified as type A in 54 patients (76.1%), type E in 14 (19.7%), type C in 2 (2.8%) and type B in 1 (1.4%) based on the Krichenko classification. A standard ODO device was used for the transcatheter closure procedure in 66 patients and the long-shank ODO device in 5. In the echocardiographic measurement of PDA, the median smallest diameter was 2.7 mm (range, 1.5-7.0 mm), and in the angiographic measurement, the median smallest diameter was 2.5 mm (range, 1.5-6.5 mm). All 71 patients underwent successful PDA closure with the ODO. Angiography following the procedure showed complete closure in 47 patients (66.2%), mild residual shunt in 13 patients (18.3%) and a trivial shunt in 11 patients (15.5%). Color flow Doppler echocardiogpaphy at 24 h post-implantation showed that complete closure was achieved in 65 patients (91.5%), and 6 patients (8.5%) had mild residual shunt. All patients (100%) had complete closure at 30 days of follow-up. The results of this study showed that the Occlutech PDA occluder device is safe and effective in the closure of PDA. As the pulmonary artery side of the device is wider than the aortic side, protrusion toward the aortic side and embolization are prevented, but there is residual shunt in the early period, although this residual shunt disappeared after a few months.
Management of a right-to-left (“reversed”) patent ductus arteriosus (PDA) focuses on control of clinical signs associated with hyperviscosity due to erythrocytosis. Pentoxifylline therapy is presented as an adjunct to routine phlebotomies for the long-term clinical management of reversed PDA in a 10-year-old Chihuahua. PMID:27247468
Management of a right-to-left ("reversed") patent ductus arteriosus (PDA) focuses on control of clinical signs associated with hyperviscosity due to erythrocytosis. Pentoxifylline therapy is presented as an adjunct to routine phlebotomies for the long-term clinical management of reversed PDA in a 10-year-old Chihuahua.
Stempniewicz, Krzysztof; Walas, Wojciech
A case of left sided chylothorax in preterm infant is reported. The chylothorax was a complication of ligation of patent ductus arteriosus. Treatment consisted of parenteral nutrition, pleural taps, drainage of pleural cavity, mechanical ventilation and replacement of immunoprotein losses. When the lymph effusion reduced, enteral nutrition was started with a formula containing medium chain triglycerides. Treatment of this patient was successful.
Mani, Arya; Radhakrishnan, Jayaram; Farhi, Anita; Carew, Khary S; Warnes, Carole A; Nelson-Williams, Carol; Day, Ronald W; Pober, Barbara; State, Matthew W; Lifton, Richard P
Patent ductus arteriosus (PDA) is a common congenital heart disease that results when the ductus arteriosus, a muscular artery, fails to remodel and close after birth. A syndromic form of this disorder, Char syndrome, is caused by mutation in TFAP2B, the gene encoding a neural crest-derived transcription factor. Established features of the syndrome are PDA, facial dysmorphology, and fifth-finger clinodactyly. Disease-causing mutations are missense and are proposed to be dominant negative. Because only a small number of families have been reported, there is limited information on the spectrum of mutations and resulting phenotypes. We report the characterization of two kindreds (K144 and K145) with Char syndrome containing 22 and 5 affected members, respectively. Genotyping revealed linkage to TFAP2B in both families. Sequencing of TFAP2B demonstrated mutations in both kindreds that were not found among control chromosomes. Both mutations altered highly conserved bases in introns required for normal splicing as demonstrated by biochemical studies in mammalian cells. The abnormal splicing results in mRNAs containing frameshift mutations that are expected to be degraded by nonsense-mediated mRNA decay, resulting in haploinsufficiency; even if produced, the protein in K144 would lack DNA binding and dimerization motifs and would likely result in haploinsufficiency. Examination of these two kindreds for phenotypes that segregate with TFAP2B mutations identified several phenotypes not previously linked to Char syndrome. These include parasomnia and dental and occipital-bone abnormalities. The striking sleep disorder in these kindreds implicates TFAP2B-dependent functions in the normal regulation of sleep.
Chiang, Fu Tsai; Chu, Kuang Hua; Chen, Ching Yuan; Chen, Chien Yi; Pan, Lung Kwang
Taguchi's analysis was adopted to optimize the various factors referring to cardiac angiographic examination used to delineating ductus arteriosus in pediatric patients. Thirty-six pediatric patients, 9 male and 27 female, mean age of 6.5±4.7yrs, range 0.6 to 16.6 years were included in the study from January 2004 to April 2005. All patients had patent ductus arteriosus (PDA). Taguchi's L9 orthogonal array was used to generate nine different designs of angiographic levels. Four control factors were selected: a) body surface area (BSA), b) projection angle, c) catheter location, and d) the volume of contrast medium. Each factor was set to three different levels. Statistical analysis, signal-to-noise (S/N) ratio, and analysis of variance (ANOVA) were used to estimate the optimum level of each control factor and to analyze the effect of each factor. The optimal combinations that obtained the highest image quality for PDA were: a) at <0.65m(2) of BSA, b) right anterior oblique (RAO) position at 30(o) plus cranial position (Cr) at 15(o) and lateral view, c) catheter location at T2-3 and d) contrast medium volume: 1.0cc/kg. The projection angle was found to be the most significant factor to delineate ductus arteriosus using the ANOVA test and was not influenced by other factors. The setting of RAO at 30(o) plus Cr at 15(o) and the LAT view obtained the optimal image quality for PDA during descending aortography.
Avila-Alvarez, Alejandro; Serantes Lourido, Marta; Barriga Bujan, Rebeca; Blanco Rodriguez, Carolina; Portela-Torron, Francisco; Bautista-Hernandez, Victor
Surgical closure of patent ductus arteriosus in premature neonates is an aggressive technique and is not free of complications. A study was designed with the aim of describing our experience with a less invasive technique, the extra-pleural approach via a posterior minithoracotomy, and to compare the results with the classic transpleural approach. A retrospective cohort study was conducted on premature neonates on whom surgical closure of the ductus was performed during a ten-year period (March 2005 to March 2015). A comparison was made of the acute complications, the outcomes on discharge, and follow-up, between the extra-pleural approach and the classic transpleural approach. The study included 48 patients, 30 in the classical approach and 18 in the extra-pleural group. The demographic and pre-operative characteristics were similar in both groups. No differences were found between the 2 groups in the incidence of acute post-operative complications (56.6 vs. 44.4%), on the dependence on oxygen at 36 weeks (33.3 vs. 55.5%), or in hospital mortality (10 vs. 16.6%). As regards the short-term progress, the extra-pleural group required fewer days until the withdrawal of supplementary oxygen (36.3 vs. 28.9) and until hospital discharge (67.5 vs. 53.2), although only the time until extubation achieved a statistically significant difference (11.5 vs. 2.7, P=.03). The extra-plural approach by posterior minithoracotomy for the surgical closure of ductus in the premature infant is viable and could bring some clinical benefits in the short-term. Copyright © 2015 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.
Szatmári, A; Németh, J; Környei, L; Palik, I; Hartyánszky, I; Lozsádi, K
Authors report their results with transcatheter closure of patent arterial duct during a period of 1 year. Thirty patients underwent the procedure at the mean age of 5.22 yrs (range 5 mos-22.3 yrs) and mean bodyweight of 19.1 kg (range 5.8-73 kg). There were 9 males and 21 females. The diagnosis of the patent arterial duct was established by physical examination and noninvasive techniques. The procedures were attempted in all patients above 5 kg bodyweight with patent arterial duct and normal pulmonary artery pressure, irrespective of the shunt-size. All procedures were performed under general anesthesia in one session with the diagnostic cardiac catheterisation. Transcatheter closure was successful in 29 patients. In one patient the device embolized into the left pulmonary artery, snaring was unsuccessful, surgical closure of the patent duct and removal of the device took place uneventfully. Control aortography 15 minutes after the coil placement showed insignificant residual shunt through the patent duct in 8 patients (27%), while echocardiography at 1 month proved complete closure in all. The patients were followed by noninvasive methods. No mortality was observed. Authors emphasize the low risk and cost-effectiveness of the procedure. They stress the importance of the patients selection. Authors applied the technique for the first time and introduced it to the regular patient-care practice in Hungary.
Lee, Seung Jae; Han, Dong Kyun; Cho, Hwa Jin; Cho, Young Kuk; Ma, Jae Sook
The clinical features of ring chromosome 6 include central nervous system anomalies, growth retardation, facial dysmorphism and other congenital anomalies. Ring chromosome 6 occurs rarely and manifests as various phenotypes. We report the case of mosaic ring chromosome 6 by conventional karyotyping in a 7-day-old male infant diagnosed with a large patent ductus arteriosus (PDA) with hypoplasia of aortic valve and aortic arch. These have not been previously reported with ring chromosome 6. He recovered from heart failure symptoms after ligation of the PDA. He showed infantile failure to thrive and delayed milestone in a follow-up evaluation. To the best of our knowledge, this is the first report of a Korean individual with ring chromosome 6 and hemodynamically significant PDA.
El-Khuffash, Afif; Weisz, Dany E; McNamara, Patrick J
Despite a large body of scientific evidence on the management of premature infants with a patent ductus arteriosus controversy remains and neonatologists remain challenged for knowing which patient to treat, what is the most optimal timing of treatment and which treatments have a positive impact on both short-term and long-term outcomes. In this review article we discuss the increased body of evidence over the past 10 years, much of which questions the role of treatment and suggests the need to reconsider how haemodynamic significance is adjudicated. In addition, we discuss novel approaches to assessment and diagnosis, and highlight areas for future investigation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Agnetti, Aldo; Aldo, Agnetti; Carano, Nicola; Nicola, Carano; Tchana, Bertrand; Bertrand, Tchana; Allegri, Valentina; Valentina, Allegri; Saracino, Antonio; Antonio, Saracino; Squarcia, Umberto; Umberto, Squarcia; Hagler, Donald J; Donald J, Hagler
Transcatheter closure is the preferred method of treatment of patent ductus arteriosus (PDA). Detachable coils are widely used to close small ducts, while the Amplatzer duct occluder (ADO) is generally employed for moderate or large ducts. Recently a new device, the Amplatzer duct occluder II (ADO II), a nitinol flexible mesh, with a symmetrical design to provide high conformability for treatment of all types of PDA, has received the European Community mark approval. We report on one of the first experience, four cases (1 male, 3 female, age ranging from six months to seven years old) with different type and size of PDA treated with the new device. The use of this new Amplatzer duct occluder in our experience has the advantage of ease and safety of placement, conformability, stability, low profile catheters, adaptability for long ducts as in type E.
Satoda, M; Zhao, F; Diaz, G A; Burn, J; Goodship, J; Davidson, H R; Pierpont, M E; Gelb, B D
Char syndrome is an autosomal dominant trait characterized by patent ductus arteriosus, facial dysmorphism and hand anomalies. Using a positional candidacy strategy, we mapped TFAP2B, encoding a transcription factor expressed in neural crest cells, to the Char syndrome critical region and identified missense mutations altering conserved residues in two affected families. Mutant TFAP2B proteins dimerized properly in vitro, but showed abnormal binding to TFAP2 target sequence. Dimerization of both mutants with normal TFAP2B adversely affected transactivation, demonstrating a dominant-negative mechanism. Our work shows that TFAP2B has a role in ductal, facial and limb development and suggests that Char syndrome results from derangement of neural-crest-cell derivatives.
AOKI, Takuma; SUNAHARA, Hiroshi; SUGIMOTO, Keisuke; ITO, Tetsuro; KANAI, Eiichi; FUJII, Yoko
Infective endocarditis (IE) in dogs with cardiac shunts has not been reported previously. However, we encountered a dog with concurrent patent ductus arteriosus (PDA) and IE. The dog was a 1-year-old, 13.9-kg female Border collie and presented with anorexia, weight loss, pyrexia (40.4°C) and lameness. A continuous murmur with maximal intensity over the left heart base (Levine 5/6) was detected on auscultation. Echocardiography revealed a PDA and severe aortic stenosis (AS) caused by aortic-valve vegetative lesions. Corynebacterium spp. and Bacillus subtilis were isolated from blood cultures. The dog responded to aggressive antibiotic therapy, and the PDA was subsequently surgically corrected. After a series of treatments, the dog showed long-term improvement in clinical status. PMID:25391395
Lin, Ting-Wei; Tseng, Chih-Wei; Huang, Chi-Yao; Wang, Kuo-Yang; Liang, Kae-Woei
Few studies had reported syndromes that include patent ductus arteriosus (PDA) with Eisenmenger syndrome and congenital deafness clustered in male siblings without facial, skeletal, or mental abnormalities. Two brothers, who were deaf and had PDA with Eisenmenger complex, were first seen at our Cardiology clinic at the ages of 25 and 41, respectively. They presented with progressive dyspnea on exertion. Upon physical examination, both brothers had clubbing and/or cyanotic toes, normal fingers, and without facial, skeletal, ophthalmological, or mental abnormalities. Echocardiography and multidetector computed tomography revealed large PDAs in both brothers. Cardiac catheterization showed bidirectional shunting via the PDA. Familial clustering of Eisenmenger PDA and congenital deafness is rare. Further studies are warranted to define possible genetic links.
Chacko, Anith; Kock, Celeste; Joshi, Jayneel A; Mitchell, Lindi; Ahmad, Samia
Persistent ductus venosus as a cause of cholestatic jaundice is very rare. Treatment varies, but is usually reserved for infants in whom complications develop. We report a 5-week-old female infant with cholestatic jaundice caused by a patent ductus venosus and subsequent successful treatment via a transcatheter occlusion using a vascular plug device. PMID:27857466
Zhang, Jian-Fa; Huang, Ding; Yang, Yi-Ning; Gao, Xiao-Ming; Ma, Yi-Tong
1. The traditional antegrade wire-guided percutaneous transcatheter approach is not ideal in closing some types of patent ductus arteriosus (PDA) with abnormal morphology. The aim of the present study was to evaluate the efficacy of a retrograde wire-guided transcatheter approach for closure of some types of PDA using the Amplatzer duct occluder (ADO). 2. Nineteen patients with abnormal PDA morphology, including a smaller ostium of the side of the pulmonary artery compared with the side of the descending aorta, severe calcification or tortuosity, were included in the present study. In these patients, after the antegrade approach failed to cross a wire from the pulmonary artery via the PDA to the descending aorta, a retrograde guidewire was passed through the PDA in the opposite direction, from the descending aorta to the pulmonary artery, to establish a femoral arteriovenous loop that assisted the deployment of the ADO in all 19 patients. The size of the PDA, as determined by angiography, was 3.1 +/- 1.1 mm and the diameter of the ADO selected was 6.5 +/- 1.5 mm. 3. In 16 cases, systolic murmur disappeared after the procedure. Systolic murmur (less than Grade II) and angiographic residual shunt remained in three cases immediately after the procedure, but disappeared 1 month later. Mean pulmonary arterial pressure decreased from 33 +/- 8 to 22 +/- 4 mmHg in all 19 patients (P < 0.01). There were no complications during or after the procedure. 4. The retrograde wire-guided technique offers an alternative approach to facilitate closure of a PDA that cannot be achieved by traditional antegrade wire-guided methods due to morphological abnormalities in the PDA.
Bagheri, Mohammad Mehdi; Niknafs, Pedram; Sabsevari, Fatemeh; Torabi, Mohammad Hosein; Bahman Bijari, Bahareh; Noroozi, Elahe; Mossavi, Hamid
Background Patent ductus arteriosus (PDA) is a common cause of morbidity. The aim of this study was to compare the efficacy of oral Acetaminophen and oral Ibuprofen for the closure of patent ductus arteriosus (PDA) in preterm infants. Objectives This study demonstrated that, there was no significant difference between treatment of PDA with either oral Acetaminophen or oral Ibuprofen in preterm neonates. Patients and Methods This clinical trial, randomized study, enrolled 120 infants, with a gestational age of < 37 weeks, who were admitted in neonatal intensive care unit of Afzalipour hospital, Kerman, Iran, in 2014. PDA was confirmed echocardiographically. The trial was registered in Iranian registry of clinical trials (Reg. No. 25542). Sixty-seven infants received oral Acetaminophen (15mg/kg every six hours for three days) and 62 infants received Ibuprofen (an initial dose of 20 mg/kg, followed by 10 mg/kg at 24 and 48 hours). To evaluate the efficacy of the treatment, a second echocardiography was done after completing the treatment. Results After the first course of the treatment, PDA closed in 55 (82.1 %) patients who received oral Acetaminophen vs. 47 (75.8 %) of those given oral Ibuprofen (P = 0.38). After the second course of treatment, PDA closed in 50 % of oral Acetaminophen group and 73.3% of oral Ibuprofen group (P = 0.21). Conclusions This study demonstrated that, there was no significant difference between treatment of PDA with either oral Acetaminophen or oral Ibuprofen in preterm neonates. Oral Ibuprofen can effectively close PDA but is unfortunately associated with some adverse effects limiting its utility thus we studied an alternative drug with similar efficacy and less adverse effects. This study has recommends Acetaminophen with minimal complications for the treatment of PDA in preterm neonates instead of Ibuprofen. PMID:27713809
Park, Hye Won; Choi, Yong-Sung; Kim, Kyo Sun; Kim, Soo-Nyung
Background Chorioamnionitis has recently been reported as a risk factor for various neonatal diseases, including cerebral palsy, bronchopulmonary dysplasia, and necrotizing enterocolitis, but its effect on patent ductus arteriosus (PDA) is unclear. We performed a systematic review and meta-analysis to evaluate the effect of chorioamnionitis on PDA. Methods We searched PubMed, EMBASE, Cochrane Library, and KoreaMed databases using the terms: “intrauterine infection” or “maternal infection” or “antenatal infection” or “chorioamnionitis” or “placenta inflammation” or “placenta pathology” or “neonatal outcome” or “neonatal morbidity” or “PDA or patent ductus arteriosus” or “ductus arteriosus,” and “prematurity” or “very low birth weight infant.” Studies were included if they were randomized controlled trials, case–control studies, or cohort studies that included information relating to chorioamnionitis and PDA. Results Among 1,571 studies, a total of 23 studies (17,708 cases) were included in the meta-analysis to analyze the relationship between chorioamnionitis and PDA, except one study that only included PDA requiring surgical ligation. The association between chorioamnionitis and PDA was statistically significant (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.19, 1.72; P < 0.0001). In subgroup analysis, clinical chorioamnionitis was not associated with PDA (OR 1.28; 95% CI 1.00, 1.64, 1.790; P = 0.05), whereas histologic chorioamnionitis (OR 1.54; 95% CI 1.10, 2.15; P = 0.01) and chorioamnionitis diagnosed from both clinical and histologic findings (OR 1.75; 95% CI 1.07, 2.86; P = 0.03) showed significant associations with PDA. Chorioamnionitis did not increase the risk of PDA requiring surgical ligation (OR 1.23; 95% CI 0.69, 2.17; P = 0.48), and antenatal steroid use reduced the risk of PDA (OR 0.62; 95% CI 0.42, 0.90; P = 0.01) after chorioamnionitis. Conclusions The results from this meta-analysis support
Park, Hye Won; Choi, Yong-Sung; Kim, Kyo Sun; Kim, Soo-Nyung
Chorioamnionitis has recently been reported as a risk factor for various neonatal diseases, including cerebral palsy, bronchopulmonary dysplasia, and necrotizing enterocolitis, but its effect on patent ductus arteriosus (PDA) is unclear. We performed a systematic review and meta-analysis to evaluate the effect of chorioamnionitis on PDA. We searched PubMed, EMBASE, Cochrane Library, and KoreaMed databases using the terms: "intrauterine infection" or "maternal infection" or "antenatal infection" or "chorioamnionitis" or "placenta inflammation" or "placenta pathology" or "neonatal outcome" or "neonatal morbidity" or "PDA or patent ductus arteriosus" or "ductus arteriosus," and "prematurity" or "very low birth weight infant." Studies were included if they were randomized controlled trials, case-control studies, or cohort studies that included information relating to chorioamnionitis and PDA. Among 1,571 studies, a total of 23 studies (17,708 cases) were included in the meta-analysis to analyze the relationship between chorioamnionitis and PDA, except one study that only included PDA requiring surgical ligation. The association between chorioamnionitis and PDA was statistically significant (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.19, 1.72; P < 0.0001). In subgroup analysis, clinical chorioamnionitis was not associated with PDA (OR 1.28; 95% CI 1.00, 1.64, 1.790; P = 0.05), whereas histologic chorioamnionitis (OR 1.54; 95% CI 1.10, 2.15; P = 0.01) and chorioamnionitis diagnosed from both clinical and histologic findings (OR 1.75; 95% CI 1.07, 2.86; P = 0.03) showed significant associations with PDA. Chorioamnionitis did not increase the risk of PDA requiring surgical ligation (OR 1.23; 95% CI 0.69, 2.17; P = 0.48), and antenatal steroid use reduced the risk of PDA (OR 0.62; 95% CI 0.42, 0.90; P = 0.01) after chorioamnionitis. The results from this meta-analysis support an association between maternal chorioamnionitis and PDA in offspring.
Morville, Patrice; Akhavi, Ahmad
The advent of Amplatzer Duct Occluder II additional Size (ADOIIAS) provided the potential to close hemodynamic significant patent ductus arteriosus (HSPDA) and to analyze the feasibility, safety and efficacy of the device. Treatment of a patent ductus arteriosus (PDA) in very premature neonates is still a dilemma for the neonatalogist who has to consider its significance and has to choose among different treatment options. Because surgical ligation and medical therapy both have their drawbacks, interventional catheterization might provide an alternative means of closing HSPDA. Between September 2013 and June 2015, 32 premature infants with complications related to HSPDA defined by ultrasound (US) underwent transcatheter closure. The procedure was performed in the catheterization laboratory by venous cannulation without angiography. The position of the occluder was directed by X-ray and US. In particular we looked at procedural details, device size selection, complications, and short and mid-term outcomes. Thirty two premature infants, all of whom had clinical complications related to HSPDA, born at gestational ages ranging between 23.6 and 36 weeks (mean ± standard deviation 28 ± 3 weeks) underwent attempted transcatheter PDA closure using the ADOIIAS. Their mean age and weight at the time of procedure was 25 days (range 8-70 days) and 1373 g (range 680-2480 g), respectively. Ten infants weighed ≤1,000g. All ducts were tubular. The mean PDA and device waist diameters were 3.2 ± 0.6mm (range 2.2-4) and 4.4 ± 0.6 mm, respectively, and the mean PDA and device lengths 5.2 ± 2.0 mm (range 2-10) and 3.4 ± 1.3 mm. Median fluoroscopy and procedural times were 11 min (range 3-24) and 28 min (range 10-90), respectively. Complete closure was achieved in all but one patient. There was no device migration. A left pulmonary artery (LPA) obstruction developed in one patient. Five infants died. Four deaths were related to complications of
Wierzbicki, Mark A; Raines, Sarah B; Gordon, Sonya G; Criscione, John C; Saunders, Ashley B; Birch, Scott; Due, Bradley; Keller, Brandis; Nash, Landon D; Miller, Matthew W; Maitland, Duncan J
Patent ductus arteriosus (PDA) is a congenital cardiovascular defect in which a fetal connection between the aorta and pulmonary artery does not spontaneously close shortly after birth. If left uncorrected serious complications and even death can occur. Surgical ligation is the traditional treatment method; however, it is an invasive procedure, that motivates development of a minimally invasive option. Shape memory polymer (SMP) foams are unique materials that hold promise in the field of minimally invasive occlusion devices. In this work, a prototype nitinol foam cage (NFC) incorporating SMP foams has been designed and evaluated in multiple mechanical and in vitro verification tests. The NFC demonstrated acceptable fatigue resistance in a preliminary strut integrity test, withstanding one million cycles without complete strut fracture. Radial force analysis of both thick- and thin-walled prototype variations generated less vessel distension and wall tension in a vessel mimic compared to a commercial device. The NFCs exhibited negligible in vitro migration, comparable to that of a commercial device, using simplified, ideal models of PDA. Deployment characteristics of the prototypes were evaluated and compared to that of a commercial device when delivered into physiological models of PDA. During mock deployments, a veterinary cardiologist noted that, while deliverable, the thin-walled NFC prototype exhibited poor deployment characteristics, however the thick-walled NFC had deployment characteristics comparable to that of a commercial device. The promising results of this study warrant further investigation of the NFC device for canine PDA closure. Copyright © 2017 Elsevier Ltd. All rights reserved.
Zhu, Limin; Vranckx, Roger; Khau Van Kien, Philippe; Lalande, Alain; Boisset, Nicolas; Mathieu, Flavie; Wegman, Mark; Glancy, Luke; Gasc, Jean-Marie; Brunotte, François; Bruneval, Patrick; Wolf, Jean-Eric; Michel, Jean-Baptiste; Jeunemaitre, Xavier
We have recently described two kindreds presenting thoracic aortic aneurysm and/or aortic dissection (TAAD) and patent ductus arteriosus (PDA) and mapped the disease locus to 16p12.2-p13.13 (ref. 3). We now demonstrate that the disease is caused by mutations in the MYH11 gene affecting the C-terminal coiled-coil region of the smooth muscle myosin heavy chain, a specific contractile protein of smooth muscle cells (SMC). All individuals bearing the heterozygous mutations, even if asymptomatic, showed marked aortic stiffness. Examination of pathological aortas showed large areas of medial degeneration with very low SMC content. Abnormal immunological recognition of SM-MHC and the colocalization of wild-type and mutant rod proteins in SMC, in conjunction with differences in their coimmunoprecipitation capacities, strongly suggest a dominant-negative effect. Human MYH11 gene mutations provide the first example of a direct change in a specific SMC protein leading to an inherited arterial disease.
Pishgoo, Bahram; Saburi, Amin; Khosravi, Arezoo
BACKGROUND Patent ductus arteriosus (PDA) at childhood is one of the five major and frequent congenital abnormalities, but it can be rarely seen in adults. Pulmonary hypertension (PHTN) and other presentations such as heart failure and edema are the identified complications of longstanding PDA, but adult case with no permanent heart symptoms and PHTN was rare. We reported a rare case of with an obvious PDA and normal pulmonary pressure. CASE REPORT A 61-year-old woman presented with dyspnea (New York Heart Association class 2), chest pain, and lower limb edema. Echocardiogram showed; normal left ventricular chamber size and function, normal size of both atria. Furthermore, an obvious PDA (diameter = 6-7 mm) connecting the aortic arch to the pulmonary artery was reported in echocardiography. No lung congestion and evidence for PHTN was reported by computed tomographic angiography [Pulmonary capillary wedge pressure (PCWP) = 30 mmHg]. The patient was treated with antihypertensive drugs and after 1 and 3 months follow-up, edema and other symptoms were resolved. CONCLUSION Finally, we conclude that PDA in adulthood can present with nonspecific cardiovascular symptoms, and it seems that PHTN is not a fixed echocardiographic finding in these patients. PMID:25477985
Shafi, Nabil A; Singh, Gagan D; Smith, Thomas W; Rogers, Jason H
To describe a novel balloon sizing technique used during adult transcatheter patent ductus arteriosus (PDA) closure. In addition, to determine the clinical and procedural outcomes in six patients who underwent PDA balloon sizing with subsequent deployment of a PDA occluder device. Transcatheter PDA closure in adults has excellent safety and procedural outcomes. However, PDA sizing in adults can be challenging due to variable defect size, high flow state, or anatomical complexity. We describe a series of six cases where the balloon- pull through technique was successfully performed for PDA sizing prior to transcatheter closure. Consecutive adult patients undergoing adult PDA closure at our institution were studied retrospectively. A partially inflated sizing balloon was pulled through the defect from the aorta into the pulmonary artery and the balloon waist diameter was measured. Procedural success and clinical outcomes were obtained. Six adult patients underwent successful balloon pull-through technique for PDA sizing during transcatheter PDA closure, since conventional angiography often gave suboptimal opacification of the defect. All PDAs were treated with closure devices based on balloon PDA sizing with complete closure and no complications. In three patients that underwent preprocedure computed tomography, the balloon size matched the CT derived measurements. The balloon pull-through technique for PDA sizing is a safe and accurate sizing modality in adults undergoing transcatheter PDA closure. © 2017 Wiley Periodicals, Inc.
We reported a 21-year-old patient with strict descending aorta coarctation and small post-ductal patent ductus arteriosus, complicated with abortion and hypertension. The patient was successfully treated by endovascular stent-graft with a single cardiac catheterization. Endovascular stent-graft is an easy, safe, and reliable intervention for the treatment of strict descending aorta coarctation and small post-ductal patent ductus arteriosus. PMID:20181210
Stauthammer, Christopher D; Olson, Janet; Leeder, Damon; Hohnadel, Kristin; Hanson, Melissa; Tobias, Anthony H
To develop procedural methodology and assess the safety, utility and effectiveness of a low profile Amplatz(®) canine duct occluder (ACDO) prototype in dogs deemed too small to undergo ductal occlusion with the commercially-available ACDO device. Twenty-one dogs with left-to-right shunting patent ductus arteriosus (PDA). Dogs were ≥1.5 kg but considered too small to accommodate a 6 Fr catheter or 4 Fr sheath within the femoral artery. Prospective canine study using a low profile ACDO prototype delivered through a 4 Fr catheter via a femoral arterial approach. Procedural methods, fluoroscopy time, perioperative complications, and residual ductal flow were evaluated, and angiographic ductal morphology and dimensions were tabulated. All 21 dogs underwent successful ductal occlusion using the prototype device, 4 Fr catheter, and right femoral artery approach. No perioperative complications or device embolization occurred. The median minimal ductal diameter was 1.9 mm (range, 0.4-3.4), and the median device size deployed was 4 mm (range, 3-6). Complete ductal occlusion was noted in 17 dogs (81%) on post-deployment angiography. Twenty dogs (95%) had no residual flow on echocardiography performed the following day. In the 17 dogs (81%) that returned for a long-term (≥3months) follow-up evaluation, all had complete ductal occlusion based on echocardiography. The low profile ACDO prototype is a safe and effective method of PDA occlusion in the small dog. The deployment procedure appears of similar technical difficulty to the commercially available ACDO. Copyright © 2015 Elsevier B.V. All rights reserved.
Novo-Matos, José; Hurter, Karin; Bektas, Rima; Grest, Paula; Glaus, Tony
Right-sided congestive heart failure (CHF) developed secondary to severe pulmonary hypertension (PH) in an 8-year-old cat with a left-to-right shunting patent ductus arteriosus (PDA). Vascular reactivity was tested prior to shunt ligation by treatment with oxygen and sildenafil. This treatment was associated with a significant decrease in pulmonary artery pressure as assessed by echocardiography. Subsequently surgical shunt ligation was planned. During thoracotomy, digital occlusion of the PDA was performed for 10 min with simultaneous catheter measurement of right ventricular pressure, which did not increase. Permanent shunt ligation resulted in a complete and sustained clinical recovery. A lung biopsy sample obtained during thoracotomy demonstrated histopathological arterial changes typical of PH. Cats can develop clinically severe PH and right-sided CHF secondary to a left-to-right PDA even at an advanced age. Assuming there is evidence of pulmonary reactivity, PDA occlusion might be tolerated and can potentially produce long-term clinical benefits.
Frydrychowicz, Alex; Bley, Thorsten A; Dittrich, Sven; Hennig, Jürgen; Langer, Mathias; Markl, Michael
Comprehensive flow velocity acquisition based on time-resolved three-dimensional phase-contrast CMR with three-directional velocity encoding was employed to assess arterial hemodynamics in a patient with a large patent ductus arteriosus with Eisenmenger's physiology. Computer-aided visualization of blood flow characteristics provided detailed information about temporal and spatial distribution of left and right ventricular outflow. Main findings included the depiction of the location and extent of two flow channels for systolic aortic filling, a relatively large amount of pulmonary artery to aortic flow confirming Eisenmenger's physiology, and a slight phase difference between right and left ventricular ejection. These results illustrate the feasibility of flow sensitive 3D CMR at 3T in relation to a potential field of clinical application such as congenital heart disease with abnormal vascular connections or shunt flow.
Hong, Haifa; Ye, Lincai; Chen, Huiwen; Xia, Yu; Liu, Yue; Liu, Jinfen; Lu, Yanan; Zhang, Haibo
We aimed to evaluate global changes in protein expression associated with patency by undertaking proteomic analysis of human constricted and patent ductus arteriosus (DA). Ten constricted and 10 patent human DAs were excised from infants with ductal-dependent heart disease during surgery. Using isobaric tags for relative and absolute quantitation-based quantitative proteomics, 132 differentially expressed proteins were identified. Of 132 proteins, voltage-gated sodium channel 1.3 (SCN3A), myosin 1d (Myo1d), Rho GTPase activating protein 26 (ARHGAP26), and retinitis pigmentosa 1 (RP1) were selected for validation by Western blot and quantitative real-time polymerase chain reaction analyses. Significant upregulation of SCN3A, Myo1d, and RP1 messenger RNA, and protein levels was observed in the patent DA group (all P ≤ 0.048). ARHGAP26 messenger RNA and protein levels were decreased in patent DA tissue (both P ≤ 0.018). Immunohistochemistry analysis revealed that Myo1d, ARHGAP26, and RP1 were specifically expressed in the subendothelial region of constricted DAs; however, diffuse expression of these proteins was noted in the patent group. Proteomic analysis revealed global changes in the expression of proteins that regulate oxygen sensing, ion channels, smooth muscle cell migration, nervous system, immune system, and metabolism, suggesting a basis for the systemic regulation of DA patency by diverse signaling pathways, which will be confirmed in further studies.
Sivanandan, Sindhu; Agarwal, Ramesh
Opinions are divided regarding the management of a persistently patent ductus arteriosus (PDA). Some of the adverse effects associated with a large hemodynamically significant duct, including prolonged ventilation, pulmonary hemorrhage, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and mortality, indicate that active management of infants with large ductal shunts may sometimes be necessary. Indomethacin and ibuprofen are the two US FDA-approved cyclooxygenase (COX) inhibitors used for the closure of a ductus in preterm babies. Both these drugs are effective in 70-80% of extremely low birthweight infants. Treatment with COX inhibitors may be associated with renal impairment, gastrointestinal hemorrhage, NEC, and spontaneous intestinal perforation when given concurrently with steroids, as well as changes in cerebrovascular auto-regulation. Ibuprofen appears to be a better choice for PDA closure, with a better side effect profile and efficacy that equals that of indomethacin. However, long-term outcome studies of ibuprofen are lacking, and prophylactic ibuprofen is ineffective in decreasing severe IVH. The choice of one drug over the other also depends on local availability of both drugs and the intravenous or enteral preparation. The oral preparation of ibuprofen appears as effective as the intravenous preparation. The use of paracetamol to close a hemodynamically significant PDA has increased in recent years. Paracetamol also decreases prostacyclin synthesis; however, unlike COX inhibitors, it does not have a peripheral vaso-constrictive effect and can be given to infants with contraindications to non-steroidal anti-inflammatory drugs. It appears to have similar efficacy based on limited data available from randomized trials. Until more data are available on efficacy, safety, and long-term outcomes, it cannot be recommended as the first choice.
Wickremasinghe, Andrea C; Rogers, Elizabeth E; Piecuch, Robert E; Johnson, Bridget C; Golden, Suzanne; Moon-Grady, Anita J; Clyman, Ronald I
To examine whether a change in the approach to managing persistent patent ductus arteriosus (PDA) from early ligation to selective ligation is associated with an increased risk of abnormal neurodevelopmental outcomes. In 2005, we changed our PDA treatment protocol for infants born at ≤27 6/7 weeks' gestation from an early ligation approach, with prompt PDA ligation if the ductus failed to close after indomethacin therapy (period 1: January 1999 to December 2004), to a selective ligation approach, with PDA ligation performed only if specific criteria were met (period 2: January 2005 to May 2009). All infants in both periods received prophylactic indomethacin. Multivariate analysis was used to compare the odds of a composite abnormal neurodevelopmental outcome (Bayley Mental Developmental Index or Cognitive Score <70, cerebral palsy, blindness, and/or deafness) associated with each treatment approach at age 18-36 months (n = 224). During period 1, 23% of the infants in follow-up failed indomethacin treatment, and all underwent surgical ligation. During period 2, 30% of infants failed indomethacin, and 66% underwent ligation after meeting prespecified criteria. Infants treated with the selective ligation strategy demonstrated fewer abnormal outcomes than those treated with the early ligation approach (OR, 0.07; P = .046). Infants who underwent ligation before 10 days of age had an increased incidence of abnormal neurodevelopmental outcome. The significant difference in outcomes between the 2 PDA treatment strategies could be accounted for in part by the earlier age of ligation during period 1. A selective ligation approach for PDAs that fail to close with indomethacin therapy is not associated with worse neurodevelopmental outcomes at age 18-36 months. Copyright © 2012 Mosby, Inc. All rights reserved.
Semberova, Jana; Sirc, Jan; Miletin, Jan; Kucera, Jachym; Berka, Ivan; Sebkova, Sylva; O'Sullivan, Sinead; Franklin, Orla; Stranak, Zbynek
Patent ductus arteriosus (PDA) remains a challenging issue in very low birth weight (VLBW) infants, and its management varies widely. Our aim in this study was to document the natural course of ductus arteriosus in a cohort of VLBW infants who underwent conservative PDA management with no medical or surgical intervention. A retrospective cohort study conducted in 2 European level-3 neonatal units. A total of 368 VLBW infants were born within the study period. Two hundred and ninety-seven infants were free of congenital malformations or heart defects and survived to hospital discharge. Out of those, 280 infants received truly conservative PDA management. In 237 (85%) of nontreated infants, the PDA closed before hospital discharge. The Kaplan-Meier model was used to document the incidence proportion of PDA closure over time for different gestational age groups. The median time to ductal closure was 71, 13, 8, and 6 days in <26+0, 26+0 to 27+6, 28+0 to 29+6, and ≥30 weeks, respectively. For different birth weight groups, the median was 48, 22, 9, and 8 days in infants weighing <750, 750 to 999, 1000 to 1249, and 1250 to 1500 g, respectively. No statistically significant relationship was found between PDA closure before hospital discharge and neonatal morbidities. The likelihood of PDA spontaneous closure in VLBW infants is extremely high. We provide in our findings a platform for future placebo-controlled trials focused on the smallest and youngest infants. Copyright © 2017 by the American Academy of Pediatrics.
Letshwiti, J B; Semberova, J; Pichova, K; Dempsey, E M; Franklin, O M; Miletin, J
Treatment of the patent ductus arteriosus (PDA) in the preterm infant remains contentious. There are numerous options of the PDA management from early targeted treatment, late (symptomatic) treatment to no treatment at all. To evaluate a three different PDA management approaches in very low birth weight (VLBW) infants. A retrospective observational time series study of three cohorts of VLBW infants born between 2004 and 2011. Infants in Symptomatic Treatment Group (STG) were echocardiographically evaluated when clinical signs suggestive of a PDA were present and treated if a haemodynamically significant PDA was confirmed. Early Targeted Group (ETG) underwent echocardiography within the first 48h and infants received ibuprofen if a large PDA was present. Conservative Treatment Group (CTG) was screened by echocardiography on day seven of life; patients with PDA were managed with increased positive end expiratory pressure and fluid restriction as a first line intervention. The primary outcome was medical and surgical treatment in the three time periods. Secondary outcomes included mortality, severe periventricular and intraventricular haemorrhage, respiratory distress syndrome and chronic lung disease. There were 138 infants diagnosed with PDA; 52 infants in STG, 52 infants in ETG and 34 infants in CTG. Ibuprofen therapy and ligation were less frequent in CTG. There was significantly decreased incidence of chronic lung disease in CTG compared to STG (18% vs. 51%; p=0.003) and to ETG (18% vs. 46%; p=0.02). There was no difference in the other short term outcomes. Conservative treatment of persistent ductus arteriosus in VLBW infants is a feasible option and future randomized trials of conservative management are warranted. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Zahn, Evan M; Nevin, Phillip; Simmons, Charles; Garg, Ruchira
To describe a new technique for transcatheter patent ductus arteriosus (PDA) closure in extremely preterm infants using commercially available technology. PDA in premature neonates continues to be a significant clinical problem contributing importantly to both morbidity and mortality. Surgical ligation and medical therapy both have their drawbacks. Hospital records and catheterization reports of all premature neonates (< 32 weeks gestation) who underwent transcatheter PDA closure between March 2013 and February 2014 were reviewed. Particular attention was paid to procedural details, complications, and short and mid-term outcomes. Six premature infants born at gestational ages ranging between 26 and 31 weeks (median, 26 weeks) underwent attempted transcatheter PDA closure using the Amplatzer Vascular Plug II (AVP II). Median age and weight was 21.5 days (16-80 days) and 1,180 g (870-2,240 g), respectively. Fluoroscopy and echocardiography were used to guide device. Contrast angiography was not used in any patient. Complete closure was achieved in all patients with no major procedural complications. Median fluoroscopy and procedural times were 9.4 (0-19.5) and 51.5 (33-87) min, respectively. All patients were alive at the time of this report. There were no instances of device migration, left pulmonary artery (LPA), or aortic coarctation. This preliminary study demonstrates that transcatheter PDA closure can be successfully performed in extremely preterm neonates using currently available technology with a high success rate and a low incidence of complications. This report also describes a novel transvenous approach using a combination of echocardiography and judicious use of fluoroscopy to avoid arterial access in this fragile patient population. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.
Niu, Mary C; Mallory, George B; Justino, Henri; Ruiz, Fadel E; Petit, Christopher J
Treatment of the large patent ductus arteriosus (PDA) in the setting of pulmonary hypertension (PH) is challenging. Left patent, the large PDA can result in irreversible pulmonary vascular disease. Occlusion, however, may lead to right ventricular failure for certain patients with severe PH. Our center has adopted a staged management strategy using medical management, noninvasive imaging, and invasive cardiac catheterization to treat PH in the presence of a large PDA. This approach determines the safety of ductal closure but also leverages medical therapy to create an opportunity for safe PDA occlusion. We reviewed our experience with this approach. Patients with both severe PH and PDAs were studied. PH treatment history and hemodynamic data obtained during catheterizations were reviewed. Repeat catheterizations, echocardiograms, and clinical status at latest follow-up were also reviewed. Seven patients had both PH and large, unrestrictive PDAs. At baseline, all patients had near-systemic right ventricular pressures. Nine catheterizations were performed. Two patients underwent 2 catheterizations each due to poor initial response to balloon test occlusion. Six of 7 patients exhibited subsystemic pulmonary pressures during test occlusion and underwent successful PDA occlusion. One patient did not undergo PDA occlusion. In follow-up, 2 additional catheterizations were performed after successful PDA occlusion for subsequent hemodynamic assessment. At the latest follow-up, the 6 patients who underwent PDA occlusion are well, with continued improvement in PH. Five patients remain on PH treatment. A staged approach to PDA closure for patients with severe PH is an effective treatment paradigm. Aggressive treatment of PH creates a window of opportunity for PDA occlusion, echocardiography assists in identifying the timing for closure, and balloon test occlusion during cardiac catheterization is critical in determining safety of closure. By safely eliminating the large PDA
Jhaveri, Nami; Soll, Roger F; Clyman, Ronald I
We hypothesized that there is a significant relationship between a neonatologist's belief that feedings must be stopped in the presence of a patent ductus arteriosus (PDA) and his or her willingness to ligate a PDA. We administered the same survey questionnaire to two separate populations of neonatologists to assess their beliefs regarding PDA treatment practices. Although >90% of U.S. and non-U.S. neonatologists reported that they would ligate a PDA when infants with birth weights <900 g required mechanical ventilation (and indomethacin was contraindicated or had failed to close the PDA), U.S. neonatologists reported that they were significantly more likely to ligate a PDA when less respiratory support was required. U.S. neonatologists were also more likely to stop feedings when a PDA was present. The reported likelihood that a neonatologist would ligate a PDA in infants who did not require mechanical ventilation was significantly increased if the neonatologist believed that feedings had to be stopped because of the PDA. After controlling for the belief that "feedings must be stopped in the presence of a PDA," the significant difference between U.S. and non-U.S. neonatologists, in their reported desire to ligate infants who did not require mechanical ventilation, was no longer present.
Oncel, Mehmet Yekta; Erdeve, Omer
Patent ductus arteriosus (PDA) is the most common cardiac condition in preterm infants. The most commonly used drugs for this purpose are cyclooxygenase inhibitors, mainly indomethacin and ibuprofen, which block the conversion of arachidonic acid to prostaglandins. On the other hand, several adverse effects have been reported with such medications, including peripheral vasoconstriction, gastrointestinal bleeding and perforation, weakened platelet aggregation, hyperbilirubinemia and renal failure. The role of oral paracetamol as an alternative treatment for the closure of PDA has gained importance in recent years. In this review, we aimed to determine safety of therapeutic drugs used in management of PDA in preterm infants rather than their efficacy in ductal closure. Two worldwide commonly used therapeutics (indomethacin and ibuprofen) and a new alternative medication as paracetamol are discussed. Ibuprofen seems to be the first choice due to its higher safety profile, as it is associated with fewer gastrointestinal and renal side effects than indomethacin. Recent studies suggest that paracetamol may be a medical alternative in the management of PDA with low adverse events and side effects.
Lai, Lillian SW; McCrindle, Brian W
OBJECTIVES: To determine variations in neonatology practice regarding the diagnosis and management of patent ductus arteriosus (PDA) in premature infants. DESIGN: Standardized telephone interview of preferences and practices. SUBJECTS: Canadian neonatologists in active clinical practice. RESULTS: Of 136 eligible Canadian neonatologists, 100 respondents (74%) estimated the proportion of infants with suspected PDA who have echocardiography to be a median of 80% (range 0% to 100%), with considerable variation both within and between centres. Only two centres had written guidelines. More recent medical school graduates were significantly more likely to use echocardiography. Increased use of echocardiography was also significantly related to increased availability. Fluid restriction and indomethacin was used as initial therapy by 89% of respondents, with the indomethacin dose standardized for 83%; surgical ligation was used when indomethacin therapy was contraindicated or had failed. Personal guidelines directed decisions regarding therapy for the majority of neonatologists. CONCLUSIONS: Among Canadian neonatologists, there is considerable variation regarding practices related to the diagnosis and management of PDA in premature infants. This variation may potentially affect the cost effectiveness of care for these patients. PMID:20401223
Chock, Valerie Y; Goel, Veena V; Palma, Jonathan P; Luh, Thomas M; Wang, Nichole A; Gaskari, Shabnam; Punn, Rajesh; Silverman, Norman H; Benitz, William E
Objective This historical cohort study investigated how a shift toward a more conservative approach of awaiting spontaneous closure of the patent ductus arteriosus (PDA) in preterm infants has affected neonatal outcomes and resource utilization. Methods We retrospectively studied very low birth weight infants diagnosed with a PDA by echocardiogram (ECHO) in 2006-2008 (era 1), when medical or surgical PDA management was emphasized, to those born in 2010-2012 (era 2) when conservative PDA management was encouraged. Multiple regression analyses adjusted for gestational age were performed to assess differences in clinical outcomes and resource utilization between eras. Results More infants in era 2 (35/89, 39%) compared with era 1 (22/120, 18%) had conservative PDA management (p < 0.01). Despite no difference in surgical ligation rate, infants in era 2 had ligation later (median 24 vs. 8 days, p < 0.0001). There was no difference in clinical outcomes between eras, while number of ECHOs per patient was the only resource measure that increased in era 2 (median 3 vs. 2 ECHOs, p = 0.003). Conclusion In an era of more conservative PDA management, no increase in adverse clinical outcomes or significant change in resource utilization was found. Conservative PDA management may be a safe alternative for preterm infants.
Nasef, Nehad; Nour, Islam
Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise. PMID:24455715
Chock, Valerie Y; Ramamoorthy, Chandra; Van Meurs, Krisa P
Preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA) are at risk for fluctuations in cerebral blood flow, but it is unclear how different hsPDA treatment strategies may affect cerebral oxygenation. To compare regional cerebral oxygen saturation (rSO(2)) as measured by near-infrared spectroscopy (NIRS) in very low birth weight (VLBW) infants with a hsPDA treated with conservative management, indomethacin, or surgical ligation. This prospective observational study enrolled 33 VLBW infants with a hsPDA diagnosed by echocardiogram and 12 control VLBW infants without a hsPDA. Infants had NIRS cerebral monitoring applied prior to conservative treatment, indomethacin, or surgical ligation. Cranial ultrasound and magnetic resonance imaging data were also collected. Infants undergoing surgical ligation had a greater time period with >20% change in rSO(2) from baseline (30%) compared to those receiving indomethacin (7.4%, p = 0.001) or control infants without a hsPDA (2.6%, p = 0.0004). NIRS measures were not associated with abnormal neuroimaging in this small cohort. These findings suggest that infants requiring surgical ligation for a hsPDA are at high risk for significant changes in cerebral oxygenation, whereas those receiving either indomethacin or conservative management maintain relatively stable cerebral oxygenation levels. Additional research is necessary to determine if NIRS monitoring identifies infants with a hsPDA at highest risk for brain injury. Copyright © 2011 S. Karger AG, Basel.
Haffajee, Jessica A; Finley, John J; Brooks, Erica L; Kuvin, Jeffrey T; Patel, Ayan R
Left ventricular (LV) apical hypoplasia is an unusual, recently identified cardiomyopathy, whose clinical course is uncertain. In this report, we describe a case of this cardiomyopathy occurring in an asymptomatic 50-year-old male with a remote history of a surgically corrected patent ductus arteriosus (PDA), primarily using transthoracic echocardiography (TTE) to illustrate the imaging characteristics. This patient had been referred to our institution for an abnormal electrocardiogram, and TTE subsequently (Figure 1) revealed a dilated left ventricle with moderately to severely reduced function; LV ejection fraction was 30% by two- and three-dimensional quantification. The left ventricle had a spherical appearance with a thin-walled, truncated, and akinetic distal LV. The right ventricle appeared elongated and was noted to wrap around the distal left ventricle, but right ventricular systolic function was normal. There were no significant valvular abnormalities, and no evidence of residual PDA flow. Subsequent cardiac magnetic resonance (CMR) imaging confirmed these findings (Figure 1). The TTE and CMR findings seen in this patient are consistent with LV apical hypoplasia. Until now, this cardiomyopathy has been described only as an isolated congenital anomaly primarily using CMR and cardiac computed tomography. To our knowledge, this is the first reported case of LV apical hypoplasia in conjunction with another congenital cardiac abnormality, and the findings demonstrate that the distinctive appearance of this cardiomyopathy can be easily identified with echocardiography. As more cases are recognized and patients are followed over time, the natural history and optimal treatment for this cardiomyopathy may be further elucidated.
Kluckow, Martin; Jeffery, Michele; Gill, Andy; Evans, Nick
Failure of closure of the patent ductus arteriosus (PDA) may be associated with harm. Early cardiac ultrasound-targeted treatment of a large PDA may result in a reduction in adverse outcomes and need for later PDA closure with no increase in adverse effects. Multicentre, double-blind, placebo-controlled randomised trial. Three neonatal intensive care units in Australia. Eligible infants born <29 weeks were screened for a large PDA and received indomethacin or placebo before age 12 h. Death or abnormal cranial ultrasound. The trial ceased enrolment early due to lack of availability of indomethacin. 164 eligible infants were screened before 12 h; of the 92 infants with a large PDA, 44 were randomised to indomethacin and 48 to placebo. There was no difference in the main outcome between groups. Infants receiving early indomethacin had significantly less early pulmonary haemorrhage (PH) (2% vs 21%), a trend towards less periventricular/intraventricular haemorrhage (PIVH) (4.5% vs 12.5%) and were less likely to receive later open-label treatment for a PDA (20% vs 40%). The 72 non-randomised infants with a small PDA were at low risk of pulmonary haemorrhage and had an 80% spontaneous PDA closure rate. Early cardiac ultrasound-targeted treatment of a large PDA is feasible and safe, resulted in a reduction in early pulmonary haemorrhage and later medical treatment but had no effect on the primary outcome of death or abnormal cranial ultrasound. Australian New Zealand Clinical Trials Registry (ACTRN12608000295347).
Fortescue, Elizabeth B.; Lock, James E.; Galvin, Teresa; McElhinney, Doff B.
Patent ductus arteriosus (PDA) accounts for approximately 10% of all congenital heart diseases, with an incidence of at least 2–4 per 1000 term births. Closure of the large, hemodynamically significant PDA is established as the standard of care, and can be performed safely and effectively using either surgical or transcatheter methods. The appropriate management of the very small, hemodynamically insignificant PDA is less clear. Routine closure of such defects has been advocated to eliminate or reduce the risk of infective endocarditis (IE). However, the risk of IE in patients with a small PDA appears to be extremely low, and IE is treatable. Although closure of the small PDA is generally safe and technically successful, it is unknown whether this treatment truly improves the risk : benefit balance compared with observation. In this article, we review the published literature on the natural history and treatment outcomes in individuals with a PDA, the epidemiology and outcomes of IE, particularly in association with PDA, and the rationale and evidence for closure of the very small PDA. PMID:20653702
Chung, Yoon Sang; Cho, Dai Yun; Kang, Hyun; Lee, Na Mi; Hong, Joonhwa
Patent ductus arteriosus (PDA) ligation is usually performed by congenital cardiac surgeons. However, due to the uneven distribution of congenital cardiac surgeons in South Korea, many institutions depend solely on adult cardiac surgeons for congenital cardiac diseases. We report the outcomes of PDA ligations performed by adult cardiac surgeons at our institution. The electronic medical records of 852 neonates at Chung-Ang University Hospital, Seoul, South Korea from November 2010 to May 2014 were reviewed to identify patients with PDA. Of the 111 neonates with a diagnosis of PDA, 26 (23%) underwent PDA ligation. PDAs were ligated within 28 days of birth (mean, 14.5±7.8 days), and the mean gestational age of these patients was 30.3±4.6 weeks (range, 26 to 40 weeks) with a mean birth weight of 1,292.5±703.5 g (range, 480 to 3,020 g). No residual shunts through the PDA were found on postoperative echocardiography. There was 1 case of 30-day mortality (3.8%) due to pneumonia, and 6 cases of in-hospital mortality (23.1%) after 30 days, which is comparable to results from other centers with congenital cardiac surgery programs. Although our outcomes may not be generalizable to all hospital settings without a congenital cardiac surgery program, in select centers, PDA ligations can be performed safely by adult cardiac surgeons if no congenital cardiac surgery program is available.
Andescavage, Nickie N; Metzler, Marina; Govindan, Vedavalli; Al-Shargabi, Tareq; Nath, Dilip S; Krishnan, Anita; Massaro, An; Wang, Yunfei; duPlessis, Adre J; Govindan, R B
Background Patent ductus arteriosus (PDA) is a common complication of prematurity and a risk factor for poor outcome. Infants undergoing surgical PDA ligation are at highest risk for neurodevelopmental injury. Autonomic dysfunction has been described in premature infants with PDA. Aim To interrogate the autonomic nervous system by analysis of advanced heart rate variability (HRV) metrics before and after surgical closure of the PDA. Study Design Prospective, observational study. Subjects Twenty-seven infants born before 28 weeks' gestation were included in this study. Methods Continuous electrocardiogram data were sampled at a rate of 125 Hz for a total of 6 hours before and 6 hours after 30 hours of surgical closure. HRV was determined by detrended fluctuation analysis to calculate the short and long root mean square (RMS(L) and RMS(S)) and α components at two time scales (long and short). Results Gestational age (GA) was positively associated with RMSL, RMSS, and αS and was negatively associated with αL. There was no difference between RMSs, RMSL, αS, or αL before and after surgery; however, median heart rate was lower after surgery (p < 0.01). Conclusion Advancing GA is highly associated with increasing HRV; however, surgical ligation does not affect HRV in the postoperative period. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Härkin, Pia; Marttila, Riitta; Pokka, Tytti; Saarela, Timo; Hallman, Mikko
To evaluate the predictive factors for the development of haemodynamically significant patent ductus arteriosus (PDA) in preterm infants and to study the morbidities associated with the treatment of PDA during the first hospitalization. Data were collected from the Finnish national register of preterm infants (<32 gestational weeks) born in 2005-2013. In total, 3668 infants were included. Morbidities during the first hospitalization were analysed and compared between infants who received treatments for the closure of PDA (n = 1132) and infants who received no treatment for PDA (n = 2536). The results were adjusted for the duration of pregnancy, intrauterine growth pattern, antenatal steroids, delivery hospital and respiratory distress syndrome (RDS). RDS and mechanical ventilation were independently associated with an increased risk of PDA requiring treatment. Medical and surgical treatments were associated with the risk of severe bronchopulmonary dysplasia (BPD). Primary surgical ligation was associated with an increased risk of severe intraventricular haemorrhage (IVH) and necrotizing enterocolitis (NEC). Medical treatment itself and also followed by surgical ligation was associated with lower mortality. The severity of lung disease rather than prematurity per se was associated with the development of PDA requiring therapy. Both medical and surgical therapies for PDA were associated with severe BPD, and primary surgical ligation was associated with NEC and severe IVH.
Lai, L S; McCrindle, B W
To determine variations in neonatology practice regarding the diagnosis and management of patent ductus arteriosus (PDA) in premature infants. Standardized telephone interview of preferences and practices. Canadian neonatologists in active clinical practice. Of 136 eligible Canadian neonatologists, 100 respondents (74%) estimated the proportion of infants with suspected PDA who have echocardiography to be a median of 80% (range 0% to 100%), with considerable variation both within and between centres. Only two centres had written guidelines. More recent medical school graduates were significantly more likely to use echocardiography. Increased use of echocardiography was also significantly related to increased availability. Fluid restriction and indomethacin was used as initial therapy by 89% of respondents, with the indomethacin dose standardized for 83%; surgical ligation was used when indomethacin therapy was contraindicated or had failed. Personal guidelines directed decisions regarding therapy for the majority of neonatologists. Among Canadian neonatologists, there is considerable variation regarding practices related to the diagnosis and management of PDA in premature infants. This variation may potentially affect the cost effectiveness of care for these patients.
Turck, Charles J; Marsh, Wallace; Stevenson, James G; York, John M; Miller, Henry; Patel, Snehal
Management of neonatal patent ductus arteriosus (PDA) often is resource-intensive and costly. Therefore, it is in hospitals' best interests to ensure the most cost-efficient use of associated resources. Clinical status, comorbidities, and response to prior therapy are considered in selecting the most appropriate intervention for PDA management. Currently, supportive measures (e.g., fluid restriction), surgical ligation, and pharmacologically based medical therapy are the primary treatment modalities for correcting PDA. Medical therapy, which comprises a small percentage (2.0%-5.0%)1 of overall PDA treatment expenses in the United States, consists of either of the 2 intravenous (IV) cyclooxygenase (COX) inhibitors: IV indomethacin and the newly available IV ibuprofen lysine. Although IV COX inhibitors represent a small portion of medical expenses, their benefits appear to be considerable. Pharmacoeconomic studies have evaluated indomethacin's beneficial impact on cost-effectiveness per quality-adjusted life year in PDA prophylaxis; however, no analysis to date prospectively assesses the effect of COX inhibitors on resource use or expenses in treating PDA. Such analysis is desirable and should consider efficacy and safety outcomes, impact on health care resource use and length of stay (LOS), and any differential effects of the agents' safety profiles; notably, IV indomethacin adversely affects renal and mesenteric blood flow and increases serum creatinine and oliguria significantly more than IV ibuprofen. These observations lay the foundation to conduct studies assessing the influence of these differences on resource use, LOS and expenses associated with PDA management.
Turck, Charles J; Marsh, Wallace; Stevenson, James G.; York, John M.; Miller, Henry; Patel, Snehal
Management of neonatal patent ductus arteriosus (PDA) often is resource-intensive and costly. Therefore, it is in hospitals' best interests to ensure the most cost-efficient use of associated resources. Clinical status, comorbidities, and response to prior therapy are considered in selecting the most appropriate intervention for PDA management. Currently, supportive measures (e.g., fluid restriction), surgical ligation, and pharmacologically based medical therapy are the primary treatment modalities for correcting PDA. Medical therapy, which comprises a small percentage (2.0%–5.0%)1 of overall PDA treatment expenses in the United States, consists of either of the 2 intravenous (IV) cyclooxygenase (COX) inhibitors: IV indomethacin and the newly available IV ibuprofen lysine. Although IV COX inhibitors represent a small portion of medical expenses, their benefits appear to be considerable. Pharmacoeconomic studies have evaluated indomethacin's beneficial impact on cost-effectiveness per quality-adjusted life year in PDA prophylaxis; however, no analysis to date prospectively assesses the effect of COX inhibitors on resource use or expenses in treating PDA. Such analysis is desirable and should consider efficacy and safety outcomes, impact on health care resource use and length of stay (LOS), and any differential effects of the agents' safety profiles; notably, IV indomethacin adversely affects renal and mesenteric blood flow and increases serum creatinine and oliguria significantly more than IV ibuprofen. These observations lay the foundation to conduct studies assessing the influence of these differences on resource use, LOS and expenses associated with PDA management. PMID:23055853
van der Lugt, N Margreth; Lopriore, Enrico; Bökenkamp, Regina; Smits-Wintjens, Vivianne E H J; Steggerda, Sylke J; Walther, Frans J
Patent ductus arteriosus (PDA) is a frequent complication in preterm infants. Ibuprofen and indomethacin (both COX inhibitors) are used for pharmacological closure of PDA. In most centers, a failed second course of COX inhibitors is followed by surgical closure. Our aim was to estimate the closure rate of clinically significant PDA after second and third courses of ibuprofen and record possible side effects. A study population, consisting of 164 preterm infants (<32 weeks' gestational age) with PDA admitted at our tertiary care center between November 2005 and September 2011, was retrospectively analyzed. Primary outcome was the closure rate after repeated courses of ibuprofen. The closure rate was similar after the first (109/164), second (24/43), and third (6/11) course of ibuprofen (X(2) = 2.1, p = 0.350). Late start of the first course of ibuprofen was a predictive factor for increased need of a second course (X(2) = 4.4, p = 0.036). No additional side effects of multiple courses of ibuprofen were detected. In conclusion, repeated courses of ibuprofen are an effective and safe alternative for surgical closure and should be considered after failure of the first course of ibuprofen.
Yamaguchi, Hiroshi; Wada, Keiko; Nagasawa, Miho; Kikusui, Takefumi; Sakai, Hitomi; Mizobuchi, Masami; Yoshimoto, Seiji; Nakao, Hideto
Some prior studies have shown that symptomatic patent ductus arteriosus (sPDA) is highly familial. Although it is estimated that both genetic and environmental factors may contribute to sPDA, evidence is still lacking. The aim of this study was to determine the risk factors for sPDA, focusing on the genetic and in utero environment by analyzing very low birth weight (VLBW) singletons and twins. This retrospective case-control study reviewed the medical records of 445 VLBW infants (25 weeks ≤ gestational age <32 weeks, 600 g ≤ birth weight <1,500 g) and compared the incidence of sPDA among monochorionic diamniotic (MD) twins (n = 65), dichorionic diamniotic (DD) twins (n = 66), and singletons (n = 314). Stepwise multiple regression analysis showed that twin siblings (p = 0.001), gestational week (p < 0.001), antenatal steroid use (p = 0.021), and premature rupture of membranes (p = 0.002) were independent predictors of sPDA. Incidence of sPDA in MD twin siblings was significantly higher than that in singletons (p < 0.01), whereas no significant difference was found between singletons and DD twins or between MD and DD twins. The current results show that being a VLBW MD twin is an independent risk factor for sPDA, and that both genetic and in utero environmental factors may contribute to its development. © 2016 S. Karger AG, Basel.
Barikbin, Payman; Sallmon, Hannes; Wilitzki, Silke; Photiadis, Joachim; Bührer, Christoph; Koehne, Petra; Schmalisch, Gerd
The indications and strategies for treatment of patent ductus arteriosus (PDA) are controversial, and the safety and long-term benefits of surgical PDA closure remain uncertain. The aim of this study was to compare the lung function of very low birth weight (VLBW) infants after successful PDA treatment with a cyclooxygenase inhibitor or secondary surgical ligation. A total of 114 VLBW infants (birth weight < 1500 g), including 94 infants (82%) with a birth weight < 1000 g, who received treatment for hemodynamically significant PDA (hsPDA), were examined at a median postmenstrual age of 48 weeks. All infants were initially given pharmacological treatment, and 40 infants (35%) required PDA ligation. Lung function testing (LFT) included tidal breathing measurements, measurement of respiratory mechanics assessed by the occlusion test, whole-body plethysmography, SF6 multiple breath washout, forced expiratory flow (V'maxFRC) by the rapid thoracoabdominal compression technique, exhaled NO (FeNO), and arterialized capillary blood gas analysis. On the day of the LFT, the 2 groups had similar postconceptional age and body weight. However, the PDA ligation group was more immature at birth (p < 0.001) and had reduced respiratory compliance (p < 0.001), lower V'maxFRC (p = 0.006), increased airway resistance (Raw) (p < 0.001), and impaired blood gases (p < 0.001). Multivariate analysis showed that PDA surgery was an independent risk factor for increased Raw. PDA ligation after failed pharmacological treatment is associated with impaired lung function as compared to successful pharmacological closure in infants at a postmenstrual age of 48 weeks. However, only Raw was independently affected by PDA ligation, while all other differences were merely explained by patient characteristics.
Aziz, K; Tasneem, H
Blood flow in the pulmonary artery was studied by Doppler colour flow mapping and cardiac catheterisation in 19 patients with a ductus arteriosus and different pulmonary artery pressures. In the four patients with normal pulmonary artery pressures colour Doppler flow mapping showed multicoloured wide and long systolic and diastolic jets in the pulmonary artery. In the 15 patients with raised pulmonary arterial pressure the systolic jets varied from multicoloured to red and were thinner: in patients with considerably raised pulmonary arterial pressure the jets became redder during diastole. The Doppler velocity tracings showed that in patients with normal pulmonary artery pressures the mean peak systolic velocity was higher than the mean end diastolic velocity--so that in all four the ratio of peak systolic velocity to end diastolic velocity was less than 2. The mean peak systolic velocity was much higher than the mean end diastolic velocity in 13 of the 15 patients with raised pulmonary artery pressure; this meant that the ratio of peak systolic velocity to end diastolic velocity was greater than 2 in 10 of 11 patients. The end diastolic velocity was significantly lower in those patients with raised pulmonary artery pressure than in those with normal artery pressure. There was an inverse linear correlation between the mean pulmonary artery pressure and end diastolic ductal jet velocity in 17 of the 19 patients. Colour flow mapping and this quantitative Doppler technique can detect pulmonary artery hypertension in patients with a ductus arteriosus. Images PMID:2278800
Côté, E; Ettinger, S J
A small number of dogs with patent ductus arteriosus (PDA) have right-to-left flow of blood through the ductus, leading to polycythemia and clinical signs associated with hyperviscosity. Three dogs with right-to-left-shunting PDA are described. Treatment consisted solely of phlebotomy, performed on an outpatient basis when indicated by exacerbation of clinical signs, for a total of 11-68 times on each dog. Each treatment entailed the removal of a mean of 19% (maximum 28%) of circulating blood volume, divided into 2 phlebotomies several hours apart, without intravenous fluid replacement. Subjectively, marked clinical improvement was noted. Intermittent clinical signs decreased in frequency and severity in all dogs. Adverse effects were rare (1 for 98 phlebotomies) and reversible. Dogs lived > 2 to > 8 years during treatment. Outpatient phlebotomy without fluid replacement was safe, and was associated with subjective improvement and prolonged survival in these dogs.
Yoon, Hakyoung; Kim, Jaehwan; Nahm, Sang-Soep; Eom, Kidong
Congenital pulmonary valve stenosis and patent ductus arteriosus are common congenital heart defects in dogs. However, concurrence of atypical pulmonary valve stenosis and patent ductus arteriosus is uncommon. This report describes the anatomic, histopathologic, and echocardiographic features in a dog with concomitant pulmonary valve stenosis and patent ductus arteriosus with atypical pulmonary valve dysplasia that included a fibrous band of tissue. A 1.5-year-old intact female Chihuahua dog weighing 3.3 kg presented with a continuous grade VI cardiac murmur, poor exercise tolerance, and an intermittent cough. Echocardiography indicated pulmonary valve stenosis, a thickened dysplastic valve without annular hypoplasia, and a type IIA patent ductus arteriosus. The pulmonary valve was thick line-shaped in systole and dome-shaped towards the right ventricular outflow tract in diastole. The dog suffered a fatal cardiac arrest during an attempted balloon pulmonary valvuloplasty. Necropsy revealed pulmonary valve dysplasia, commissural fusion, and incomplete opening and closing of the pulmonary valve because of a fibrous band of tissue causing adhesion between the right ventricular outflow tract and the dysplastic intermediate cusp of the valve. A fibrous band of tissue between the right ventricular outflow track and the pulmonary valve should be considered as a cause of pulmonary valve stenosis. Pulmonary valve stenosis and patent ductus arteriosus can have conflicting effects on diastolic and systolic dysfunction, respectively. Therefore, beta-blockers should always be used carefully, particularly in patients with a heart defect where there is concern about left ventricular systolic function.
Bahr, Anne; Miller, Matthew; Gordon, Sonya
First-pass nuclear angiocardiography (FPNA) was performed in 5 normal dogs and in 19 dogs with left-to-right shunting patent ductus arteriosus (PDA). Affected dogs were evaluated before and after an occlusion procedure (surgical ligation or transarterial coil embolization). Two methods of analysis were used to evaluate the pulmonary time-activity curves and assess the magnitude of the shunt. One method involved the calculation of a simple count ratio (C2:C1). The other method used gamma variate modeling to estimate the ratio of pulmonary to systemic blood flow (QP:QS). Values for normal dogs (mean +/- SD) were C2:C1 = 0.39 +/- 0.11 and QP:QS = 1.10 +/- 0.03. Values for affected dogs were C2:C1 = 0.59 +/- 0.17, QP:QS = 2.01 +/- 0.46 before intervention and QP:QS = 1.21 +/- 0.17, C2:C1 = 0.42 +/- 0.12 after intervention. Both methods detected significant differences between normal and affected dogs (QP:QS, t-test, P < .001; C2:C1; t-test; P = .018) and between affected dogs pre- and postocclusion (QP:QS. paired t-test, P < .001; C2:C1, paired t-test, P = .002). However, QP:QS was a better separator of normal from affected animals. First-pass nuclear angiocardiography, by the gamma variate method, may be a useful, adjunct diagnostic test in evaluation of animals with left-to-fight shunting PDA, particularly in animals with residual shunting after an occlusion procedure.
Olgun, Haşim; Ceviz, Naci; Kartal, İbrahim; Caner, İbrahim; Karacan, Mehmet; Taştekin, Ayhan; Becit, Necip
There are limited data about the results of repeated oral ibuprofen (OIBU) treatment. This study aimed to describe patent ductus arteriosus (PDA) closure rates and adverse events after repeated courses of OIBU in premature infants with PDA. Preterm infants with hemodynamically significant (hs)PDA were enrolled in the study. If the first course of OIBU treatment failed, a second and, if required, third course was administered. A total of 100 patients received OIBU. In six patients, treatment could not be completed due to death (n=3) and side effects (n=3). In three patients, adverse effects related to OIBU (thrombocytopenia and impairment of renal function) developed during the first course. During the second and third courses, no new adverse event occurred. After all courses, the PDA closure rate was determined as 88%. The rate was 71% after the first course, 40% after the second course, and 35% after the third course. Although the second course resulted in a significant increase in the closure rate (p<0.05), the rate did not increase significantly with the third course (p>0.05). The mean postnatal age at the start of the first dose of OIBU was not significantly different among the responders and non-responders to the first course (p>0.05). Clinical characteristics did not affect the closure rate significantly. The number of courses did not have a significant effect on death, when gestational age and birth weight were used as covariates [p=0.867, Exp(B)=0.901, 95% confidence interval=0.264-3.1]. A second course of OIBU seems effective and safe for use in preterm infants with hsPDA. Although a third course of OIBU results in PDA closure in some additional patients, the difference is not significant. Thus, surgical ligation should be considered after the second course, especially in patients with signs of severe heart failure. Copyright © 2016. Published by Elsevier B.V.
Backes, Carl H; Rivera, Brian K; Bridge, Jeffrey A; Armstrong, Aimee K; Boe, Brian A; Berman, Darren P; Fick, Tyler; Holzer, Ralf J; Hijazi, Ziyad M; Abadir, Sylvia; Justino, Henri; Bergersen, Lisa; Smith, Charles V; Kirpalani, Haresh
Patent ductus arteriosus (PDA) is a precursor to morbidity and mortality. Percutaneous (catheter-based) closure is the procedure of choice for adults and older children with a PDA, but use during infancy (<1 year) is not well characterized. Investigate the technical success and safety of percutaneous PDA closure during infancy. Scopus, Web of Science, Embase, PubMed, and Ovid (Medline) were searched through December 2015 with no language restrictions. Publications needed to clearly define the intervention as percutaneous PDA closure during infancy (<1 year of age at intervention) and must have reported adverse events (AEs). The study was performed according to the Systematic Reviews and Meta-Analysis checklist and registered prospectively. The quality of the selected studies was critically examined. Data extraction and assignment of AE attributability and severity were independently performed by multiple observers. Outcomes were agreed on a priori. Data were pooled by using a random-effects model. Thirty-eight studies were included; no randomized controlled trials were found. Technical success of percutaneous PDA closure was 92.2% (95% confidence interval [CI] 88.8-95.0). Overall AE and clinically significant AE incidence was 23.3% (95% CI 16.5-30.8) and 10.1% (95% CI 7.8-12.5), respectively. Significant heterogeneity and publication bias were observed. Limitations include lack of comparative studies, lack of standardized AE reporting strategy, and significant heterogeneity in reporting. Percutaneous PDA closure during infancy is feasible and associated with few catastrophic AEs; however, the limitations constrain the interpretability and generalizability of the current findings. Copyright © 2017 by the American Academy of Pediatrics.
Gulack, Brian C.; Laughon, Matthew M.; Clark, Reese H.; Sankar, Meera N.; Hornik, Christoph P.; Smith, P. Brian
Background Patent ductus arteriosus (PDA) is common in extremely premature infants and associated with increased morbidity and mortality. Medical management of PDA uses either indomethacin or ibuprofen. Despite numerous studies, uncertainty exists as to which drug is safer or more effective; we sought to fill this knowledge gap. Methods We identified infants <28 weeks gestational age discharged from neonatal intensive care units included in the Pediatrix Medical Group Clinical Data Warehouse between 2006 and 2012 who were treated with indomethacin or ibuprofen between postnatal day 2 and 14. Infants treated with both drugs or infants with a congenital malformation were excluded. We used multivariable logistic regression to determine the association of indomethacin versus ibuprofen on clinical outcomes. Results Of 6349 patients who met study criteria, 1177 (19%) received ibuprofen and 5172 (81%) received indomethacin. The median gestational age was 25 weeks (interquartile range 24–26), and 2894 (46%) infants were <750 g at birth. On unadjusted analysis, infants who received ibuprofen had significantly higher incidences of death prior to discharge, surgical ligation of the PDA prior to discharge, death or spontaneous intestinal perforation within 7 days of therapy, death or surgical ligation of the PDA prior to discharge, and an elevated creatinine within 7 days of treatment. However, on multivariable analysis, no significant differences in outcomes were observed (odds ratio for death/PDA ligation for ibuprofen vs. indomethacin = 1.12 [95% CI 0.91–1.39]). Conclusions We observed similar effectiveness and safety profiles for indomethacin and ibuprofen in the medical management of PDA in premature infants. PMID:26386610
Sung, Se In; Chang, Yun Sil; Chun, Ji Young; Yoon, Shin Ae; Yoo, Hye Soo; Ahn, So Yoon; Park, Won Soon
To determine whether a nonintervention approach for treating hemodynamically significant patent ductus arteriosus (PDA) is associated with decreased mortality and/or morbidity compared with a mandatory closure approach in extremely low birth weight infants. We reviewed the medical records of 178 infants of 23-26 weeks' gestational age with PDA, requiring ventilator treatment, and with hemodynamically significant PDA ≥2 mm in size. Mandatory closure was used during period I (July 2009 to December 2011, n = 81), and nonintervention was used during period II (January 2012 to June 2014, n = 97). During period I, 64% of infants were first treated with indomethacin, and 82% were ultimately ligated surgically. During period II, no infant was treated with indomethacin and/or ligation. The average postnatal day of PDA closure was day 13 and day 44 during periods I and II, respectively. There was significantly more use of diuretics and fluid restriction during period II compared with period I. There was no difference in mortality or morbidities such as necrotizing enterocolitis or intraventricular hemorrhage. The incidence of bronchopulmonary dysplasia (BPD) and the propensity score adjusted OR of BPD were significantly lower during period II compared with period I. Despite longer PDA exposure, nonintervention was associated with significantly less BPD compared with mandatory closure. Additional study is warranted to determine the benefits and risks of non-intervention for the hemodynamically significant PDA in extremely low birth weight infants. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.
El‐Said, Howaida G.; Bratincsak, Andras; Foerster, Susan R.; Murphy, Joshua J.; Vincent, Julie; Holzer, Ralf; Porras, Diego; Moore, John; Bergersen, Lisa
Background The technique and safety of transcatheter patent ductus arteriosus (PDA) closure have evolved during the past 20 years. We sought to report a multicenter experience of PDA closure with a focus on the rate of adverse events (AE) and a review of institutional practice differences. Methods and Results Outcome data on transcatheter PDA closure were collected at 8 centers prospectively using a multicenter registry (Congenital Cardiac Catheterization Project on Outcome Registry). Between February 2007 and June 2010, 496 PDA closures were recorded using a device in 338 (68%) or coils in 158 (32%). Most patients had an isolated PDA (90%). Fifty percent of patients were between 6 months and 3 years old, with only 40 patients (8%) <6 months old. Median minimum PDA diameter was 2.5 mm (range 1 to 12 mm; IQR 2 to 3 mm) for device closure and 1 mm (range 0.5 to 6 mm; IQR 1 to 2 mm) for coil closure (P<0.001). A device rather than coil was used in patients <3 years, weight <11 kg, and with a PDA minimum diameter >2 mm (all P<0.001). Three of 8 centers exclusively used a device for PDAs with a diameter >1.5 mm. In 9% of cases (n=46), an AE occurred; however, only 11 (2%) were classified as high severity. Younger age was associated with a higher AE rate. Coil‐related AEs were more common than device‐related AEs (10% versus 2%, P<0.001). Conclusions PDA closure in the present era has a very low rate of complications, although these are higher in younger children. Technical intervention‐related events were more common in coil procedures compared with device procedures. For PDAs ≤2.5 mm in diameter, institutional differences in preference for device versus coil exist. PMID:24284214
Itaya, M; Ifuku, M; Toshima, H; Takahashi, H; Koga, Y; Ohishi, K
Abnormal ventricular septal motion is usually observed after open heart surgery, but its mechanism is not fully understood. Our previous study suggested that a sudden reduction of left ventricular (LV) volume overload after corrective surgery would be one mechanism, showing that postoperative abnormal septal motion is more frequent in patients who have preoperative LV volume overload. The purpose of this study was to investigate further the direct effect of LV volume alone on the ventricular septal motion in 22 patients who underwent non-surgical closure of a patent ductus arteriosus (PDA) by the Porstmann's method. The non-surgical closure of a PDA reduced LV diastolic diameter (LVDd) from 55.7 +/- 7.3 mm to 48.1 +/- 5.2 mm (P less than 0.001), and LV systolic diameter (LVDs) from 36.3 +/- 7.0 mm to 34.1 +/- 7.0 mm (p less than 0.01). Septal motion decreased in amplitude from 8.5 +/- 2.4 mm to 3.8 +/- 3.4 mm (p less than 0.01) and eight (36%) patients developed abnormal septal motion, while LV posterior wall excursions remained unchanged. When compared these eight patients with 14 without abnormal septal motion, the magnitude of postoperative LVDd reduction (delta LVDd) and its ratio to preoperative volume (delta LVDd/pre op LVDd) were significantly greater in patients with abnormal septal motion. Thus sudden reduction in LV volume overload alone could induce abnormal septal motion without altering other factors such as adhesion of the pericardium.(ABSTRACT TRUNCATED AT 250 WORDS)
Wickremasinghe, Andrea C.; Rogers, Elizabeth E.; Piecuch, Robert E.; Johnson, Bridget C.; Golden, Suzanne; Moon-Grady, Anita J.; Clyman, Ronald I.
Objective To examine whether a change in the approach to management of persistent patent ductus arteriosus (PDA), from “early ligation” to “selective ligation,” is associated with an increased risk of abnormal neurodevelopmental outcome. Study design In 2005, we changed our PDA treatment protocol (in infants ≤27 6/7 weeks gestation) from an “early ligation” approach, with PDA ligation quickly if they failed to close after indomethacin (Period 1: 1/99–12/04), to a “selective ligation” approach, with PDA ligation only if specific criteria were met (Period 2: 1/05–5/09). All infants in both periods received prophylactic indomethacin. Multivariate analysis was used to compare the odds of a composite Abnormal Neurodevelopmental Outcome (Bayley MDI or Cognitive score <70, cerebral palsy, blindness, and/or deafness) associated with each treatment approach at 18–36 months (n=224). Results During Period 1, 23% of the infants in follow-up failed indomethacin treatment, and all were ligated; during Period 2, 30% of infants failed indomethacin, and 66% were ligated after meeting pre-specified criteria. Infants treated with the “selective ligation” strategy had fewer Abnormal Outcomes than infants treated with the “early ligation” approach (OR=0.07, p=0.046). Infants ligated before 10 days of age had an increased incidence of Abnormal Neurodevelopmental Outcome. The significant difference in outcomes between the two PDA treatment strategies could be accounted for, in part, by the earlier age of ligation during Period 1. Conclusions A “selective ligation” approach for PDAs that fail to close with indomethacin does not worsen neurodevelopmental outcome at 18–36 months. PMID:22795222
Simon, Sorina R; van Zogchel, Lieke; Bas-Suárez, Maria Pilar; Cavallaro, Giacomo; Clyman, Ronald I; Villamor, Eduardo
Several cohort studies have shown an association between low platelet counts in the first day(s) of life and patent ductus arteriosus (PDA) in preterm infants. However, these results have not been confirmed by other studies. To perform a meta-analysis of all the studies addressing the relationship between platelet counts in the first day(s) of life and PDA in preterm infants. PubMed/MEDLINE and EMBASE were searched from their inception until December 2014. Results from 11 cohort studies involving 3,479 preterm infants (gestational age <32 weeks) were pooled using random-effects modeling. Meta-analysis showed a significant positive association between PDA and platelet counts <150 × 10(9)/l [6 studies, risk ratio (RR) = 1.215, 95% CI: 1.027-1.436], between PDA and platelet counts <100 × 10(9)/l (5 studies, RR = 1.255, 95% CI: 1.034-1.525), and between significant PDA (SPDA) and platelet counts <100 × 10(9)/l (5 studies, RR = 1.254, 95% CI: 1.021-1.540). The association between SPDA and platelet counts <150 × 10(9)/l was not statistically significant (6 studies, RR = 1.289, 95% CI: 0.925-1.795). Pooled standard differences in mean platelet counts between infants with and without PDA/SPDA were not statistically different. This meta-analysis reveals a marginal but significant association between low platelet counts in the first day(s) of life and PDA/SPDA in very preterm infants. This association needs to be confirmed in prospective studies. © 2015 S. Karger AG, Basel.
Lam, Jennifer Y; Lopushinsky, Steven R; Ma, Irene W Y; Dicke, Frank; Brindle, Mary E
Patent ductus arteriosus (PDA) in the nonpremature pediatric patient is currently treated by surgical ligation or catheter occlusion. There is no clear superiority of one technique over the other. This meta-analysis compares the clinical outcomes of the two treatment options for PDA. We performed a literature search of MEDLINE, Embase, PubMed, and the Cochrane database of randomized controlled trials (RCTs) that took place between 1950 and February 2014 and hand-searched references from included studies. We excluded studies of adult or premature patients and those without a direct comparison between surgical and catheter-based treatments of PDAs. Outcomes of interest were reintervention, total complications, length of stay, and cost. One thousand three hundred thirty-three manuscripts were screened. Eight studies fulfilled the inclusion criteria (one RCT and seven observational studies [N = 1,107]). In pooled observational studies, there were significantly decreased odds (OR, 0.12; 95% CI, 0.03-0.42) for reintervention in the surgical ligation group but insignificantly higher odds for overall complications (OR, 2.01; 95% CI, 0.68-5.91). There were no complications reported in the RCT, but surgical ligation was associated with decreased odds for reintervention and a longer length of stay. Funnel plots revealed a possible publication bias and a quality review identified comparability bias. Both therapies have comparable outcomes. Reintervention is more common with catheter-based treatment, but overall complication rates are not higher and hospital stay is shorter. Our data span > 2 decades and may not reflect current surgical and catheterization outcomes. Large, randomized, prospective studies may help determine the optimal treatment strategy.
Wang, Kai; Pan, Xuanren; Tang, Qiaoyun; Pang, Yusheng
Patent ductus arteriosus (PDA) remains a common congenital heart disease in pediatric patients, and the new trend of catheterization therapy is still associated with some potential risks and complications. Compared with surgical closure, the clinical effect of catheterization therapy in pediatric PDA patients requires meta-analysis. A systematic literature search of PubMed, Cochrane Library, Embase, Science Citation Index, Web of Science, and the Chinese Biomedicine literature database was conducted. Eligible studies included controlled trials of pediatric PDA patients receiving catheterization therapy vs surgical closure. Relative risks (RRs), standard mean differences, and 95% confidence intervals (CIs) were calculated and heterogeneity was assessed with the I(2) test. Seven studies with a total of 810 patients met the inclusion criteria. Catheterization therapy neither significantly increased the primary success rate (RR: 0.92, 95% CI: 0.82-1.03, P = 0.16) nor reduced the total postprocedure complications (RR: 0.74, 95% CI: 0.44-1.25, P = 0.26) and blood transfusion (RR: 1.10, 95% CI: 0.16-7.67, P = 0.93). Catheterization was associated with a statistically significant increase in residual shunts (RR: 5.19, 95% CI: 1.41-19.20, P = 0.01) and reduction in length of hospital stay (standard mean difference: -1.66, 95% CI: -2.65 to -0.67, P = 0.001). Catheterization therapy in pediatric PDA patients did not show a significant advantage in primary success rate, total complications, or blood transfusion, but it was associated with increase in residual shunts and reduction in length of hospital stay. © 2014 Wiley Periodicals, Inc.
Clyman, Ronald; Wickremasinghe, Andrea; Jhaveri, Nami; Hassinger, Denise C; Attridge, Joshua T; Sanocka, Ulana; Polin, Richard; Gillam-Krakauer, Maria; Reese, Jeff; Mammel, Mark; Couser, Robert; Mulrooney, Neil; Yanowitz, Toby D; Derrick, Matthew; Jegatheesan, Priya; Walsh, Michele; Fujii, Alan; Porta, Nicolas; Carey, William A; Swanson, Jonathan R
To test the hypothesis that infants who are just being introduced to enteral feedings will advance to full enteral nutrition at a faster rate if they receive "trophic" (15 mL/kg/d) enteral feedings while receiving indomethacin or ibuprofen treatment for patent ductus arteriosus. Infants were eligible for the study if they were 23(1/7)-30(6/7) weeks' gestation, weighed 401-1250 g at birth, received maximum enteral volumes ≤60 mL/kg/d, and were about to be treated with indomethacin or ibuprofen. A standardized "feeding advance regimen" and guidelines for managing feeding intolerance were followed at each site (N = 13). Infants (N = 177, 26.3 ± 1.9 weeks' mean ± SD gestation) were randomized at 6.5 ± 3.9 days to receive "trophic" feeds ("feeding" group, n = 81: indomethacin 80%, ibuprofen 20%) or no feeds ("fasting [nil per os]" group, n = 96: indomethacin 75%, ibuprofen 25%) during the drug administration period. Maximum daily enteral volumes before study entry were 14 ± 15 mL/kg/d. After drug treatment, infants randomized to the "feeding" arm required fewer days to reach the study's feeding volume end point (120 mL/kg/d). Although the enteral feeding end point was reached at an earlier postnatal age, the age at which central venous lines were removed did not differ between the 2 groups. There were no differences between the 2 groups in the incidence of infection, necrotizing enterocolitis, spontaneous intestinal perforation, or other neonatal morbidities. Infants required less time to reach the feeding volume end point if they were given "trophic" enteral feedings when they received indomethacin or ibuprofen treatments. Copyright © 2013 Mosby, Inc. All rights reserved.
Golombek, S G; Sola, A; Baquero, H; Borbonet, D; Cabañas, F; Fajardo, C; Goldsmit, G; Lemus, L; Miura, E; Pellicer, A; Pérez, J M; Rogido, M; Zambosco, G; van Overmeire, B
To report the process and results of the first neonatal clinical consensus of the Ibero-American region. Two recognized experts in the field (Clyman and Van Overmeire) and 45 neonatologists from 23 countries were invited for active participation and collaboration. We developed 46 questions of clinical-physiological relevance in all aspects of patent ductus arteriosus (PDA). Guidelines for consensus process, literature search and future preparation of educational material and authorship were developed, reviewed and agreed by all. Participants from different countries were distributed in groups, and assigned to interact and work together to answer 3-5 questions, reviewing all global literature and local factors. Answers and summaries were received, collated and reviewed by 2 coordinators and the 2 experts. Participants and experts met in Granada, Spain for 4.5 h (lectures by experts, presentations by groups, discussion, all literature available). 31 neonatologists from 16 countries agreed to participate. Presentations by each group and general discussion were used to develop a consensus regarding: general management, availability of drugs (indomethacin vs. ibuprofen), costs, indications for echo/surgery, etc. Many steps were learnt by all present in a collaborative forum. This first consensus group of Ibero-American neonatologists SIBEN led to active and collaborative participation of neonatologists of 16 countries, improved education of all participants and ended with consensus development on clinical approaches to PDA. Furthermore, it provides recommendations for clinical care reached by consensus. Additionally, it will serve as a useful foundation for future SIBEN Consensus on other topics and it could become valuable as a model to decrease disparity in care and improve outcomes in this and other regions.
Mouzinho, A I; Rosenfeld, C R; Risser, R
Symptomatic patent ductus arteriosus (sPDA) may occur in up to 50% of very-low-birth-weight (VLBW, less than or equal to 1500 g) infants. We reported a 16% incidence in 1979-1980 in a totally inborn population, demonstrating the importance of early fluid management. Although survival of VLBW infants, especially those less than 1000 g, has increased, sPDA has not been carefully re-examined. Therefore, we sought to determine if the incidence, morbidity, treatment, or risk factors for sPDA had changed in this population. Between January 1, 1987 and December 31, 1989 all VLBW infants with sPDA surviving greater than 72 h (119/636) were identified and compared to matched controls (n = 70). Incidence and onset of sPDA were 19% and 10 +/- 6 days (+/- S.D.), respectively, the former increasing from 8% to 33% between 1251-1500 g and 500-750 g, respectively (P less than 0.001). Fluid and colloid administration were similar in sPDA and control infants. sPDA was associated with the occurrence of chronic lung disease (18% vs 7%, P = 0.005) and intracranial hemorrhage (53% vs 21%, P less than 0.001). Using stepwise logistic regression analysis we were unable to create a model that accurately predicted sPDA. Medical management and indomethacin were unsuccessful in 66% and 25%, respectively, of infants so treated; 43% required surgical ligation. Although survival of VLBW infants has increased, our incidence of sPDA remains low, with greater than 80% of infants demonstrating spontaneous closure when fluid and colloid administration are judiciously used.
El-Said, Howaida G; Bratincsak, Andras; Foerster, Susan R; Murphy, Joshua J; Vincent, Julie; Holzer, Ralf; Porras, Diego; Moore, John; Bergersen, Lisa
The technique and safety of transcatheter patent ductus arteriosus (PDA) closure have evolved during the past 20 years. We sought to report a multicenter experience of PDA closure with a focus on the rate of adverse events (AE) and a review of institutional practice differences. Outcome data on transcatheter PDA closure were collected at 8 centers prospectively using a multicenter registry (Congenital Cardiac Catheterization Project on Outcome Registry). Between February 2007 and June 2010, 496 PDA closures were recorded using a device in 338 (68%) or coils in 158 (32%). Most patients had an isolated PDA (90%). Fifty percent of patients were between 6 months and 3 years old, with only 40 patients (8%) <6 months old. Median minimum PDA diameter was 2.5 mm (range 1 to 12 mm; IQR 2 to 3 mm) for device closure and 1 mm (range 0.5 to 6 mm; IQR 1 to 2 mm) for coil closure (P<0.001). A device rather than coil was used in patients <3 years, weight <11 kg, and with a PDA minimum diameter >2 mm (all P<0.001). Three of 8 centers exclusively used a device for PDAs with a diameter >1.5 mm. In 9% of cases (n=46), an AE occurred; however, only 11 (2%) were classified as high severity. Younger age was associated with a higher AE rate. Coil-related AEs were more common than device-related AEs (10% versus 2%, P<0.001). PDA closure in the present era has a very low rate of complications, although these are higher in younger children. Technical intervention-related events were more common in coil procedures compared with device procedures. For PDAs ≤2.5 mm in diameter, institutional differences in preference for device versus coil exist.
Meißner, Udo; Chakrabarty, Raktima; Topf, Hans-Georg; Rascher, Wolfgang; Schroth, Michael
The patent ductus arteriosus (PDA) is associated with various complications of prematurity. Cyclooxygenase-inhibitors are the first-line intervention for closure of the PDA. However, the rates of PDA closure still are unsatisfactory. Therefore, an individual trial was performed by changing the strategy for treating neonates with ibuprofen to induce the closure of PDA. In a retrospective study, patients receiving 20, 10, and 10 mg/kg bodyweight ibuprofen (group 1) were compared by chart review with those receiving 10, 5, 5 mg/kg (group 2). The rate of PDA closure, the incidence of side effects related to the use of ibuprofen, and the need for surgical intervention for closure of the PDA were analyzed. A higher rate of closure after three doses in group 1 could be observed (60.9 vs 52.6%; p = 0.75), which was not significant but indicated a clear positive trend. If closure of the PDA was unsuccessful, intravenous ibuprofen was continued for an additional 2 days. After 5 days, 91.3% of PDA in group 1 was closed compared with 68.4% PDA in group 2. In summary, only 8.7% of the group 1 neonates needed surgical closure of PDA after insufficient medicamentous closure compared with 31.6% in group 2 (p = 0.25). Although not statistically significant, a clear positive trend for using the higher-dose medication can be seen. More work dealing with the limitations of a retrospective study must be done. Based on the data from this study, high-dose ibuprofen seems able to increase the rate of effective medicamentous PDA closure without any further unwanted side effects.
Sivakumar, Kothandam; Bhagyavathy, Anpon; Gnanapragasam, Francis
Large patent ductus arteriosus with large left-to-right shunt results in heart failure, and if untreated, leads to multiorgan dysfunction. Use of radiographic iodinated contrast media for angiogram during transcatheter duct closure may aggravate preexistent renal dysfunction. Aortogram with contrast media was avoided in a patient with renal failure, and echocardiogram guided deployment of duct occluder device in the cardiac catheterization laboratory for closure of a large duct. This article highlights use of a nitinol-based occluder that employs nonporous polytetrafluoroethylene fabric to aid in instantaneous duct closure.
Rangel-Abundis, A; Baduí, E; Verdín, R; Escobar, C V; Enciso, R; Valdespino, A
The spontaneous aneurysm of the ductus arteriosus is an extremely rare disease. From a total of 24 adult cases reported in the literature up to 1987, only in one case the ductus was open and other, was recanalized after being closed. We described the second case in the literature in a patient with totally permeable ductus arteriosus who developed a spontaneous aneurysm and endarteritis, showing the great importance of the diagnostic procedures such as echocardiogram, tomography and angiogram, as well as the surgical treatment which was successful in our patient. The probable etiology of this disease is discussed.
Terek, Demet; Yalaz, Mehmet; Ulger, Zulal; Koroglu, Ozge Altun; Kultursay, Nilgun
Background: Although, patent ductus arteriosus (PDA) is associated with significant morbidity due to hemodynamic instability in preterm infants, the effect of ductus closure on mortality and morbidity is a controversial issue. The aim is to evaluate the efficacy of oral and intravenous (IV) ibuprofen treatment on ductal closure and effects on mortality and bronchoplumonary dysplasia. Materials and Methods: The medical records of 292 premature infants treated at Ege University Neonatal Intensive Care Unit were retrospectively evaluated. Patients were classified into 3 groups as; No PDA, hemodynamically insignificant PDA (hiPDA) and hemodynamically significant PDA (hsPDA) according to the presence and hemodynamical significance of PDA by echocardiography. hsPDA group was treated with IV or oral ibuprofen. Results: Patent ductus arteriosus was diagnosed by routine echocardiography in 145 patients, of whom 78 (53.7%) had hsPDA. All 65 infants with hiPDA had spontaneous PDA closure. Echocardiographic measurements were similar to those patients treated with oral or IV ibuprofen, as in the response rate to treatment without serious adverse effects. The presence of respiratory distress syndrome, surfactant therapy, late sepsis, bronchopulmonary dysplasia (BPD) and mortality rates were significantly higher in patients with hsPDA. However, with stepwise logistic regression; 5th min Apgar score (odds ratio [OR], 1.321, 95% confidence interval [CI], 1.063-1.641, P = 0.012) and gestational age (OR, 1.422, 95% CI, 1.212-1.662, P < 0.001) were the only significant variables associated with mortality. Gestational age (OR, 0.680, 95% CI, 0.531-0.871, P = 0.002) was the only significant variable associated with BPD shown with logistic regression. Conclusion: Ibuprofen treatment is effective for hsPDA closure with minimal side effects. HiPDA can close spontaneously; therefore treatment decision should be individualized. However, medical treatment of PDA does not reduce mortality and
Resende, M H F; More, K; Nicholls, D; Ting, J; Jain, A; McNamara, P J
The decision to perform patent ductus arteriosus (PDA) ligation is controversial. Patient selection is oftentimes poorly standardized, leading to delays in referral and inappropriate intervention. A system for PDA ligation categorization and triaging process was introduced in 2006 at a quaternary hospital in Canada to streamline referrals and enhance perioperative care. We aimed to evaluate the impact of this dedicated PDA ligation triaging system comparing pre- and postimplementation of this system. We performed a retrospective chart review. Demographic and cardiorespiratory data of neonates ⩽30 weeks gestation age at birth, who were referred for and/or had a PDA ligation performed during two distinct epochs (EPOCH 1 (2003 to 2005) and EPOCH 2 (2010 to 2012)), were analyzed. All surgeries were performed at The Hospital for Sick Children, the regional referral center for PDA ligation. The primary outcome was incidence of PDA ligation and procedural cancellations. Secondary outcomes included postoperative need for cardiovascular or respiratory support. Subgroup analysis was performed in neonates <1000 vs >1000 g at the time of surgery during both epochs. A total of 198 neonates underwent surgery with no difference in baseline demographics between epochs. The incidence of PDA ligation as a proportion of total live births under 30 weeks in Central East Region of Ontario was lower in the second epoch (EPOCH 1: 117/1092 (10.7%) vs EPOCH 2: 81/1520 (5.3%)). During the second epoch, 24% of referrals for surgery were canceled after review by our PDA ligation team. There were no overall differences in the proportion of neonates with oxygenation failure, ventilation failure or Post-Ligation Cardiac Syndrome (PLCS), after surgery, between epochs. The proportion of neonates who developed systemic hypotension was higher in patients <1000 g (n=34 (34%) vs n=17 (17.4%), P=0.01) at the time of surgery. In addition, we identified a reduction in the proportion of neonates
Chang, Yun Hee; Lee, Jae Young; Kim, Jeong Eun; Kim, Ji-yong; Youn, YoungAh; Lee, Eun-Jung; Moon, Sena; Lee, Ju Young; Sung, In Kyung
Outcomes after surgical ligation of patent ductus arteriosus (PDA) in preterm infants are often complicated by prematurity associated comorbidities. The Aristotle comprehensive complexity score (ACCS) has been proposed as a useful tool for complexity adjustment in the analysis of outcome after congenital heart surgery. The aims of this study were to define preoperative risk factors for mortality and to demonstrate the usefulness of ACCS to predict mortality after surgical ligation of PDA in the preterm. Included were 49 preterm babies (≤35 weeks of gestation) who had surgical ligation of PDA between May 2009 and July 2012. Median gestational age was 27.6 weeks (range, 23 to 35 weeks) and median birth weight was 1,040 g (range, 520 to 2,280 g). Median age at operation was 15 days (range, 4 to 44 days) and median weight was 1,120 g (range, 400 to 2,880 g). Initial oral ibuprofen was ineffective in 24 patients and contraindicated in 25. All surgical ligations were done at bedside in the neonatal intensive care unit. Preoperative clinical and laboratory profiles were reviewed and ACCS was derived. Eight of 49 patients (16.3%) died at a median of 14 days (range, 2 to 73 days) after PDA ligation. Patients who had contraindications for oral ibuprofen (odds ratio [OR] 8.94; p=0.049), coagulopathy (OR 12.13; p=0.025), renal dysfunction (OR 28.88; p=0.003), intraventricular hemorrhage greater than grade II or seizure (OR 34.00; p=0.002), and ACCS points (OR 29.594; p<0.05) were significantly associated with an increased risk for mortality. Among the risk factors, ACCS showed the largest area under curve (0.991) by receiver-operating characteristic curve analysis. Optimal cutoff value of ACCS for mortality were 15 or greater, with sensitivity of 87.5%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 97.6%. The ACCS, especially for procedure-independent complexity factors, is a useful tool to predict mortality after ligation of PDA in
Roclawski, Marek; Pankowski, Rafal; Smoczynski, Andrzej; Ceynowa, Marcin; Kloc, Wojciech; Wasilewski, Wojciech; Jende, Piotr; Liczbik, Wieslaw; Beldzinski, Piotr; Libionka, Witold; Pierzak, Olaf; Adamski, Stanislaw; Niedbala, Miroslaw
The aim of this study was to determine the influence of lateral thoracotomy on the development of scoliosis in subjects undergoing repair of coarctation of the aorta (CoAo) and patent ductus arteriosus (PDA). A group of 133 patients with CoAo and PDA was evaluated. Forty-five patients with CoAo and 38 with PDA were operated on using lateral thoracotomy (operative group) while 12 patients with CoAo and 31 with PDA were treated using balloon dilatation and stent or coil implantation (non-operative group). Clinical examination and the evaluation of spinal roentgenograms were performed. Among the operated patients 46.6% of those with CoAo and 39.5% of those with PDA had clinical scoliosis. In the non-operated patients scoliosis was present in only 16.6% of those with CoAo and 12.9% of those with PDA. Scoliosis ranged between 10° and 42° and it was mild in the majority of cases. In 90.4% of the operated scoliotic patients with CoAo and 73.3% of those with PDA the curve was thoracic and in 47.6% of the CoAo group and 53,3% of the PDA group the curve was left sided. All curves were right sided in non-operated subjects. Scoliosis in the operated group was higher in males than in females (63.3% versus 60% in CoAo and 68.2% versus 37.5% in PDA). The prevalence of scoliosis after thoracotomy was significantly higher than after non-surgical methods of treatment of both CoAo and PDA as well as in the general population. The rate of single thoracic and the rate of left thoracic curves in patients after thoracotomy is higher than in patients treated non-surgically or in idiopathic scoliosis. The rate of scoliosis after thoracotomy is higher in males than females especially following thoracotomy for PDA.
Huang, Yingying; Wong, Yee Shan; Wu, Jumiati; Kong, Jen Fong; Chan, Jing Ni; Khanolkar, Laxmikant; Rao, Dasari P; Boey, Freddy Y C; Venkatraman, Subbu S
Patent Ductus Arteriosus (PDA) is a cardiovascular defect that occurs in 1 out of every 2000 births, and if left untreated, may lead to severe cardiovascular problems. Current options for occluding utilize meta scaffolds with polymer fabric, and are permanent. The purpose of this study was to develop a fully degradable occluder for the closure of PDA, that can be deployed percutaneously without open-heart surgery. For percutaneous deployment, both elasticity and sufficient mechanical strength are required of the device components. As this combination of properties is not achievable with currently-available homo- or copolymers, blends of biodegradable poly(ε-caprolactone) (PCL) and poly(L-lactide-co-ε-caprolactone) (PLC) with various compositions were studied as the potential material for the PDA occlusion device. Microstructures of this blend were characterized by differential scanning calorimetry (DSC) and tensile tests. DSC results demonstrated the immiscibility between PCL and its copolymer PLC. Furthermore, the mechanical properties, i.e. elastic modulus and strain recovery, of the blends could be largely tailored by changing the continuous phase component. Based on the thermo-mechanical tests, suitable blends were selected to fabricate a prototype of PDA occluder and its in vitro performance, in term of device recovery (from its sheathed configuration), biodegradation rate and blood compatibility, was evaluated. The current results indicate that the device is able to recover elastically from a sheath within 2-3min for deployment; the device starts to disintegrate within 5-6 months, and the materials have no adverse effects on the platelet and leucocyte components of the blood. Biocompatibility implantation studies of the device showed acceptable tissue response. Finally, an artificial PDA conduit was created in a pig model, and the device deployment was tested from a sheath: the device recovered within 2-3min of unsheathing and fully sealed the conduit, the
Lee, Ji Seong; Park, Ji Young; Ko, Seong Min; Seo, Dong-Man
Right aortic arch with isolation of the left subclavian artery is a rare anomaly. The incidence of bilateral ductus arteriosus is sporadic, and a right aortic arch with isolation of the left subclavian artery in association with bilateral ductus arteriosus is therefore extremely rare. Since the symptoms and signs of isolation of the left subclavian artery can include the absence or underdevelopment of the left arm, subclavian steal syndrome, or pulmonary artery steal syndrome, the proper therapeutic approach is controversial. We report a case in which surgical reconstruction was used to treat isolation of the left subclavian artery with right aortic arch in association with bilateral ductus arteriosus and a ventricular septal defect. PMID:26665110
Backes, Carl H; Kennedy, Kevin F; Locke, Megan; Cua, Clifford L; Ball, Molly K; Fick, Tyler A; Rivera, Brian K; Smith, Charles V; Holzer, Ralf J; Boe, Brian A; Berman, Darren P; Bergersen, Lisa; Armstrong, Aimee K
The authors sought to identify risk factors associated with major adverse events (MAEs) in infants <6 kg undergoing transcatheter patent ductus arteriosus (PDA) occlusion. Transcatheter PDA occlusion is among the safest of interventional cardiac procedures in adults and older children, but use among infants <6 kg has not been characterized adequately. Using the IMPACT (IMproving Pediatric and Adult Congenital Treatments) registry, we identified infants <6 kg undergoing transcatheter PDA occlusion (January 1, 2011, to March 1, 2015). Using mixed-effects multivariate regression, the authors assessed characteristics predictive of MAE or composite failure (procedural failure or MAE). Individual safety metrics (e.g., embolization, malposition) were also examined for differences across weight thresholds: extremely low weight (LW) (<2 kg), very LW (2 to <4 kg), and LW (4 to <6 kg). Transcatheter PDA occlusion was attempted in 747 infants <6 kg at 73 hospitals. Rate of procedural success was 94.3%. MAEs were observed in 12.6% of cases; the most common events were acute arterial injury and device embolization in 3.5% and 2.4% of cases, respectively. Younger age (<30 days) was associated with greater risk of a MAE (risk ratio: 3.3; 95% confidence interval: 1.5 to 7.6) and composite failure (risk ratio: 3.0; 95% confidence interval: 1.4 to 6.7). Risk of embolization was higher among extremely LW (10.5%) than very LW or LW infants (1.6% and 2.5%, respectively; p = 0.050). Among infants <6 kg, transcatheter PDA occlusion is technically feasible, but risks of MAE are noteworthy. These findings may help inform patient selection and procedural approach for transcatheter PDA occlusion and direct targeted research efforts to support the practice of evidence-based medicine. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Elzenga, N J; Gittenberger-de Groot, A C
Forty-one specimens with pulmonary atresia and confluent pulmonary arteries were studied to establish the frequency and the nature of anomalies of both the ductus arteriosus and the central pulmonary arteries and their possible interrelation. The specimens were divided according to the type of pulmonary atresia: valvar atresia (12 cases) versus "muscular" atresia of the pulmonary orifice (29 cases). Abnormal connexions between the duct and the adjacent great arteries, as well as stenosis of a pulmonary artery, were common in cases with atresia of the pulmonary orifice and relatively rare in cases with imperforate valve. The abnormal connexions consisted of a proximal displacement of the origin of the duct from the aorta and displacement of the entry site of the duct into the pulmonary trunk towards one of the main pulmonary arteries. A left duct thus connected to the left and a right duct to the right pulmonary artery. Pulmonary artery stenosis, exclusively occurring in those specimens with a duct connecting to a pulmonary artery, were located in the segment of pulmonary artery between the pulmonary trunk and the duct. Histological examination revealed ductal tissue in the wall of a pulmonary artery in more than half of the cases with atresia of the pulmonary orifice. Ductal tissue in a pulmonary artery and pulmonary artery stenosis frequently coexisted. It is concluded that stenoses in the central pulmonary arteries may be related to the duct. The relationship resembles that between the duct and coarctation of the aorta.
Joseph, G; Muthunayagam, J V; Mandalay, A
Definitive treatment of congenital apical muscular ventricular septal defect (VSD) with large left-to-right shunt, severe pulmonary hypertension, and major associated lesions such as patent ductus arteriosus (PDA) has so far been possible only by surgery that has significant attendant morbidity and mortality . Transcatheter device closure of both shunt lesions, if feasible, is a potentially simpler and safer alternative to surgery.
Tekgündüz, Kadir Şerafettin; Ceviz, Naci; Caner, İbrahim; Olgun, Haşim; Demirelli, Yaşar; Yolcu, Canan; Şahin, İrfan Oğuz; Kara, Mustafa
Haemodynamically significant patent ductus arteriosus is a significant cause of morbidity and mortality in pre-term infants. This retrospective study was conducted to investigate the usefulness of lower-dose paracetamol for the treatment of patent ductus arteriosus in pre-term infants. A total of 13 pre-term infants who received intravenous paracetamol because of contrindications or side effects to oral ibuprofen were retrospectively enrolled. In the first patient, the dose regimen was 15 mg/kg/dose, every 6 hours. As the patient developed significant elevation in transaminase levels, the dose was decreased to 10 mg/kg/dose, every 8 hours in the following 12 patients. Echocardiographic examination was conducted daily. In case of closure, it was repeated after 2 days and when needed thereafter in terms of reopening. A total of 13 patients received intravenous paracetamol. Median gestational age was 29 weeks ranging from 24 to 31 weeks and birth weight was 950 g ranging from 470 to 1390 g. The median postnatal age at the first intravenous paracetamol dose was 3 days ranging from 2 to 9 days. In 10 of the 13 patients (76.9%), patent ductus arteriosus was closed at the median 2nd day of intravenous paracetamol ranging from 1 to 4 days. When the patient who developed hepatotoxicity was eliminated, the closure rate was found to be 83.3% (10/12). Intravenous paracetamol may be a useful treatment option for the treatment of patent ductus arteriosus in pre-term infants with contrindication to ibuprofen. In our experience, lower-dose paracetamol is effective in closing the patent ductus arteriosus in 83.3% of the cases.
Ohlsson, Arne; Shah, Prakeshkumar S
In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. Concerns have been raised that in neonatal mice paracetamol may cause adverse effects on the developing brain, and an association between prenatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. To determine the efficacy and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for closure of a PDA in preterm or low-birth-weight infants. We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, EMBASE and CINAHL. We searched abstracts from the meetings of the Pediatric Academic Societies and the Perinatal Society of Australia and New Zealand. We searched clinicaltrials.gov; controlled-trials.com; anzctr.org.au; World Health Organization International Clinical Trials Registry Platform at who.int/ictrp for ongoing trials and the Web of Science for articles quoting identified randomised controlled trials. We searched the first 200 hits on Google Scholar(TM) to identify grey literature. All searches were conducted in December 2013. A repeat search of MEDLINE in August 2014 did not identify any new trials. We identified two randomised controlled trials (RCTs) that compared oral paracetamol to oral ibuprofen for the treatment of an echocardiographically diagnosed PDA in infants born preterm (≤ 34 weeks postmenstrual age (PMA)). We performed data collection and analyses in accordance with the
Comparison of the Mortality and In-Hospital Outcomes of Preterm Infants Treated with Ibuprofen for Patent Ductus Arteriosus with or without Clinical Symptoms Attributable to the Patent Ductus Arteriosus at the Time of Ibuprofen Treatment.
Yoo, Hani; Lee, Jin A; Oh, Sohee; Jung, Young Hwa; Sohn, Jin A; Shin, Seung Han; Choi, Chang Won; Kim, Ee Kyung; Kim, Han Suk; Kim, Beyong Il
The aim of this study was to assess the differences in the mortality and in-hospital outcomes of preterm infants with < 28 weeks of gestation who received ibuprofen treatment according to the presence of clinical symptoms (any of oliguria, hypotension, or moderate to severe respiratory difficulty) attributable to hemodynamically-significant patent ductus arteriosus (hsPDA) at the time of first ibuprofen treatment. In total, 91 infants born from April 2010 to March 2015 were included. Fourteen infants (15.4%) received ibuprofen treatment when there were clinical symptoms due to hsPDA (clinical symptoms group). In clinical symptoms group, infants were younger (25 [23-27] vs. 26 [23-27] weeks; P = 0.012) and lighter (655 [500-930] vs. 880 [370-1,780] grams; P < 0.001). Also, the clinical risk index for babies (CRIB)-II scores were higher and more infants received invasive ventilator care ≤ 2 postnatal days. More infants received multiple courses of ibuprofen in clinical symptoms group. Although the frequency of secondary patent ductus arteriosus (PDA) ligation and the incidence of bronchopulmonary dysplasia (BPD) was higher in the clinical symptoms group in the univariate analysis, after multivariate logistic regression analysis adjusting for the CRIB-II score, birthweight, birth year, and the invasive ventilator care ≤ 2 postnatal days, there were no significant differences in mortality, frequency of secondary ligation and in-hospital outcomes including necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), BPD or death. Our data suggest that we can hold off on PDA treatment until the clinical symptoms become prominent.
Comparison of the Mortality and In-Hospital Outcomes of Preterm Infants Treated with Ibuprofen for Patent Ductus Arteriosus with or without Clinical Symptoms Attributable to the Patent Ductus Arteriosus at the Time of Ibuprofen Treatment
The aim of this study was to assess the differences in the mortality and in-hospital outcomes of preterm infants with < 28 weeks of gestation who received ibuprofen treatment according to the presence of clinical symptoms (any of oliguria, hypotension, or moderate to severe respiratory difficulty) attributable to hemodynamically-significant patent ductus arteriosus (hsPDA) at the time of first ibuprofen treatment. In total, 91 infants born from April 2010 to March 2015 were included. Fourteen infants (15.4%) received ibuprofen treatment when there were clinical symptoms due to hsPDA (clinical symptoms group). In clinical symptoms group, infants were younger (25 [23–27] vs. 26 [23–27] weeks; P = 0.012) and lighter (655 [500–930] vs. 880 [370–1,780] grams; P < 0.001). Also, the clinical risk index for babies (CRIB)-II scores were higher and more infants received invasive ventilator care ≤ 2 postnatal days. More infants received multiple courses of ibuprofen in clinical symptoms group. Although the frequency of secondary patent ductus arteriosus (PDA) ligation and the incidence of bronchopulmonary dysplasia (BPD) was higher in the clinical symptoms group in the univariate analysis, after multivariate logistic regression analysis adjusting for the CRIB-II score, birthweight, birth year, and the invasive ventilator care ≤ 2 postnatal days, there were no significant differences in mortality, frequency of secondary ligation and in-hospital outcomes including necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), BPD or death. Our data suggest that we can hold off on PDA treatment until the clinical symptoms become prominent. PMID:27914140
Hirt, Déborah; Van Overmeire, Bart; Treluyer, Jean-Marc; Langhendries, Jean-Paul; Marguglio, Arnaud; Eisinger, Mark J; Schepens, Paul; Urien, Saïk
AIMS To describe ibuprofen pharmacokinetics in preterm neonates with patent ductus arteriosus (PDA) and to establish relationships between doses, plasma concentrations and ibuprofen efficacy and safety. METHODS Sixty-six neonates were treated with median daily doses of 10, 5 and 5 mg kg−1 of ibuprofen-lysine by intravenous infusion on 3 consecutive days. A population pharmacokinetic model was developed with NONMEM. Bayesian individual pharmacokinetic estimates were used to calculate areas under the curve (AUC) and to simulate doses. A logistic regression was performed on PDA closure. RESULTS Ibuprofen pharmacokinetics were described by a one-compartment model with linear elimination. Mean population pharmacokinetic estimates with corresponding intersubject variabilities (%) were: elimination clearance CL = 9.49 ml h−1 (62%) and volume of distribution V = 375 ml (72%). Ibuprofen CL significantly increased with postnatal age (PNA): CL = 9.49*(PNA/96.3)1.49. AUC after the first dose (AUC1D), the sum of AUC after the three doses (AUC3D) and gestational age were significantly higher in 57 neonates with closing PDA than in nine neonates without PDA closure (P = 0.02). PDA closure was observed in 50% of the neonates when AUC1D < 600 mg l−1 h (or AUC3D < 900 mg l−1 h) and in 91% when AUC1D > 600 mg l−1 h (or AUC3D > 900 mg l−1 h) (P = 0.006). No correlation between AUC and side-effects could be demonstrated. CONCLUSIONS To achieve these optimal AUCs, irrespective of gestational age, three administrations at 24 h intervals are recommended of 10, 5, 5 mg kg−1 for neonates younger than 70 h, 14, 7, 7 mg kg−1 for neonates between 70 and 108 h and 18, 9, 9 mg kg−1 for neonates between 108 and 180 h. WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Ibuprofen is a nonsteroidal anti-inflammatory agent that induces closure of the patent ductus arteriosus in neonates. Few studies of ibuprofen pharmacokinetics have been performed and were limited to small groups of preterm
Merritt, T A; Harris, J P; Roghmann, K; Wood, B; Campanella, V; Alexson, C; Manning, J; Shapiro, D L
A controlled clinical trial comparing early closure (mean = 48.8 hours) of the patent ductus arteriosus using indomethacin to conventional medical management, with intervention only after cardiopulmonary decompensation (mean = 167.4 hours), was undertaken in 24 preterm infants with severe respiratory distress syndrome and evidence of PDA. An interval analysis of one-half the projected sample revealed that infants undergoing early closure of the PDA had significantly reduced occurrence of BPD or mortality by 6 months of age. A comparison of birth weight, Apgar scores, gestational age, age of initial PDA diagnosis, and fluid therapy during the first seven days of life showed no significant differences between early intervention and control groups. At the time of the interval analysis, there were no differences between the groups in duration of intermittent mandatory ventilation or oxygen exposure. Studies will be required to determine whether these and other variables can be altered by early closure of the PDA.
Sigler, M; Handt, S; Seghaye, M; von Bernuth, G; Grabitz, R
OBJECTIVE—To evaluate the in vivo biocompatibility of three different devices following interventional closure of a patent ductus arteriosus (PDA) in an animal model. MATERIALS AND METHODS—A medical grade stainless steel coil (n = 8), a nickel/titanium coil (n = 10), and a polyvinylalcohol foam plug knitted on a titanium wire frame (n = 11) were used for interventional closure of PDA in a neonatal lamb model. The PDA had been maintained by repetitive angioplasty. Between one and 278 days after implantation the animals were killed and the ductal block removed. In addition to standard histology and scanning electron microscopy, immunohistochemical staining for biocompatibility screening was also undertaken. RESULTS—Electron microscopy revealed the growth of a cellular layer in a cobblestone pattern on the implant surfaces with blood contact, which was completed as early as five weeks after implantation of all devices. Immunohistochemical staining of these superficial cells showed an endothelial cell phenotype. After initial thrombus formation causing occlusion of the PDA after implantation there was ingrowth of fibromuscular cells resembling smooth muscle cells. Transformation of thrombotic material was completed within six weeks in the polyvinylalcohol plug and around the nickel/titanium coil, and within six months after implantation of the stainless steel coil. An implant related foreign body reaction was seen in only one of the stainless steel coil specimens and in two of the nickel/titanium coil specimens. CONCLUSION—After implantation, organisation of thrombotic material with ingrowth of fibromuscular cells was demonstrated in a material dependent time pattern. The time it took for endothelium to cover the implants was independent of the type of implant. Little or no inflammatory reaction of the surrounding tissue was seen nine months after implantation. Keywords: congenital heart disease; patent ductus arteriosus; catheter technique
Terrin, Gianluca; Conte, Francesca; Oncel, Mehmet Yekta; Scipione, Antonella; McNamara, Patrick J; Simons, Sinno; Sinha, Rahul; Erdeve, Omer; Tekgunduz, Kadir S; Dogan, Mustafa; Kessel, Irena; Hammerman, Cathy; Nadir, E; Yurttutan, Sadik; Jasani, Bonny; Alan, Serdar; Manguso, Francesco; De Curtis, Mario
We performed a systematic review and meta-analysis of all the available evidence to assess the efficacy and safety of paracetamol for the treatment of patent ductus arteriosus (PDA) in neonates, and to explore the effects of clinical variables on the risk of closure. MEDLINE, Scopus and ISI Web of Knowledge databases, using the following medical subject headings and terms: paracetamol, acetaminophen and patent ductus arteriosus. Electronic and manual screening of conference abstracts from international meetings of relevant organisations. Manual search of the reference lists of all eligible articles. Studies comparing paracetamol versus ibuprofen, indomethacin, placebo or no intervention for the treatment of PDA. Data regarding efficacy and safety were collected and analysed. Sixteen studies were included: 2 randomised controlled trials (RCTs) and 14 uncontrolled studies. Quality of selected studies is poor. A meta-analysis of RCTs does not demonstrate any difference in the risk of ductal closure (Mantel-Haenszel model, RR 1.07, 95% CI 0.87 to 1.33 and RR 1.03, 95% CI 0.92 to 1.16, after 3 and 6 days of treatment, respectively). Proportion meta-analysis of uncontrolled studies demonstrates a pooled ductal closure rate of 49% (95% CI 29% to 69%) and 76% (95% CI 61% to 88%) after 3 and 6 days of treatment with paracetamol, respectively. Safety profiles of paracetamol and ibuprofen are similar. Efficacy and safety of paracetamol appear to be comparable with those of ibuprofen. These results should be interpreted with caution, taking into account the non-optimal quality of the studies analysed and the limited number of neonates treated with paracetamol so far. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Wustefeld-Janssens, B G; Burrow, R; Mõtsküla, P; Martin, M; Dukes-McEwan, J
Patent ductus arteriosus (PDA) is infrequently reported in cats and represents between 1-7.3 per cent of left to right shunting cardiac congenital anomalies. The objective of this study was to report the presenting complaints, clinical examination findings, diagnostic findings, treatment outcomes and survival times in cats diagnosed with a PDA in the UK. Medical records from three major UK referral centres were searched for cats that were diagnosed with PDA from January 2004 to December 2012. Data obtained for analysis included: signalment, clinical examination findings including murmur characteristics, diagnostic imaging findings, treatment outcomes and survival times. Nineteen cats were included in the analysis. The most common reason for referral was investigation of an incidentally detected heart murmur without clinical signs (13/19; 68 per cent). Pulmonary arterial hypertension (PAH) was diagnosed in seven (37 per cent) cats and those cats with PAH were significantly more likely to present with signs of disease (P=0.004). Median survival time in cats that were diagnosed with PDA and died due to cardiac causes was 898 days (interquartile range 459-1011 days). The median survival time of those cats that had an additional congenital anomaly was significantly shorter to those cats without a congenital anomaly (P=0.008). British Veterinary Association.
Dang, Dan; Wang, Dongxuan; Zhang, Chuan; Zhou, Wenli; Zhou, Qi; Wu, Hui
Oral ibuprofen has demonstrated good effects on symptomatic patent ductus arteriosus (PDA) but with many contraindications and potential side-effects. In the past two years, oral paracetamol administration to several preterm infants with PDA has been reported. Here, a randomized, non-blinded, parallel-controlled and non-inferiority trial was designed to evaluate the efficacy and safety profiles of oral paracetamol to those of standard ibuprofen for PDA closure in premature infants. One hundred and sixty infants (gestational age ≤ 34 weeks) with echocardiographically confirmed PDA were randomly assigned to receive either oral paracetamol (n = 80) or ibuprofen (n = 80). After the initial treatment course in both groups, the need for a second course was determined by echocardiographic evaluation. The main outcome was rate of ductal closure, and secondary outcomes were adverse effects and complications. The ductus was closed in 65 (81.2%) infants of the paracetamol group compared with 63 (78.8%) of the ibuprofen group. The 95% confidence interval of the difference between these groups was [-0.080,0.128], demonstrating that the effectiveness of paracetamol treatment was not inferior to that of ibuprofen. In fact, the incidence of hyperbilirubinemia or gastrointestinal bleeding in the paracetamol group was significantly lower than that of the ibuprofen group. No significant differences in other clinical side effects or complications were noted. This comparison of drug efficacy and safety profiles in premature infants with PDA revealed that oral paracetamol was comparable to ibuprofen in terms of the rate of ductal closure and even showed a decreased risk of hyperbilirubinemia or gastrointestinal bleeding. Therefore, paracetamol may be accepted as a first-line drug treatment for PDA in preterm infants. ChiCTR.org ChiCTR-TRC-12002177.
Joseph, George; Mandalay, Asishkumar; Zacharias, T U; George, Biju
A 21-year-old female developed severe unremitting intravascular hemolysis following closure of a large patent ductus arteriosus using an Amplatzer duct occluder. Percutaneous deployment of fibered platinum coils within the nitinol wire cage of the Amplatzer duct occluder abolished the residual shunt through the device and resulted in cessation of intravascular hemolysis and reversal of its adverse sequelae. Copyright 2002 Wiley-Liss, Inc.
Jesudian, Vimala; Ravikumar, Radhakrishnan; Kumar, R Suresh
Right aortic arch with isolation of the left subclavian artery is a rare anomaly. It has been reported to occur with conotruncal anomalies and may be associated with 22q11 deletion. Multidetector-row computed tomographic angiogram images of a 15-year-old African boy with Tetralogy of Fallot who had right aortic arch and isolated left subclavian artery arising from the left pulmonary artery by way of ductus arteriosus are presented.
Brissaud, Olivier; Guichoux, Julie
Patent ductus arteriosus (PDA) is one of the most common problems in the care of premature infants, especially the extremely premature. There is no real consensus regarding the diagnostic criteria or treatment of a hemodynamically significant PDA. Its diagnosis, assessment, and treatment still remain challenges. Therefore, we investigated clinical practices in French tertiary neonatology centers regarding the management of PDA to compare their similarities and differences. We sent a questionnaire by email to the PDA specialist in every French tertiary neonatal intensive care unit. It contained 27 items regarding the unit's structure, method of diagnosing PDA, and treatment choices. The completed questionnaire were returned via email and analyzed blindly. The questionnaire response rate was 87.5%, which allowed us to draw some conclusions regarding French clinical practices in the care of neonates with PDA. Although the diagnostic criteria are quite similar, the therapeutic practices are rather different across neonatal care units. We highlight the great variability in French clinical practices when it comes to treating PDA and underscore the necessity for harmonization of these practices, which could be achieved using multicenter, randomized studies to identify the advantages of one approach compared with another.
Bhattacharya, Shoumo; Chen, Yiwei; Hu, Jingjing; Li, Fen
Background Patent ductus arteriosus (PDA) is one of the most common congenital heart defects. Transcription factor AP-2 beta (TFAP2B) mutations are associated with the Char syndrome, a disorder associated with PDA, and with facial and fingers abnormalities. Recently, we identified two TFAP2B mutations in two families without Char syndrome phenotype, c.601+5G>A and c.435_438delCCGG, and these TFAP2B mutations were associated with familial isolated PDA. The aim of this study was to identify the effects of these mutations on TFAP2B function. Methods Plasmids containing the wild-type or mutated TFAP2B were constructed and transfected in cells. Plasmids containing the TFAP2B coactivator, Cpb/p300-interacting transactivator 2 (CITED2), was also transfected. TFAP2B expression was detected by luciferase expression and by Western blot analysis. Results These mutations resulted in loss of transactivation function, which could not be improved by Cpb/p300-interacting transactivator 2. The c.601+5G>A mutated gene did not express any protein, whereas the c.435_438delCCGG mutation did not impact the transactivation function activated by the wild-type TFAP2B. Conclusions These results suggest that a haploinsufficiency effect of TFAP2B could be involved in familial isolated PDA. PMID:24507797
Mannan, Javed; Amin, Sanjiv B
Objective This study aims to perform a meta-analysis of randomized studies to evaluate if chest shielding during phototherapy is associated with decreased incidence of patent ductus arteriosus (PDA) in premature infants. Design/Methods We used published guidelines for the meta-analysis of clinical trials. The search strategy included electronic searches of CINAHL, CENTRAL Cochrane Library, MEDLINE, PubMed, and abstracts presented at the Pediatric Academic Societies. Inclusion criteria were randomized controlled trials (RCTs), quasi-RCTs or cluster RCTs published in English and involving chest shielding during phototherapy in premature infants with PDA as an outcome. Exclusion criteria involved case reports, case series, and multiple publications from the same author. Heterogeneity testing using Q statistics was performed to evaluate the variance between studies. Results Two RCTs met study criteria. There was heterogeneity (I(2): 55.4%) between the two trials. Meta-analysis of RCTs using the random effect model demonstrated that chest shielding during phototherapy was associated with decreased incidence of PDA (odds ratio: 0.47, 95% confidence interval: 0.23-0.96). There was no publication bias on Eggers test. Heterogeneity was seen in gestational age, gender, prophylactic use of postnatal indomethacin, duration of phototherapy, and assessment of PDA. Conclusion Chest shielding during phototherapy may be associated with decreased incidence of PDA among premature infants. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Furzan, J A; Reisch, J; Tyson, J E; Laird, P; Rosenfeld, C R
The incidence of symptomatic patent ductus arteriosus (sPDA) in very-low-birth-weight infants has been reported almost exclusively from referral centers. Moreover, the incidence has varied considerably. We prospectively evaluated the incidence and risk factors of sPDA in a totally inborn population of infants less than or equal to 1500 g birth weight (n = 120) receiving conservative fluid management and examined the role of echocardiography in predicting sPDA before clinical signs are evident. The incidence of sPDA was relatively low (16%) and the age at onset was relatively late (mean +/- S.E. = 14.7 +/- 3.0 days) when compared to prior reports. Echocardiographic changes preceded physical and radiographic findings of sPDA. Fluid volume within the range administered to our infants was unrelated to the occurrence of sPDA. However, risk factors identifiable within 24 h of birth were defined: obstetric estimate of gestational age, race, mean fluid volume intake in the initial 24 h, and early treatment with volume expanders. From these risk factors, 79% of infants with sPDA and 79% without sPDA could be predicted by stepwise discriminant function analyses. These findings may be employed in studies needed to assess the benefit of early surgical or pharmacologic therapy for infants at highest risk for sPDA.
Oncel, Mehmet Yekta; Yurttutan, Sadik; Erdeve, Omer; Uras, Nurdan; Altug, Nahide; Oguz, Serife Suna; Canpolat, Fuat Emre; Dilmen, Ugur
To compare the efficacy and safety of oral paracetamol and oral ibuprofen for the pharmacological closure of patent ductus arteriosus (PDA) in preterm infants. This prospective, randomized, controlled study enrolled 90 preterm infants with gestational age ≤ 30 weeks, birthweight ≤ 1250 g, and postnatal age 48 to 96 hours who had echocardiographically confirmed significant PDA. Each enrolled patient received either oral paracetamol (15 mg/kg every 6 hours for 3 days) or oral ibuprofen (initial dose of 10 mg/kg, followed by 5 mg/kg at 24 and 48 hours). Spontaneous closure rate for the entire study group was 54%. After the first course of treatment, the PDA closed in 31 (77.5%) of the patients assigned to the oral ibuprofen group vs 29 (72.5%) of those enrolled in the oral paracetamol group (P = .6). The reopening rate was higher in the paracetamol group than in the ibuprofen group, but the reopening rates were not statistically different (24.1% [7 of 29] vs 16.1% [5 of 31]; P = .43). The cumulative closure rates after the second course of drugs were high in both groups. Only 2 patient (2.5%) in the paracetamol group and 3 patients (5%) in the ibuprofen group required surgical ligation. This randomized, controlled clinical study compared oral paracetamol with ibuprofen in preterm infants and demonstrated that paracetamol may be a medical alternative in the management of PDA. Copyright © 2014 Mosby, Inc. All rights reserved.
Fajardo, Maria Florencia; Claure, Nelson; Swaminathan, Sethuraman; Sattar, Sumbal; Vasquez, Amelia; D'Ugard, Carmen; Bancalari, Eduardo
Left to right (L-R) shunting through a patent ductus arteriosus (PDA) can reduce systemic and cerebral blood flow in preterm infants. To minimize this, the positive end-expiratory pressure (PEEP) is often raised to increase pulmonary vascular resistance and reduce L-R shunting. The effects of this maneuver on systemic and cerebral hemodynamics and oxygenation are not well documented. To compare the effects of different PEEP on the left ventricular output (LVO), superior vena cava (SVC) flow, LVO/SVC flow ratio, cerebral oxygenation (CrSO2) and gas exchange in mechanically ventilated preterm infants with PDA. Sixteen mechanically ventilated infants of 23-30 weeks' gestational age with L-R shunting through the PDA were studied. Ultrasound measurements of LVO and SVC flow, CrSO2, arterial oxygen saturation and transcutaneous CO2 tension (TcPCO2) obtained at PEEP of 2 and 8 cm H2O were compared with baseline values at 5 cm H2O. There was a small but significant reduction in LVO and the LVO/SVC flow ratio at PEEP of 8 compared to 5 cm H2O. SVC flow and CrSO2 did not differ significantly. Increasing PEEP to 8 cm H2O in ventilated preterm infants with a PDA produced a modest decrease in L-R ductal shunting as indicated by a lower LVO/SVC flow ratio. The higher PEEP did not have a significant effect on cerebral perfusion or oxygenation. © 2013 S. Karger AG, Basel.
Kang, Sok-Leng; Jivanji, Salim; Mehta, Chetan; Tometzki, Andrew J; Derrick, Graham; Yates, Robert; Khambadkone, Sachin; de Giovanni, Joseph; Stumper, Oliver; Dhillon, Rami; Bhole, Vinay; Slavik, Zdenek; Rigby, Michael; Noonan, Patrick; Smith, Ben; Knight, Brodie; Richens, Trevor; Wilson, Neil; Walsh, Kevin; James, Adam; Thomson, John; Bentham, Jamie; Hayes, Nicholas; Nazir, Sajid; Adwani, Satish; Shauq, Arjamand; Ramaraj, Ram; Duke, Christopher; Taliotis, Demetris; Kudumula, Vikram; Yong, San-Fui; Morgan, Gareth; Rosenthal, Eric; Krasemann, Thomas; Qureshi, Shakeel; Crossland, David; Hermuzi, Tony; Martin, Robin P
This study aimed to report our national experience with transcatheter patent ductus arteriosus (PDA) occlusion in infants weighing <6 kg. The technique of transcatheter PDA closure has evolved in the past two decades and is increasingly used in smaller patients but data on safety and efficacy are limited. Patients weighing < 6 kg in whom transcatheter PDA occlusion was attempted in 13 tertiary paediatric cardiology units in the United Kingdom and Ireland were retrospectively analyzed to review the outcome and complications. A total of 408 patients underwent attempted transcatheter PDA closure between January 2004 and December 2014. The mean weight at catheterization was 4.9 ± 1.0 kg and mean age was 5.7 ± 3.0 months. Successful device implantation was achieved in 374 (92%) patients without major complication and of these, complete occlusion was achieved in 356 (95%) patients at last available follow-up. Device embolization occurred in 20 cases (5%). The incidence of device related obstruction to the left pulmonary artery or aorta and access related peripheral vascular injury were low. There were no deaths related to the procedure. Transcatheter closure of PDA can be accomplished in selected infants weighing <6 kg despite the manufacturer's recommended weight limit of 6 kg for most ductal occluders. The embolization rate is higher than previously reported in larger patients. Retrievability of the occluder and duct morphology needs careful consideration before deciding whether surgical ligation or transcatheter therapy is the better treatment option. © 2017 Wiley Periodicals, Inc.
Goudjil, Sabrina; Imestouren, Fatiha; Armougon, Aurelie; Razafimanantsoa, Lucie; Mahmoudzadeh, Mahdi; Wallois, Fabrice; Leke, André; Kongolo, Guy
To evaluate the impact of patent ductus arteriosus (PDA) on the pulse phase difference (PPD) between the left foot (postductal region) and the right hand (preductal region). PPD was determined from arterial photoplethysmography signals (pulse waves) measured by infrared sensors routinely used for pulse oximetry in 56 premature infants less than 32 weeks gestation. Only infants with significant PDA (sPDA) diagnosed by echocardiography were treated with ibuprofen (for 3 days). Patients were classified according to whether or not they responded (Success/Failure) to this treatment. The Control group was composed of infants in whom ductus had already closed spontaneously at the time of the first echocardiography. The 3 groups were compared in terms of PPD at the beginning (T1) and at the end (T2) of the study. For patients in the Failure (n = 17) and Success groups (n = 18), T1 corresponded to the first day of treatment and T2 to the day after completion of the course of ibuprofen. In the Control group (n = 21), T1 corresponded to 1 to 3 days of life (DOL), and T2 to 4-6 DOL. Compared to the Control group, PPD was higher in the Failure (at T1 and T2) and Success (at T1) groups characterized by sPDA. After ibuprofen therapy, PPD in the Success group decreased to about the level observed in the Control group. The area under the ROC curve of PPD for the diagnosis of sPDA was 0.98 (95% CI 0.96-1); for an optimal cut-off of PPD ≥ 1.65 deg/cm, the sensitivity was 94.2% and the specificity was 98.3%. In this study, PPD was correlated with ductus arteriosus status evaluated by echocardiography, indicating involvement of the ductal shunt in the mechanism of redistribution in systemic vascular territories. PPD can be considered for the diagnosis of hemodynamically significant PDA.
Davis, P; Turner-Gomes, S; Cunningham, K; Way, C; Roberts, R; Schmidt, B
To determine the precision (interobserver agreement) and accuracy (agreement with criterion standard) of clinical and radiological signs in premature infants at risk of patent ductus arteriosus (PDA) with left-to-right shunting. Masked comparison of clinical and radiological examination with Doppler flow echocardiography (criterion standard). Neonatal intensive care unit. One hundred infants with birth weights less than 1750 g were studied once between days 3 and 7 of life. A third of the cohort was intubated at the time of study. Five independent observers noted the presence or absence of an increased pulse volume, an active precordium, a heart murmur, a cardiothoracic ratio greater than 60%, increased pulmonary vascular markings on a concurrent chest x-ray film, and a relative increase of the cardiothoracic ratio compared with that from the previous chest x-ray film. Pulsed and color flow Doppler echocardiography was performed within 4 hours. All 100 tapes were reviewed by a second pediatric cardiologist. Twenty-three infants had a PDA with left-to-right shunting. The precision of clinical signs was modest, with average kappa values of 0.15 for pulse volume, 0.32 for precordium, and 0.41 for murmur. Pulse quality (43%) and murmur (42%) had the highest mean sensitivities. Corresponding specificities were 74% for pulse volume and 87% for murmur. The combination of a cardiac murmur with an abnormal pulse volume had the highest positive predictive value (77%). The radiological examination did not improve the observers' ability to distinguish between patients with and without PDA. The precision and accuracy of clinical and radiological signs of a PDA with left-to-right shunting are unsatisfactory. Therefore, Doppler flow echocardiography is required to diagnose PDA confidently in preterm infants between days 3 and 7 of life.
Liebowitz, Melissa; Clyman, Ronald I
To determine whether prophylactic indomethacin (PINDO) has more or less morbidity than delayed conservative management of the moderate-to-large patent ductus arteriosus (PDA). We performed a prospective double cohort controlled study of infants delivered at ≤27(6/7) weeks gestation (n = 397). From January 2005 through April 2011, all infants were treated with PINDO (n = 247). From May 2011 through August 2016, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch, n = 150). Echocardiograms were performed on day 7 and at planned intervals until the PDA was small or closed. A single neonatologist prospectively collected all data. The incidence of moderate-to-large PDA on day 7 and duration of exposure to moderate-to-large PDA were significantly less in the PINDO epoch (incidence = 10%, median = 2 days) than the conservative epoch (incidence = 67%, median = 14 days). Ligation rates were low in both epochs (PINDO = 14%, conservative = 5%). In multivariate analyses, PINDO infants had a significantly lower incidence of bronchopulmonary dysplasia (BPD) (risk ratio = 0.68, CI: 0.46-0.89) and BPD or death (risk ratio= 0.78, CI: 0.62-0.95) than conservative infants. There were no differences between the epochs in death, intraventricular hemorrhage grades 3 and 4, necrotizing enterocolitis, or retinopathy of prematurity receiving treatment. The effects of PINDO on BPD and BPD or death were no longer significant when analyses were adjusted for presence of a moderate-to-large PDA on day 7. The significant effects of PINDO were independent of whether or not a ligation was performed. PINDO decreases BPD and BPD or death compared with delayed conservative PDA management. These effects are mediated by closure of the PDA. Copyright © 2017 Elsevier Inc. All rights reserved.
Boghossian, Nansi S; Do, Barbara T; Bell, Edward F; Dagle, John M; Brumbaugh, Jane E; Stoll, Barbara J; Vohr, Betty R; Das, Abhik; Shankaran, Seetha; Sanchez, Pablo J; Wyckoff, Myra H; Bethany Ball, M
Optimal management of the patent ductus arteriosus (PDA) in preterm infants remains controversial. Therefore, studies identifying infants who are most likely to benefit from PDA treatment are needed. We sought to examine if significant intrauterine growth restriction, defined by birth weight z-score, reduces the efficacy of PDA closure with indomethacin or ibuprofen and thereby increases the need for surgical closure of PDA after pharmacologic treatment. We studied infants 23-28weeks' gestation born 2006-2013 at NICHD Neonatal Research Network centers. We examined the responses to PDA treatment with indomethacin and/or ibuprofen and whether the PDA was subsequently closed surgically. Logistic regression generated adjusted odds ratios (ORs) for the associations between the z-score groups (<-2, -2 to -0.5, and >-0.5) and PDA surgery following pharmacologic treatment. 5606 infants were diagnosed with PDA; 3587 (64.0%) received indomethacin or ibuprofen or both, and 909 (25.3%) underwent PDA surgery. Mothers of infants with PDA non-closure were less likely to have hypertension (19% vs. 28%). Infants with non-closure were more likely to be female (53% vs. 49%), have lower gestational age and birth weight and to develop sepsis (42% vs. 31%). Compared to infants with z-score>-0.5, PDA surgery was increased among infants with z-score -2 to -0.5 (OR=1.23; 95% CI 1.02-1.47) but not among infants with z-score<-2. Infants with birth weight z-score -2 to -0.5 are more likely than normally grown infants to require PDA surgery following pharmacologic treatment. Copyright © 2017 Elsevier B.V. All rights reserved.
Demir, Nihat; Peker, Erdal; Ece, İbrahim; Balahoroğlu, Ragıp; Tuncer, Oğuz
To compare rectal ibuprofen with oral ibuprofen for the closure of hemodynamically significant patent ductus arteriosus (hsPDA) in very low birth weight (VLBW) preterm infants. In a prospective, randomized study, 72 VLBW infants who had hsPDA received either rectal or oral ibuprofen. The plasma concentration of ibuprofen and renal functions were determined in both groups by the high-performance liquid chromatography (HPLC) method and cystatin-C (cys-C), respectively. The hsPDA closure rate of the group that received rectal ibuprofen was similar to oral ibuprofen (86.1% versus 83.3%) after the first course of the treatment (p = 0.745). A statistically significant difference was identified between the mean plasma cys-C levels before and after treatment in both the rectal and oral ibuprofen groups (p = 0.004 and p< 0.001, respectively). The mean plasma ibuprofen concentration was similar in both groups after the first dose (rectal 44.06 ± 12.4; oral, 48.28 ± 22.8) and the third dose (rectal, 45.34 ± 24.3; oral, 48.94 ± 24.8) (p > 0.05 for all values). Rectal ibuprofen is as effective as oral ibuprofen for hsPDA closure in VLBW infants. The rise in the cys-C level with rectal and oral treatment shows that patients with borderline renal function should be evaluated and followed closely.
Breatnach, Colm R; Franklin, Orla; James, Adam T; McCallion, Naomi; El-Khuffash, Afif
Right ventricular (RV) functional assessment in premature infants includes basal longitudinal strain (RV BLS), RV systolic tissue Doppler velocity (RV s'), tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (FAC). A hyperdynamic left ventricle (LV) may influence RV measures of displacement (TAPSE) and velocity (RV s') but not measures of relative change of length (RV BLS) or area (FAC). We aimed to explore this hypothesis in preterm infants with a patent ductus arteriosus (PDA). We measured LV function (ejection fraction (LV EF); left ventricular output) and RV function (RV BLS; RV s'; TAPSE; FAC) on days 1, 2 and 5-7 in infants <29 weeks. The cohort was divided based on PDA presence by days 5-7. LV and RV function measurements were compared between the groups using two-way analysis of variance with repeated measures. 121 infants with a mean (SD) gestation and birth weight of 26.8 (1.4) weeks and 968 (250) g were enrolled. By days 5-7, the PDA remained open in 83 (69%), with evidence of hyperdynamic LV function. There was no difference in RV s' (5.3 (0.9) vs 5.1 (1.0) cm/s, p=0.3) or TAPSE (6.2 (1.3) vs 6.1 (1.2) mm, p=0.7) between infants with and without a PDA, but infants in the PDA group had lower RV FAC (41 (8) vs 47 (10) %, p<0.01) and lower RV BLS (-24.2 (5.0) vs -26.2 (4.1) %, p=0.03). LV influence on RV functional parameters must be taken into account when interpreting of RV function using those techniques. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Leonhardt, A; Strehl, R; Barth, H; Seyberth, H W
To determine the efficacy and the renal side effects of indomethacin treatment for closure of a patent ductus arteriosus (PDA) in premature infants during an individualized fluid regime that avoids hypovolaemia and subsequent prostaglandin-dependent renal perfusion. Observational retrospective analysis of the efficacy of indomethacin in premature infants with PDA treated in a single institution from June 1992 to May 2000. The clinical course and renal effects were analysed in the subgroup of infants born from June 1995 to May 2000. The management of infants at risk and the treatment of infants with PDA followed a standardized protocol that included echocardiographic screening for PDA, indomethacin treatment before congestive failure develops (early symptomatic treatment) and an individualized fluid intake. In total, 412 infants with a gestational age < or = 32 wk were identified. Fifty-six infants with a PDA (14%) were treated with indomethacin [mean birthweight 936 (95% confidence interval 866-1006) g; gestational age 27.3 (26.8-27.9) wk]. Indomethacin treatment was successful in 52 infants (93%). The clinical course and renal effects were analysed in 41 infants. Most infants received three indomethacin doses of 0.2 mg kg(-1) every 12 h. Urine output transiently decreased from 5.6 (4.6-6.4) to 4.6 (3.9-5.3) ml kg(-1) (h(-1). Serum creatinine temporarily increased from 0.90 (0.83-0.98) to 1.06 (0.87-1.24)mg dl(-1). Fluid intake was 158 (148-168) ml kg(-1) d(-1) before indomethacin and decreased to 142 (131-154) ml kg(-1) d(-1). Indomethacin is very effective for closure of a PDA, even in very premature infants, and is not associated with clinically significant renal side effects.
Kushnir, Alla; Pinheiro, Joaquim Mb
Ibuprofen treatment of patent ductus arteriosus (PDA) has been shown to be as effective as indomethacin in small randomized controlled trials, with possibly fewer adverse effects. However, adverse renal effects of ibuprofen have been noted in some trials and suspected in our practice.The purpose of this study was to examine whether ibuprofen and indomethacin treatment of PDA have comparable effects on renal function as evidenced by urine output and serum creatinine. Retrospective chart review of 350 patients. Serum creatinine and urine output were recorded prior to start of treatment, during each course and after the last course of treatment. Pre-treatment mean creatinine and urine output values were compared to treatment and post treatment means using 2-factor repeated measures ANOVA. 165 patients were treated with indomethacin (2005-2006) and 185 received ibuprofen (2007-2008). There was no difference between treatment groups in demographics or baseline renal function. For both groups, the number of treatment courses was inversely correlated with birth weight and gestational age. Analysis of the first course including all patients, revealed significant increase in creatinine and decrease in urine output with both drugs, with a more pronounced effect of indomethacin on creatinine. In the subgroup of 219 patients who received only one treatment course, there was a significant increase in creatinine after indomethacin, but not after ibuprofen. In the 131 who received 2 or more courses, the decrease in urine output and increase in creatinine were not different between drugs. There were significant decreases in urine output observed in the second and third courses of ibuprofen treatment (both by 0.9 mL/kg/hr). Both drugs have a similar short-term effect on renal function. Indomethacin had a more prominent initial effect, while ibuprofen decreased renal function during the second and third courses similarly to indomethacin. The changes in renal function seen with
Djer, Mulyadi M; Saputro, Dimas Dwi; Putra, Sukman Tulus; Idris, Nikmah Salamia
Transcatheter closure of patent ductus arteriosus (PDA) has been suggested to be the standard treatment of PDA. Although, in general, the procedure shows a high successful rate, outcomes may vary among pediatric cardiology centers. To evaluate the effectiveness of transcatheter closure of PDA in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, this was a retrospective study on patients who underwent transcatheter closure of PDA in Cipto Mangunkusumo Hospital during the period of 2002-2013. Hospital registry was reviewed and data about patients' characteristics, PDA severity, procedure, and outcomes were retrieved. There were 298 patients, of whom 90 were males, who underwent transcatheter closure of PDA during the study period. Median age was 3.4 years (1 months-18 years), and median body weight was 12 (3.6-59) kg. The diameter of PDA ranged from 1.1 to 15.4 mm with a median of 3.7 mm. Device could be deployed in all patients, in which most were the Amplatzer ductal occluder (69.8 %) and the remainders were coils. Median fluoroscopy time was 15.4 (1.5-87) min, and procedure time was 76 (30-200) min. Complete closure was achieved in most patients (97.3 %), whereas device migration occurred in a minority (0.3 %) of patients. No major complication occurred during or after the procedure. Transient anemia and bradycardia were found in 3.7 and 1.3 % patients, respectively. Most patients were discharged from the hospital at 1 day after the procedure. Transcatheter closure method is a safe and effective procedure to close PDA.
Shankaran, Seetha; McDonald, Scott A.; Das, Abhik; Ehrenkranz, Richard A.; Goldberg, Ronald N.; Stoll, Barbara J.; Tyson, Jon E.; Higgins, Rosemary D.; Schendel, Diana; Hougaard, David M; Skogstrand, Kristin; Thorsen, Poul; Carlo, Waldemar A.
Permanent ductal closure involves anatomic remodeling, in which transforming growth factor (TGF)-β appears to play a role. Our objective was to evaluate the relationship, if any, between blood spot TGF-β on day 3 and day 7 of life and patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. Prospective observational study involving ELBW infants (n = 968) in the National Institute of Child Health and Human Development Neonatal Research Network who had TGF-β measured on filter paper spot blood samples using a Luminex assay. Infants with a PDA (n = 493) were significantly more immature, had lower birth weights, and had higher rates of respiratory distress syndrome than those without PDA (n = 475). TGF-β on days 3 and 7 of life, respectively, were significantly lower among neonates with PDA (median 1,177 pg/ml [range 642–1,896]; median 1,386 pg/ml [range 868–1,913]) compared with others without PDA (median 1,334 pg/ml [range 760–2,064]; median 1,712 pg/ml [range 1,014–2,518 pg/ml]). The significant difference persisted when death or PDA was considered a composite outcome. TGF-β levels were not significantly different among subgroups of infants with PDA who were not treated (n = 51) versus those who were treated medically (n = 283) or by surgical ligation (n = 159). TGF-β was not a significant predictor of death or PDA (day 3 odds ratio [OR] 0.99, 95 % confidence interval [CI] 0.83–1.17; day 7 OR 0.88, 95 % CI 0.74–1.04) on adjusted analyses. Our results suggest that blood spot TGF-β alone is unlikely to be a reliable biomarker of a clinically significant PDA or its responsiveness to treatment. PMID:22684193
Blohm, Martin Ernst; Hartwich, Jana; Obrecht, Denise; Kersten, Jan Felix; Singer, Dominique
This prospective single-center observational study compared impedance cardiography [electrical velocimetry (EV)] with transthoracic echocardiography (TTE, based on trans-aortic flow) and analyzed the influence of physiological shunts, such as patent ductus arteriosus (PDA) or patent foramen ovale (PFO), on measurement accuracy. Two hundred and ninety-one triplicate simultaneous paired left ventricular stroke volume (LVSV) measurements by EV (LVSVEV) and TTE (LVSVTTE) in 99 spontaneously breathing neonates (mean weight 3270 g; range 1227-4600 g) were included. For the whole cohort, the mean absolute LVSVEV was 5.5 mL, mean LVSVTTE was 4.9 mL, resulting in an absolute Bland-Altman bias of -0.7 mL (limits of agreement LOA -3.0 to 1.7 mL), relative bias -12.8 %; mean percentage error MPE 44.9 %; true precision TPEV 33.4 % (n = 99 aggregated data points). In neonates without shunts (n = 32): mean LVSVEV 5.0 mL, mean LVSVTTE 4.6 mL, Bland-Altman bias -0.4 mL (LOA -2.8 to 2.0 mL), relative bias -8.2 %; MPE 50.7 %; TPEV 40.9 %. In neonates with shunts (PDA and/or PFO; n = 67): mean LVSVEV 5.8 mL, mean LVSVTTE 5.0 mL, bias -0.8 mL (LOA -3.1 to 1.5 mL), relative bias -14.8 %, MPE 41.9 %, TPEV 29.3 %. Accuracy was affected by PDA and/or PFO, with a significant increase in the relative difference in LVSVEV versus LVSVTTE: Subjects without shunts -2.9 % (n = 91), PFO alone -9.6 % (n = 125), PDA alone -14.0 % (n = 12), and PDA and PFO -18.5 % (n = 63). Physiological shunts (PDA and/or PFO) in neonates affect measurement accuracy and cause overestimation of LVSVEV compared with LVSVTTE.
Stern, Seth J; Wadekar, Neelum; Mertens, Luc; Manlhiot, Cedric; McCrindle, Brian W; Jaeggi, Edgar T; Nield, Lynne E
Foetuses with simple tetralogy of Fallot almost universally have a patent ductus arteriosus. Two recently identified cases had an absent patent ductus arteriosus, requiring emergent intervention at birth. The objective of this study was to determine whether foetuses diagnosed with tetralogy of Fallot and no patent ductus arteriosus have poorer outcomes compared with those with tetralogy of Fallot+patent ductus arteriosus. All foetal cases of tetralogy of Fallot between January, 2000 and 2012 were retrospectively identified from The Hospital for Sick Children (Toronto, Canada) database. Cases - tetralogy of Fallot+no patent ductus arteriosus confirmed on postnatal echo - and controls - tetralogy of Fallot+patent ductus arteriosus, matched for gestational age - were identified from prenatal records, and both clinical and echocardiographic data were reviewed. Optimal outcome was defined as valve-sparing repair with no residual lesions. Student's t-tests and Fisher's exact χ2 were used to compare groups. n=115 foetuses were diagnosed with tetralogy of Fallot: 11 (9%) had no patent ductus arteriosus, and were matched to 22 controls - mean gestational age at diagnosis 23.2±4.2 weeks, 23.4±6.6 weeks, respectively. Cases had a higher proportion of right aortic arches (64% versus 14%, p<0.001). Foetal and postnatal echocardiographic data did not reveal significant differences in branch pulmonary artery sizes, pulmonary valve sizes, or ventricular function. No differences were identified for cyanosis at birth (2/10 versus 7/20, p=0.67), or catheter intervention (5/10 versus 4/22, p=0.12). Optimal outcome rates were similar between cases and controls (4/11 (36%) versus 5/21 (24%), p=0.68). The patent ductus arteriosus does not appear to have an impact on clinical outcome in foetuses with tetralogy of Fallot.
Tefera, Endale; Qureshi, Shakeel A; Bermudez-Cañete, Ramòn; Rubio, Lola
At high altitude, patent arterial ducts tend to be larger and associated with pulmonary hypertension. Patent ductus arteriosus device closure in this background could be challenging. We report our experience with percutaneous closure of patent arterial ducts using a variety of devices in patients residing in a high altitude. This is a retrospective review of the case records of 145 patients (age 9 months-20 years, mean 5.6 ± 3.9 years, and weight 7-54 kg, mean 17.7 ± 9.4) with duct sizes ranging between 2 and 21 mm, (mean, 5.8 ± 2.7) who underwent percutaneous closure of patent arterial ducts. One hundred thirty-six (93.8%) of the patients were from a geographic area of 2100-2800 m above sea level. Successful device closure was achieved in 143 cases. It was difficult to achieve device stability in two patients with expansile ducts. Therefore, they were treated surgically. The devices used were various types of duct occluder devices in 131 patients, while atrial and ventricular septal occluders were used in eight patients. For the group, mean systolic pulmonary artery (PA) pressure decreased from 47.0 ± 16.7 mmHg before occlusion to 29.0 ± 7.4 mmHg after occlusion (P ≤ 0.001)., mean diastolic PA pressure from 25.0 ± 10.9 mmHg to 14.8 ± 6.0 mmHg and the average mean PA pressure decreased from 35.9 ± 13.5 mmHg to 21.1 ± 6.5 mmHg. Complications (4.8%) included device and coil embolization, bleeding, and pulse loss. On follow-up (mean duration of 36.1 ± 12.1 months, range 12-62 months), 137 patients were in functional class 1, 3 had residual shunt, 2 had device migration and one patient had persisting pulse loss. Successful duct closure was achieved in the vast majority of patients, even though the ducts were larger and significant number of them had pulmonary hypertension in this high altitude group. There was a relatively higher incidence of residual shunts and device migration in this series, generally due to the nonavailability of optimal device and
Preoperative left ventricular internal dimension in end-diastole as earlier identification of early patent ductus arteriosus operation and postoperative intensive care in very low birth weight infants.
Saida, Ken; Nakamura, Tomohiko; Hiroma, Takehiko; Takigiku, Kiyohiro; Yasukochi, Satoshi
Patent ductus arteriosus (PDA) is common in premature infants. In very low birth weight infants (VLBWI), PDA requires surgical therapy in many cases. It is unclear to know at-risk infants showing cardio-dysfunction after PDA surgery. The purpose of this study was to identify at-risk infants showing cardio-dysfunction after surgery for patent ductus arteriosus (PDA). We examined the relationship between left ventricular (LV) performance before and after PDA ligation in a retrospective observational cohort study. We studied 64 preterm neonates with symptomatic PDA before and after surgical ligation. Echocardiographic examinations were performed pre- and postoperatively. M-mode measurements included left ventricular internal dimension in end-diastole (LVIDd) and LV fractional shortening (FS). All cases showed decreased LVFS after PDA closure. Most cases (49/64, 77%) showed postoperative FS decreased to below normal (<28%). Preoperative relative LVIDd was significantly larger in abnormal FS infants (137 ± 18%) than in normal FS infants (118 ± 11%; p<0.01). A cut-off value of preoperative relative LVIDd (absolute LVIDd/normal value) for predicting postoperative cardio-dysfunction was 127.4% (sensitivity, 0.735; specificity, 0.933; area under curve, 0.817). Determination of preoperative LVIDd might facilitate earlier identification of infants needing early PDA surgery and postoperative intensive care. © 2013 Elsevier Ireland Ltd. All rights reserved.
Quintero-Rivera, Fabiola; Xi, Qiongchao J.; Keppler-Noreuil, Kim M.; Lee, Ji Hyun; Higgins, Anne W.; Anchan, Raymond M.; Roberts, Amy E.; Seong, Ihn Sik; Fan, Xueping; Lage, Kasper; Lu, Lily Y.; Tao, Joanna; Hu, Xuchen; Berezney, Ronald; Gelb, Bruce D.; Kamp, Anna; Moskowitz, Ivan P.; Lacro, Ronald V.; Lu, Weining; Morton, Cynthia C.; Gusella, James F.; Maas, Richard L.
Cardiac left ventricular outflow tract (LVOT) defects represent a common but heterogeneous subset of congenital heart disease for which gene identification has been difficult. We describe a 46,XY,t(1;5)(p36.11;q31.2)dn translocation carrier with pervasive developmental delay who also exhibited LVOT defects, including bicuspid aortic valve (BAV), coarctation of the aorta (CoA) and patent ductus arteriosus (PDA). The 1p breakpoint disrupts the 5′ UTR of AHDC1, which encodes AT-hook DNA-binding motif containing-1 protein, and AHDC1-truncating mutations have recently been described in a syndrome that includes developmental delay, but not congenital heart disease [Xia, F., Bainbridge, M.N., Tan, T.Y., Wangler, M.F., Scheuerle, A.E., Zackai, E.H., Harr, M.H., Sutton, V.R., Nalam, R.L., Zhu, W. et al. (2014) De Novo truncating mutations in AHDC1 in individuals with syndromic expressive language delay, hypotonia, and sleep apnea. Am. J. Hum. Genet., 94, 784–789]. On the other hand, the 5q translocation breakpoint disrupts the 3′ UTR of MATR3, which encodes the nuclear matrix protein Matrin 3, and mouse Matr3 is strongly expressed in neural crest, developing heart and great vessels, whereas Ahdc1 is not. To further establish MATR3 3′ UTR disruption as the cause of the proband's LVOT defects, we prepared a mouse Matr3Gt-ex13 gene trap allele that disrupted the 3′ portion of the gene. Matr3Gt-ex13 homozygotes are early embryo lethal, but Matr3Gt-ex13 heterozygotes exhibit incompletely penetrant BAV, CoA and PDA phenotypes similar to those in the human proband, as well as ventricular septal defect (VSD) and double-outlet right ventricle (DORV). Both the human MATR3 translocation breakpoint and the mouse Matr3Gt-ex13 gene trap insertion disturb the polyadenylation of MATR3 transcripts and alter Matrin 3 protein expression, quantitatively or qualitatively. Thus, subtle perturbations in Matrin 3 expression appear to cause similar LVOT defects in human and mouse. PMID
Background Ibuprofen treatment of patent ductus arteriosus (PDA) has been shown to be as effective as indomethacin in small randomized controlled trials, with possibly fewer adverse effects. However, adverse renal effects of ibuprofen have been noted in some trials and suspected in our practice. The purpose of this study was to examine whether ibuprofen and indomethacin treatment of PDA have comparable effects on renal function as evidenced by urine output and serum creatinine. Methods Retrospective chart review of 350 patients. Serum creatinine and urine output were recorded prior to start of treatment, during each course and after the last course of treatment. Pre-treatment mean creatinine and urine output values were compared to treatment and post treatment means using 2-factor repeated measures ANOVA. Results 165 patients were treated with indomethacin (2005-2006) and 185 received ibuprofen (2007-2008). There was no difference between treatment groups in demographics or baseline renal function. For both groups, the number of treatment courses was inversely correlated with birth weight and gestational age. Analysis of the first course including all patients, revealed significant increase in creatinine and decrease in urine output with both drugs, with a more pronounced effect of indomethacin on creatinine. In the subgroup of 219 patients who received only one treatment course, there was a significant increase in creatinine after indomethacin, but not after ibuprofen. In the 131 who received 2 or more courses, the decrease in urine output and increase in creatinine were not different between drugs. There were significant decreases in urine output observed in the second and third courses of ibuprofen treatment (both by 0.9 mL/kg/hr). Conclusion Both drugs have a similar short-term effect on renal function. Indomethacin had a more prominent initial effect, while ibuprofen decreased renal function during the second and third courses similarly to indomethacin. The
Chen, Zhao-yang; Wu, Li-ming; Luo, Yu-kun; Lin, Chao-gui; Peng, Ya-fei; Zhen, Xing-chun; Chen, Liang-long
Transcatheter Amplatzer occlusion of patent ductus artertiosus (PDA) has emerged as a minimally invasive alternative to surgical closure. The goal of this study was to compare long-term clinical outcomes between two procedures, especially on chronic residual shunt, late or very late procedure-related complications, and regression of pulmonary hypertension and left ventricular dilation. A total 255 patients having isolated PDA with a minimal diameter of >or= 4 mm treated from January 2000 to July 2003 were included in this study and have been followed up until July 2008. The patients were assigned to either the device or surgical closure group according to the patients' and/or their parents' preference. Baseline physical exams, chest roentgenography, electrocardiography, and echocardiography were performed preprocedure and at each follow-up. Seventy-two patients accepted the transcatheter procedure (Group-TC) and 183 underwent surgical operation (Group-SO) for PDA closure, both groups were similar in their demographics and preoperative clinical characteristics. There were no cardiac deaths and late complications such as infectious endocarditis and Amplatzer duct occluder (ADO) dislodge in either group. More acute procedure-related complications were recorded in Group-SO (13.7%) compared with Group-TC (1.4%) (P = 0.004). The recovery time was (8.7 +/- 2.3) days for the Group-SO and (1.3 +/- 0.5) days for the Group-TC (P < 0.001). The survival freedom from persistent residual shunt, defined as residual shunt that can not resolve automatically, was 91.3% for Group-SO and 98.6% for Group-TC (P = 0.037 by Log-rank test). There was no significant difference in regression of pulmonary hypertension and left ventricular dilation; neither survival freedom from pulmonary hypertension nor abnormal left ventricular end-diastolic volume index were significantly different between the surgical group and the Amplatzer group. Our study confirmed the long-term safety and efficacy of
Kaempf, J W; Wu, Y X; Kaempf, A J; Kaempf, A M; Wang, L; Grunkemeier, G
It remains unclear whether indomethacin (INDO) and/or surgical ligation (LIGATE) are necessary to improve outcomes in premature infants with a patent ductus arteriosus (PDA). We have adopted a conservative approach to PDA management that emphasizes waiting for spontaneous closure unless certain cardiorespiratory distress criteria are met. This was a before-after observational study in infants born 501 to 1,500 g in two distinct epochs. Era 1 (January 2005 to December 2007) featured traditional management with INDO and LIGATE used early to close all moderate and large PDAs in infants receiving any respiratory support. Era 2 (January 2008 to June 2009) emphasized modest fluid restriction, watchful waiting and limited INDO and LIGATE to only those infants with large PDAs who met certain cardiorespiratory distress criteria. Era 1 included 139 infants with a PDA, mean (s.d.) gestational age 27.5 (2) weeks; Era 2 72 infants, mean (s.d.) gestational age 27.5 (2) weeks. In Era 2, INDO use significantly decreased (79% of infants to 26%, P<0.001), and 28 day total fluids decreased (140 vs. 130 ml kg(-1) day(-1), P<0.001). LIGATE rate was 45% in Era 1, 33% in Era 2 (P=0.11). There were no significant differences in supplemental oxygen, nasal continuous positive airway pressure, or mechanical ventilation days. There were no significant differences in mortality or individual morbidities. The combined outcome of chronic lung disease (CLD) or mortality after Day 7 significantly increased (Era 1, 40%, Era 2, 54%, P=0.04). More infants were discharged home with a PDA in Era 2, but most resolved spontaneously and the need for closure therapy after discharge from the neonatal intensive care unit (NICU) did not increase. Multiple regression analysis demonstrated Era 2 management did not predict an increased risk of one or more interlinked morbidities. Tolerance of the PDA with watchful waiting for spontaneous closure, modest fluid reduction, and less INDO use is a reasonable
Wild, L M; Nickerson, P A; Morin, F C
The clinical syndrome of persistent pulmonary hypertension of the newborn includes a developmentally abnormal pulmonary microvasculature which contains excessive amounts of muscle and which cannot adapt to air breathing in the perinatal period. Surgical ligation of the ductus arteriosus of the fetal lamb has produced a physiologic model of pulmonary hypertension of the newborn. The aim of the present investigation is to determine whether surgical ligation of the ductus arteriosus in fetal sheep produces anatomic changes in the pulmonary blood vessels. The pulmonary vasculature of seven neonatal lambs that underwent surgical ligation of the ductus arteriosus from 6 to 17 d before birth was compared to that of five control lambs with a patent ductus arteriosus without fetal surgery and three control lambs with a patent ductus arteriosus that underwent sham surgery. Quantitative microscopic analysis of the barium gelatin-filled peripheral pulmonary vascular bed revealed an increase in the proportion of partially and fully muscularized pulmonary arteries at the level of the terminal bronchiole and within the acinus (p less than 0.0001). This finding demonstrates that medial muscle develops in areas of the distal pulmonary vascular bed where it is normally absent. Periadventitial fibrosis surrounding intraacinar pulmonary arteries was also present. No change in the number of small intraacinar arteries was detected. This structural remodeling of the peripheral pulmonary vascular bed was initiated in utero by ductus arteriosus occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)
Hong, Haifa; Xia, Yu; Sun, Yanjun; Ye, Lincai; Liu, Jinfen; Bai, Jie; Zhang, Haibo
Patency of the ductus arteriosus (DA) after birth is essential in ductal-dependent congenital heart disease. The Na(+)/Ca(2+) exchanger (NCX) has been demonstrated to play a key role in regulating vascular tone. The potassium-dependent Na(+)/Ca(2+) exchanger (NCKX) is a related family of NCX depending on the K(+) gradients which triggers DA constriction. The present study investigated the comparative expression of NCX and NCKX between a constricted DA and patent DA in human ductal-dependant congenital heart disease. Human DAs, which were patent (n = 10, age = 20.2 ± 4.3 days) or constricted (n = 10, age = 18.3 ± 3.9 days), were excised during surgery from neonates with ductal-dependent congenital heart disease. Western blotting analysis, real-time quantitative polymerase chain reaction analysis and immunofluorescence studies were performed to detect the protein and mRNA levels of NCX1, NCKX3, and NCKX4. The expressions of NCX1 and NCKX4 were significantly higher in the patent DA group at both the protein and mRNA levels, and expression was localized to the smooth muscle layer. These findings indicate that NCX1 and NCKX4 are up-regulated in human postnatal patent DAs and may represent potential therapeutic targets for maintaining DA patency in ductal-dependent congenital heart disease.
van Nie, C J
A macroscopic description of four hearts showing three arterial ostia in the base of the pig's heart was carried out. Portions of the vascular walls were histologically examined in three hearts. All hearts belong to the Tetralogy of Fallot group. Spitzer's hypothesis concerning the phylogenetic development of the mammalian heart was tested against the observations. The hypothesis could not be verified. The study leads to the conclusion that the ductus arteriosus has its origin in the base of the heart in the four hearts studied.
... closure is a procedure that uses a thin, hollow tube placed into a blood vessel. The doctor passes a small metal coil or other blocking device through the catheter to the site of the PDA. This blocks blood flow through the vessel. These coils can ...
Amin, S B; Handley, C; Carter-Pokras, O
The objective of this study was to determine whether neonatal-perinatal fellowship programs (NFTPs) in the United States vary in indomethacin use for the management of patent ductus arteriosus (PDA) in < or =28 week gestational age infants at birth. A 53-item web-based survey was sent to 84 NFTP directors who received prenotification, followed 2 weeks later by a reminder letter. A total of 56 NFTP directors responded (67% maximum response rate). Wide variation exists in the maximum number of indomethacin courses used to close ductus, use of indomethacin for reopened PDA beyond 14 days, ductal closure definition, contraindications before consideration of indomethacin, interventions for contraindications, and reported ductal closer rate after each indomethacin course. Indomethacin therapy for symptomatic PDA and short course of indomethacin are common practices. Indomethacin use for the management of PDA in premature infants varies among NFTP directors. Practice attitudes may explain variations in ductal closure and ligation rates. Because practice variations may have implications for long-term outcome of vulnerable premature infants, studies relevant to the management of PDA in premature infants are needed.
Goudjil, Sabrina; Imestouren, Fatiha; Armougon, Aurelie; Razafimanantsoa, Lucie; Mahmoudzadeh, Mahdi; Wallois, Fabrice; Leke, André; Kongolo, Guy
Objective To evaluate the impact of patent ductus arteriosus (PDA) on the pulse phase difference (PPD) between the left foot (postductal region) and the right hand (preductal region). Materials and Methods PPD was determined from arterial photoplethysmography signals (pulse waves) measured by infrared sensors routinely used for pulse oximetry in 56 premature infants less than 32 weeks gestation. Only infants with significant PDA (sPDA) diagnosed by echocardiography were treated with ibuprofen (for 3 days). Patients were classified according to whether or not they responded (Success/Failure) to this treatment. The Control group was composed of infants in whom ductus had already closed spontaneously at the time of the first echocardiography. The 3 groups were compared in terms of PPD at the beginning (T1) and at the end (T2) of the study. For patients in the Failure (n = 17) and Success groups (n = 18), T1 corresponded to the first day of treatment and T2 to the day after completion of the course of ibuprofen. In the Control group (n = 21), T1 corresponded to 1 to 3 days of life (DOL), and T2 to 4–6 DOL. Results Compared to the Control group, PPD was higher in the Failure (at T1 and T2) and Success (at T1) groups characterized by sPDA. After ibuprofen therapy, PPD in the Success group decreased to about the level observed in the Control group. The area under the ROC curve of PPD for the diagnosis of sPDA was 0.98 (95% CI 0.96–1); for an optimal cut-off of PPD ≥1.65 deg/cm, the sensitivity was 94.2% and the specificity was 98.3%. Conclusion In this study, PPD was correlated with ductus arteriosus status evaluated by echocardiography, indicating involvement of the ductal shunt in the mechanism of redistribution in systemic vascular territories. PPD can be considered for the diagnosis of hemodynamically significant PDA. PMID:24892695
Tano, Kazutoshi; Ichikawa, Yoichi
A 45-year-old male with Down syndrome( DS) had abnormal findings pointed out by chest X-ray and admitted to our hospital. He had undergone ligation of the patent ductus arteriosus 33 years before. Computed tomography showed a giant aortic aneurysm at the aortopulmonary window. Aortic arch replacement was performed under cardiopulmonary bypass and circulatory arrest. The postoperative course was uneventful. Postoperative ductal aneurysm in an adult is relatively rare and needs early operation because of the high risk of rupture. In this case, considering the size of the aneurysm, the timing of diagnosis seemed to be late. As the life expectancy of patients with DS has been lengthning recently, their regular health examinations is mandatory to improve the life expectancy and quality of life.
Neu, J; Ariagno, R L; Johnson, J D; Pitlick, P T; Cohen, R S; Beets, C L; Sunshine, P
Over a two year period, 52 infants were found to have clinical signs of patent ductus arteriosus (PDA). Twenty-seven responded to fluid restriction and furosemide; the remaining 25 infants entered the Indomethacin (IN) study protocol. Their mean (+/- SE) gestational age was 29.3 (+/- 0.6) weeks and birth weight was 1,142 (+/- 80) gm. Either a placebo or IN (0.25 mg/kg) orally was given for two doses, 24 hours apart; if no response occurred, the patient was crossed over to the opposite medication. Using Chi-square analysis, a significant response rate to IN was found. There were no significant differences in birth weights, gestational ages, or fluid intake between responders and nonresponders. However, both responders and nonresponders required a prolonged ventilator course, suggesting factors other than PDA causing prolonged ventilatory requirements in these babies.
Occhipinti, Federica; De Carolis, Maria Pia; De Rosa, Gabriella; Bersani, Iliana; Lacerenza, Serafina; Cota, Francesco; Rubortone, Serena Antonia; Romagnoli, Costantino
Echocardiographic flow patterns of patent ductus arteriosus (PDA) are useful to predict the development of hemodynamically significant ductus in premature infants. N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations seem to be useful to detect PDA. We investigated how NT-proBNP levels change on the basis of different flow patterns during the first day of life, and whether NT-proBNP might represent a reliable decision tool in PDA management. Neonates with gestational age <32 weeks were assessed prospectively, using paired Doppler-echocardiographic evaluation and NT-proBNP values, at T0 (6-24 h of life), and daily until ductal closure. At T0, NT-proBNP concentrations of 41 neonates correlated to the kind of pattern (p = 0.018) with the highest values in neonates with pulsatile or growing patterns. A value <9854 pg/ml identified neonates with spontaneous closure (sensitivity 71.8%, specificity 100%). Overall, 32 infants needed treatment. Pre-treatment NT-proBNP values increased compared to those at T0, significantly in neonates with growing pattern at T0 (p = 0.001). After treatment, NT-proBNP concentrations decreased compared to pre-treatment values (p = 0.0024), more markedly in the responders than in the non-responders (p = 0.042). NT-proBNP concentrations at T0 show a good agreement with different flow patterns and represent a useful tool to identify neonates at risk of developing hemodynamically significant PDA.
Singhi, Anil Kumar; Sivakumar, Kothandam
Test occlusion with a balloon is done to predict operability of large hypertensive patent ductus arteriosus (PDA). If the fall in the pulmonary artery pressures is inadequate, a complete closure is not desired. To create a predictable premeasured fenestration in a nitinol occluder device used for closing hypertensive PDA. A large nitinol occluder device was punctured with an 18G needle to advance a 0.035˝ stiff guide wire through the occluder before loading it into the delivery system. The occluder with the guidewire was then deployed across the PDA. A coronary guide catheter was later threaded through the guidewire into the fabric of the device, which was still held by the delivery cable. A coronary stent was deployed across the fenestration in the occluder to keep it patent. An 8-year-old boy with Down syndrome and hypertensive PDA was hemodynamically assessed. Even though there was a fall in the pulmonary vascular resistance index and pressures on test occlusion, the pulmonary artery pressures were labile with fluctuations. A customized fenestration was made in a 16 mm muscular ventricular septal defect occluder (MVSO) with a 4.5 mm bare-metal coronary stent. The pulmonary artery pressures remained at half of the aortic pressures after the procedure. This fenestration model precisely and predictably fenestrated a large occluder device used to close a hypertensive large PDA. Long-term patency of these fenestrations has to be assessed on the follow-up, and may be improved through larger fenestrations, systemic anticoagulation and use of covered stents. PMID:27011694
Singhi, Anil Kumar; Sivakumar, Kothandam
Test occlusion with a balloon is done to predict operability of large hypertensive patent ductus arteriosus (PDA). If the fall in the pulmonary artery pressures is inadequate, a complete closure is not desired. To create a predictable premeasured fenestration in a nitinol occluder device used for closing hypertensive PDA. A large nitinol occluder device was punctured with an 18G needle to advance a 0.035˝ stiff guide wire through the occluder before loading it into the delivery system. The occluder with the guidewire was then deployed across the PDA. A coronary guide catheter was later threaded through the guidewire into the fabric of the device, which was still held by the delivery cable. A coronary stent was deployed across the fenestration in the occluder to keep it patent. An 8-year-old boy with Down syndrome and hypertensive PDA was hemodynamically assessed. Even though there was a fall in the pulmonary vascular resistance index and pressures on test occlusion, the pulmonary artery pressures were labile with fluctuations. A customized fenestration was made in a 16 mm muscular ventricular septal defect occluder (MVSO) with a 4.5 mm bare-metal coronary stent. The pulmonary artery pressures remained at half of the aortic pressures after the procedure. This fenestration model precisely and predictably fenestrated a large occluder device used to close a hypertensive large PDA. Long-term patency of these fenestrations has to be assessed on the follow-up, and may be improved through larger fenestrations, systemic anticoagulation and use of covered stents.
Roofthooft, Daniëlla W E; van Beynum, Ingrid M; de Klerk, Johan C A; van Dijk, Monique; van den Anker, John N; Reiss, Irwin K M; Tibboel, Dick; Simons, Sinno H P
Finding the optimal pharmacological treatment of a patent ductus arteriosus (PDA) in preterm neonates remains challenging. There is a growing interest in paracetamol as a new drug for PDA closure. In this prospective observational cohort study, we evaluated the effectiveness of intravenous paracetamol in closing a PDA in very low birth weight infants with a hemodynamically significant PDA who either did not respond to ibuprofen or had a contraindication for ibuprofen. They received high-dose paracetamol therapy (15 mg/kg/6 h intravenous) for 3-7 days. Cardiac ultrasounds were performed before and 3 and 7 days after treatment. Thirty-three patients were included with a median gestational age of 25(1/7) weeks (IQR 1.66), a median birth weight of 750 g (IQR 327), and a median postnatal age of 14 days (IQR 12). Paracetamol was ineffective in 27/33 patients (82 %). Even more, after previous exposure to ibuprofen, this was even 100 %. In this study, paracetamol after ibuprofen treatment failure was not effective for PDA closure in VLBW infants. From the findings of this study, paracetamol treatment for PDA closure cannot be recommended for infants with a postnatal age >2 weeks. Earlier treatment with paracetamol for PDA might be more effective.
Kramoh, Euloge Kouadio; Miró, Joaquim; Bigras, Jean-Luc; Turpin, Sophie; Lambert, Raymond; Lapierre, Chantal; Jin, Weidong; Dahdah, Nagib
Reduced left lung perfusion has been described following percutaneous occlusion of the patent ductus arteriosus (PDA). We aimed to identify the incidence of lung perfusion abnormalities and the associated risk factors in our consecutive series. Between November 1994 and December 2003, 150 procedures were performed on 145 patients, age 4.6 +/- 4 years. Gianturco coil was used in 88.2%, Amplatzer duct occluder in 6.7%, and Rashkind Umbrella in 5.5%. Lung perfusion scan was scheduled within 48 h (LPS-1), at 6-12 months (LPS-2) and later (LPS-3) in the case of persistent abnormalities. Left lung perfusion <40% was considered abnormal. LPS-1 was obtained in 95.8% and was abnormal in 31%. LPS-2, available in 48.2%, returned to normal in 65.7% (p < 0.001). LPS-3, required in 6.2%, was normal in 55.6% (p = 0.07). Identifiable risk factors were low age and height (p < 0.01), higher Q(p)/Q(s) ratio (p < 0.05), and larger PDA size indexed for height (p < 0.001) or body surface area (p < 0.01). The number of coils or loops deployed in the pulmonary end of the PDA did not influence lung perfusion. In conclusion, we describe a high incidence of left lung perfusion reduction following percutaneous PDA occlusion, more likely in the young with large PDA. However, spontaneous recovery usually occurs within a few months.
Behbodi, Elham; Villamor-Martínez, Eduardo; Degraeuwe, Pieter L. J.; Villamor, Eduardo
The contribution of chorioamnionitis (CA) to mortality and morbidity in preterm infants is difficult to assess because observational studies frequently present significant differences in baseline characteristics of the infants exposed or non-exposed to CA. In an attempt to perform a thorough assessment of the possible association between CA and patent ductus arteriosus (PDA) in preterm infants, we conducted a meta-analysis in which adjusted odds ratios (ORs) were pooled and we analyzed the effects of potential confounders, such as gestational age (GA) or birth weight (BW). We identified 45 relevant studies (27186 patients, 7742 CA cases). Random effects meta-analysis of crude ORs showed a significant positive association between CA and PDA (OR 1.352, 95% CI 1.172 to 1.560). Adjusted ORs were reported in 11 studies (19577 infants). Meta-analysis of these studies showed a significant negative association between CA and PDA (OR 0.802, 95% CI 0.751 to 0.959). Meta-regression showed that the differences in GA or BW between the CA-exposed and non-exposed groups were significantly correlated with the effect size of the association between PDA and CA. In conclusion, our study confirms that confounders need to be taken into account when assessing the association between CA and clinical outcomes in preterm infants. PMID:27892517
Huang, Xintao; Wang, Fang; Wang, Kai
Paracetamol has been suggested as an effective treatment for patent ductus arteriosus (PDA). However, the comparative efficacy and safety between paracetamol and ibuprofen were not determined. A meta-analysis of randomized controlled trials (RCTs) was performed. Relevant studies were identified via database searching. A fixed or random effect model was applied depending on the extent of heterogeneity. Five RCTs with 677 neonates were included. The efficacies for the primary (risk ratio [RR]: 1.03, p = .56) and overall PDA closure were comparable between the two medications (RR: 1.02, p = .62). Neonates of the two groups were comparable for the incidence of PDA complications, including necrotizing enterocolitis (RR: 0.86, p = .70), intraventricular hemorrhage (RR: 0.84, p = .55), bronchopulmonary dysplasia (RR: 0.69, p = .16), and retinopathy of prematurity (RR: 0.58, p = .15), and the risks of sepsis (RR = 0.88, p = .48) and death (RR: 1.45, p = .45) within hospitalization. However, treatment with paracetamol was associated with a trend of reduced risk of renal failure (RR: 0.20, p = .07), and a significantly reduced risk of gastrointestinal bleeding (RR: 0.28, p = .009). Paracetamol may confer comparable treatment efficacy for the closure of PDA as ibuprofen, although paracetamol is associated with lower risk of adverse events.
El-Saiedi, Sonia A; El Sisi, Amal M; Mandour, Rodina Sobhy; Abdel-Aziz, Doaa M; Attia, Wael A
In this study, we examined the differences in cost and effectiveness of various devices used for the closure of small to medium sized patent ductus arteriosus (PDA). We retrospectively studied 116 patients who underwent closure of small PDAs between January 2010 and January 2015. Three types of devices were used: the Amplatzer duct occluder (ADO) II, the cook detachable coil and the Nit Occlud coil (NOC). Immediate and late complications were recorded and patients were followed up for 3 months after the procedure. All statistical calculations were performed using Statistical Package for the Social Science software. P <0.05 were considered significant. We successfully deployed ADO II devices in 33 out of 35 cases, cook detachable coils in 36 out of 40 cases and NOCs in 38 out of 41 cases. In the remaining nine cases, the first device was unsuitable or embolized and required retrieval and replacement with another device. Eleven patients (9.5%) developed vascular complications and required anticoagulation therapy. Patients who had hemolysis or vascular complications remained longer in the intensive care unit, with consequently higher total cost (P = 0.016). Also, the need for a second device increased the cost per patient. The cook detachable coil is the most cost-effective device for closure of small-to medium-sized PDAs. Calculations of the incremental cost-effectiveness. (ICE) revealed that the Cook detachable coil had less ICE than the ADO II and NOC. The NOC was more effective with fewer complications.
Behbodi, Elham; Villamor-Martínez, Eduardo; Degraeuwe, Pieter L J; Villamor, Eduardo
The contribution of chorioamnionitis (CA) to mortality and morbidity in preterm infants is difficult to assess because observational studies frequently present significant differences in baseline characteristics of the infants exposed or non-exposed to CA. In an attempt to perform a thorough assessment of the possible association between CA and patent ductus arteriosus (PDA) in preterm infants, we conducted a meta-analysis in which adjusted odds ratios (ORs) were pooled and we analyzed the effects of potential confounders, such as gestational age (GA) or birth weight (BW). We identified 45 relevant studies (27186 patients, 7742 CA cases). Random effects meta-analysis of crude ORs showed a significant positive association between CA and PDA (OR 1.352, 95% CI 1.172 to 1.560). Adjusted ORs were reported in 11 studies (19577 infants). Meta-analysis of these studies showed a significant negative association between CA and PDA (OR 0.802, 95% CI 0.751 to 0.959). Meta-regression showed that the differences in GA or BW between the CA-exposed and non-exposed groups were significantly correlated with the effect size of the association between PDA and CA. In conclusion, our study confirms that confounders need to be taken into account when assessing the association between CA and clinical outcomes in preterm infants.
Levinson, Michelle B; Messina, Catherine; Mintzer, Jonathan P
Previous studies have suggested an association between high maintenance fluid volumes during the first several postnatal days and patent ductus arteriosus (PDA) requiring treatment in very low birth weight (VLBW) neonates. However, no studies have specifically examined fluid administration during the first postnatal day with regard to PDA-related outcomes. We seek to determine whether additional intravenous fluid administration beyond prescribed goals during the first postnatal day is associated with PDA requiring treatment. Retrospective data were collected from neonates with birth weight <1250 g. Infants receiving fluids beyond initially documented goals, stratified by relative degree of additional fluids, were compared to those receiving no additional intravenous fluids for the primary outcome of PDA requiring treatment and secondarily for other neonatal morbidities. Two hundred VLBW neonates were included. Controlling for birth weight and gestational age, fluid administration beyond prescribed goals during the first postnatal day was not associated with increased PDA requiring treatment. Additionally, no statistically significant associations between additional fluids and secondary outcomes were observed. No significant relationship between fluid volumes during the first postnatal day and PDA requiring treatment were observed. Further prospective analysis of early fluid management in VLBW neonates is warranted.
Kawase, Koya; Sugiura, Tokio; Nagaya, Yoshiaki; Yamada, Takaharu; Sugimoto, Mari; Ito, Koichi; Togawa, Takao; Nagasaki, Rika; Kato, Takenori; Kouwaki, Masanori; Koyama, Norihisa; Saitoh, Shinji
Persistent patent ductus arteriosus (PDA) is a frequent complication in preterm infants. Single nucleotide polymorphisms (SNP) in several genes, including angiotensin II receptor, type 1 (AGTR1), transcription factor AP-2 beta (TFAP2B) and tumor necrosis factor receptor-associated factor 1 (TRAF1), have been reported to be associated with PDA in preterm infants. The aim of this study was to evaluate the relationships between PDA in preterm infants and polymorphisms in AGTR1, TFAP2B and TRAF1 in the Japanese population. The subjects consisted of 107 preterm infants with gestational age <32 weeks. Extremely low-birthweight infants were treated with prophylactic indomethacin during the first 24 h after birth. Five SNP, namely, rs5186 in AGTR1, rs987237 and rs6930924 in TFAP2B, and rs1056567 and rs10985070 in TRAF1, were genotyped using TaqMan SNP genotyping assays. There were no significant differences in the distributions of the genotypes and allele frequencies of all studied SNP between the PDA group (n = 46) and the non-PDA group (n = 61). There were no significant associations between the studied SNP and the incidence of PDA in Japanese preterm infants. These SNP may not be clinically important predisposing factors for PDA in Japanese preterm infants. © 2015 Japan Pediatric Society.
Cotton, Robert B.; Shah, Lisa P.; Poole, Stanley D.; Ehinger, Noah J.; Brown, Naoko; Shelton, Elaine L.; Slaughter, James C.; Baldwin, H. Scott; Paria, Bibhash C.; Reese, Jeff
Persistent patency of the ductus arteriosus (PDA) is a common problem in preterm infants. The antacid cimetidine is a potent antagonist of the H2 histamine receptor but also inhibits certain cytochrome P450 enzymes (CYPs), which may affect DA patency. We examined whether cimetidine contributes to PDA and is mediated by CYP inhibition rather than H2 blockade. Analysis of a clinical trial to prevent lung injury in premature infants revealed a significant association between cimetidine treatment and PDA. Cimetidine and ranitidine, both CYP inhibitors as well as H2 blockers, caused relaxation of the term and preterm mouse DA. CYP enzymes that are inhibited by cimetidine were expressed in DA subendothelial smooth muscle. The selective CYP3A inhibitor ketoconazole induced greater DA relaxation than cimetidine, whereas famotidine and other H2 antagonists with less CYP inhibitory effects caused less dilation. Histamine receptors were developmentally regulated and localized in DA smooth muscle. However, cimetidine caused DA relaxation in histamine-deficient mice, consistent with CYP inhibition, not H2 antagonism, as the mechanism for PDA. Oxygen-induced DA constriction was inhibited by both cimetidine and famotidine. These studies show that antacids and other compounds with CYP inhibitory properties pose a significant and previously unrecognized risk for PDA in critically ill newborn infants. PMID:23454087
Cotton, Robert B; Shah, Lisa P; Poole, Stanley D; Ehinger, Noah J; Brown, Naoko; Shelton, Elaine L; Slaughter, James C; Baldwin, H Scott; Paria, Bibhash C; Reese, Jeff
Persistent patency of the ductus arteriosus (PDA) is a common problem in preterm infants. The antacid cimetidine is a potent antagonist of the H2 histamine receptor but it also inhibits certain cytochrome P450 enzymes (CYPs), which may affect DA patency. We examined whether cimetidine contributes to PDA and is mediated by CYP inhibition rather than H2 blockade. Analysis of a clinical trial to prevent lung injury in premature infants revealed a significant association between cimetidine treatment and PDA. Cimetidine and ranitidine, both CYP inhibitors as well as H2 blockers, caused relaxation of the term and preterm mouse DA. CYP enzymes that are inhibited by cimetidine were expressed in DA subendothelial smooth muscle. The selective CYP3A inhibitor ketoconazole induced greater DA relaxation than cimetidine, whereas famotidine and other H2 antagonists with less CYP inhibitory effects caused less dilation. Histamine receptors were developmentally regulated and localized in DA smooth muscle. However, cimetidine caused DA relaxation in histamine-deficient mice, consistent with CYP inhibition, not H2 antagonism, as the mechanism for PDA. Oxygen-induced DA constriction was inhibited by both cimetidine and famotidine. These studies show that antacids and other compounds with CYP inhibitory properties pose a significant and previously unrecognized risk for PDA in critically ill newborn infants.
Maeno, Y V; Kamenir, S A; Sinclair, B; van der Velde, M E; Smallhorn, J F; Hornberger, L K
Although most neonates with d-transposition of the great arteries (TGA) have an uncomplicated preoperative course, some with a restrictive foramen ovale (FO), ductus arteriosus (DA) constriction, or pulmonary hypertension may be severely hypoxemic and even die shortly after birth. Our goal was to determine whether prenatal echocardiography can identify these high-risk fetuses with TGA. We reviewed the prenatal and postnatal echocardiograms and outcomes of 16 fetuses with TGA/intact ventricular septum or small ventricular septal defect. Of the 16 fetuses, 6 prenatally had an abnormal FO (fixed position, flat, and/or redundant septum primum). Five of the 6 had restrictive FO at birth. Five fetuses had DA narrowing at the pulmonary artery end in utero, and 6 had a small DA (diameter z score of <-2.0). Of 4 fetuses with the most diminutive DA, 2 also had an abnormal appearance of the FO, and both died immediately after birth. One other fetus had persistent pulmonary hypertension. Eight fetuses had abnormal Doppler flow pattern in the DA (continuous high-velocity flow, n=1; retrograde diastolic flow, n=7). Abnormal features of the FO, DA, or both are present in fetuses with TGA at high risk for postnatal hypoxemia. These features may result from the abnormal intrauterine hemodynamics in TGA. A combination of restrictive FO and DA constriction in TGA may be associated with early neonatal death.
Hiraishi, S; Horiguchi, Y; Misawa, H; Oguchi, K; Kadoi, N; Fujino, N; Yashiro, K
The pulsed Doppler technique was used to record the flow velocity patterns in the ductus arteriosus and the pulmonary artery in 26 patients with either isolated or complicated patent ductus arteriosus (PDA). In all patients, abnormal Doppler signals indicating left-to-right (L-R) or right-to-left shunt flow or both could be obtained at the site of the ductus arteriosus. These Doppler flow patterns determined within the ductus coincided with the direction of ductal flow seen on the contrast two-dimensional echocardiogram. No Doppler signals of shunt flow were demonstrated in any of 42 control subjects. The peak, mean, and diastolic velocities of the L-R shunt flow within the ductus were measured from the ductal flow velocity profiles. With the Doppler-derived measurements of the mean and diastolic velocities, patients with normal pulmonary arterial pressure and those with evidence of pulmonary hypertension could be correctly identified. In addition, the mean velocity of the diastolic antegrade flow portion obtained from the proximal left pulmonary artery, which was related to ductal L-R shunting, was measured in 16 patients with isolated PDA. This Doppler flow determinant showed a good linear correlation with the L-R shunt ratio determined by Fick's method (r = .88, p less than .01). Our technique permits the noninvasive evaluation of shunt flow dynamics in patients with PDA.
Krebs, Luke T.; Norton, Christine R.; Gridley, Thomas
Summary The ductus arteriosus is an arterial vessel that shunts blood flow away from the lungs during fetal life, but normally occludes after birth to establish the adult circulation pattern. Failure of the ductus arteriosus to close after birth is termed patent ductus arteriosus, and is one of the most common congenital heart defects. Our previous work demonstrated that vascular smooth muscle cell expression of the Jag1 gene, which encodes a ligand for Notch family receptors, is essential for postnatal closure of the ductus arteriosus in mice. However, it was not known what cell population was responsible for receiving the Jag1-mediated signal. Here we show, using smooth muscle cell-specific deletion of the Rbpj gene, which encodes a transcription factor that mediates all canonical Notch signaling, that Notch signal reception in the vascular smooth muscle cell compartment is required for ductus arteriosus closure. These data indicate that homotypic vascular smooth muscle cell interactions are required for proper contractile smooth muscle cell differentiation and postnatal closure of the ductus arteriosus in mice. PMID:26742650
Krebs, Luke T; Norton, Christine R; Gridley, Thomas
The ductus arteriosus is an arterial vessel that shunts blood flow away from the lungs during fetal life, but normally occludes after birth to establish the adult circulation pattern. Failure of the ductus arteriosus to close after birth is termed patent ductus arteriosus, and is one of the most common congenital heart defects. Our previous work demonstrated that vascular smooth muscle cell expression of the Jag1 gene, which encodes a ligand for Notch family receptors, is essential for postnatal closure of the ductus arteriosus in mice. However, it was not known what cell population was responsible for receiving the Jag1-mediated signal. Here we show, using smooth muscle cell-specific deletion of the Rbpj gene, which encodes a transcription factor that mediates all canonical Notch signaling, that Notch signal reception in the vascular smooth muscle cell compartment is required for ductus arteriosus closure. These data indicate that homotypic vascular smooth muscle cell interactions are required for proper contractile smooth muscle cell differentiation and postnatal closure of the ductus arteriosus in mice. © 2016 Wiley Periodicals, Inc.
Leonard, M E; Hutchins, G M; Moore, G W
The reason that the normal ductus arteriosus has a muscular media, contrasting with the elastic lamellar structure of the adjacent great arteries, is unknown. We examined the hypothesis that the anatomic relationship of the ductus arteriosus to the vagus and recurrent laryngeal nerves during early development might be of importance in influencing ductal morphology. Normal human embryos from the Carnegie Embryological Collection and embryos and fetuses from the Hopkins Pathology Collection were studied microscopically, by reconstructions made from serial histologic sections, or by gross dissection. At Carnegie stage 16 the recurrent laryngeal nerves pass medially from the vagus nerve to the laryngeal area and are caudal to the bilaterally symmetric sixth aortic arches. By stage 18 the right sixth aortic arch has disappeared and the left sixth aortic arch is in a more caudal position relative to the larynx. The left vagus nerve and its recurrent laryngeal branch form a sling supporting the distal (or ductus arteriosus component) of the left sixth aortic arch. In subsequent development there is greater relative separation of the larynx and ductus arteriosus. The media of the ductus arteriosus beneath the supporting nerves is thinner and has less elastic fiber formation than the elastic lamellar media of the adjacent aortic arches. The study shows that the vagus and recurrent laryngeal nerves are in a position to provide mechanical support to the ductus arteriosus during its development and that the morphology of the media of the supported ductus arteriosus differs from that of the adjacent unsupported aortic arches. It is suggested that this local mechanical support may be the reason that the normal ductus arteriosus differentiates as a muscular artery and is therefore able to obliterate its lumen in postnatal life. Without such support the ductal media could develop the abundant elastic fibers characteristic of the normal unsupported aorta and pulmonary trunk and
Talemal, L; Donofrio, M T
D-transposition of the great arteries (D-TGA) is the most commonly diagnosed cyanotic congenital heart disease presenting in the neonatal period. The survival after an arterial switch operation, with freedom from adverse cardiovascular events, has been reported to be as high as 93% at 25 years. However, despite excellent surgical outcomes, there continues to be significant preoperative morbidity and potential mortality due to compromise in the delivery room from foramen ovale closure requiring urgent balloon atrial septostomy for stabilization in the first minutes of life. The prenatal diagnosis of D-TGA using fetal echocardiography has aided in the perinatal management and delivery planning of these infants, lowering preoperative morbidity and mortality and preventing delivery room compromise. Fetuses with D-TGA have more highly oxygenated blood supplying the pulmonary arteries and ductus arteriosus which likely results in ductal constriction and increased pulmonary blood flow. This may be the cause of foramen ovale restriction or closure in-utero, which then increases the risk for postnatal compromise at delivery. Theories regarding the cause of the abnormal pulmonary vasculature that may be seen in D-TGA, including aorto-pulmonary collateral formation, have been proposed but to our knowledge, observation of the ultrasound findings throughout mid and late gestation describing the progression of the abnormal fetal physiology have not been previously described. We present a case of D-TGA in which serial assessment using fetal echocardiography enabled observation of the in-utero progression of disease, predicting postnatal compromise and facilitating the planning of life-saving specialized delivery room care and intervention.
Meijer, M; Beijerink, N J
A left-to-right shunting patent ductus arteriosus (PDA) is a common congenital heart defect in dogs. If it is left uncorrected, life expectancy in most cases is decreased due to the development of left-sided congestive heart failure. The aim of this study was to describe the dogs diagnosed with PDA in the Utrecht University Companion Animal Clinic from 2003 to 2011. The medical records of 102 patients were retrieved, and the clinical presentation and outcome of PDA closure by surgical ligation or transarterial catheter occlusion (TCO) were reviewed. In the TCO group, the result of coiling was compared with the placement of an Amplatz Canine Duct Occluder (ACDO). A predisposition to PDA was found in the German Brak, Stabyhoun, and Schapendoes. Dogs treated with surgical ligation were significantly older and heavier than those treated with TCO; within the TCO group, dogs treated with ACDO were significantly older and heavier The initial success rate (complete disappearance of the audible murmur in a patient that survived the procedure) was not significantly different between the different treatment modalities. Major complications were more common with surgical ligation, but the incidence of minor complications was not significantly different. There was no diference in survival between dogs treated with surgical ligation and dogs treated with TCO. This study shows a previously unreported predisposition to PDA in certain breeds. Both surgical ligation and TCO are suitable techniques for PDA closure, although major complications were more common with surgical ligation. ACDO appears to be the method with the least complications and thus can be considered the safest method.
Dani, Carlo; Poggi, Chiara; Mosca, Fabio; Schena, Federico; Lista, Gianluca; Ramenghi, Luca; Romagnoli, Costantino; Salvatori, Enrica; Rosignoli, Maria Teresa; Lipone, Paola; Comandini, Alessandro
Patent ductus arteriosus (PDA) is one of most common complications in preterm infants. Although ibuprofen represents the first choice for the closure of PDA, this treatment can cause severe gastrointestinal and adverse renal effects and worsen platelet function. The successful closure of the PDA with paracetamol has been recently reported in several preterm infants, and the safety of paracetamol for this use has been suggested by the available data. We present the design of a randomized, multicenter, controlled study, whose aim is to assess the effectiveness and safety of intravenous paracetamol in comparison to intravenous ibuprofen for the treatment of PDA in preterm infants. A total of 110 infants born at 25(+0) to 31(+6) weeks of gestational age will be enrolled and randomized to receive paracetamol or ibuprofen (55 patients per group) starting at 24-72 h of life. The primary endpoint of the study is the comparison of the PDA closing rate observed after a 3-day course with paracetamol or ibuprofen. The secondary endpoints include the closure rate of PDA after the second course of treatment with ibuprofen, the re-opening rate of the PDA, the incidence of surgical ligation, and the occurrence of adverse effects. The results of this study will provide new information about the possible use of paracetamol in the treatment of PDA. Paracetamol could offer several important therapeutic advantages over current treatment options, and it could become the treatment of choice for the management of PDA, mainly due to its more favorable side effect profile. Clinicaltrials.gov NCT02422966 . Eudract no. 2013-003883-30.
Taggart, Nathaniel W; Cetta, Frank; O'Leary, Patrick W; Seward, James B; Eidem, Benjamin W
In adults, the left atrial (LA) volume has been shown to reflect diastolic function and is a powerful predictor of cardiac morbidity and mortality. Normative LA volume values in children and the effect of loading conditions on the LA volume in those with congenital heart disease are lacking. The purposes of the present study were to (1) establish normal LA volume values for children, (2) assess the effect of left ventricular volume loading conditions on LA volume, and (3) describe the effect of abnormal myocardial relaxation on the LA volume. We retrospectively reviewed the echocardiograms from 3 pediatric cohorts: group N (n = 522), children with normal echocardiographic findings; group VSD/PDA (n = 71), children with ventricular septal defect (VSD; n = 50) or patent ductus arteriosus (PDA; n = 21); and group HC (n = 63), children with hypertrophic cardiomyopathy (HC). In group N, we identified the LA volume indexed to the body surface area (LA volume index) as a consistent measure of the LA volume in children 3 to 23 months old (mean 16 ± 3 ml/m(2)) and 2 to 17 years old (mean 22 ± 4 ml/m(2)). LA dilation was more common in group VSD/PDA than in group N (27% vs 2%, p <0.0001) and in children with moderate or large shunts than in those with smaller shunts (61% vs 5%, p <0.0001). In group HC, the LA volume index correlated with the mitral valve E/e' ratio (p <0.0001). In conclusion, this is the first study to establish normal pediatric LA volume values. The LA volume index is a reproducible measure of LA size in children ≥ 3 months old. The LA volume index reflects a chronically increased left ventricular volume load in children with VSD or PDA and chronically elevated left ventricular filling pressures in children with HC. Copyright © 2010 Elsevier Inc. All rights reserved.
Broadhouse, Kathryn M; Finnemore, Anna E; Price, Anthony N; Durighel, Giuliana; Cox, David J; Edwards, Anthony David; Hajnal, Joseph V; Groves, Alan M
Many pathologies seen in the preterm population are associated with abnormal blood supply, yet robust evaluation of preterm cardiac function is scarce and consequently normative ranges in this population are limited. The aim of this study was to quantify and validate left ventricular dimension and function in preterm infants using cardiovascular magnetic resonance (CMR). An initial investigation of the impact of the common congenital defect patent ductus arteriosus (PDA) was then carried out. Steady State Free Procession short axis stacks were acquired. Normative ranges of left ventricular end diastolic volume (EDV), stroke volume (SV), left ventricular output (LVO), ejection fraction (EF), left ventricular (LV) mass, wall thickness and fractional thickening were determined in "healthy" (control) neonates. Left ventricular parameters were then investigated in PDA infants. Unpaired student t-tests compared the 2 groups. Multiple linear regression analysis assessed impact of shunt volume in PDA infants, p-value ≤ 0.05 being significant. 29 control infants median (range) corrected gestational age at scan 34+6(31+1-39+3) weeks were scanned. EDV, SV, LVO, LV mass normalized by weight and EF were shown to decrease with increasing corrected gestational age (cGA) in controls. In 16 PDA infants (cGA 30+3(27+3-36+1) weeks) left ventricular dimension and output were significantly increased, yet there was no significant difference in ejection fraction and fractional thickening between the two groups. A significant association between shunt volume and increased left ventricular mass correcting for postnatal age and corrected gestational age existed. CMR assessment of left ventricular function has been validated in neonates, providing more robust normative ranges of left ventricular dimension and function in this population. Initial investigation of PDA infants would suggest that function is relatively maintained.
Mitra, Souvik; Chan, Anthony K; Paes, Bosco A
To conduct a meta-analysis of the association of platelet counts and pharmacotherapeutic failure in preterms with a patent ductus arteriosus (PDA). MEDLINE, Embase, Science Citation Index, abstracts and conference proceedings were searched, and principal authors contacted. Included studies reported indomethacin or ibuprofen use for PDA closure, compared a group which failed treatment versus a group which did not and reported the association between platelet counts and indomethacin or ibuprofen failure. Two reviewers independently screened results and assessed methodological quality using the Newcastle-Ottawa Scale. Results are expressed as mean difference in platelet counts and summary odds ratios (OR) using a random effects model. 1105 relevant studies were identified; eight involving 1087 preterms were included. Platelet counts were significantly lower in infants who failed pharmacotherapy (Meandifference:-30.88 × 10(9)/L; 95% CI:-45.69 × 10(9),-16.07 × 10(9)/L; I2 = 24%; pheterogeneity = 0.24). Similar results were obtained based on either pharmacotherapeutic agent. Treatment failure was also significantly associated with pre-treatment thrombocytopenia (summary OR:1.75; 95% CI:1.23-2.49, I2 = 36%, pheterogeneity = 0.20). Platelet counts are significantly lower in preterms who fail primary treatment for PDA. Pre-treatment thrombocytopenia is associated with higher odds of failure. Further cohort studies reporting platelet counts in prostaglandin inhibitor failure are needed for meta-analyses to firmly establish or refute a stronger association.
El-Saiedi, Sonia A; El Sisi, Amal M; Mandour, Rodina Sobhy; Abdel-Aziz, Doaa M; Attia, Wael A
Aims: In this study, we examined the differences in cost and effectiveness of various devices used for the closure of small to medium sized patent ductus arteriosus (PDA). Setting and Design: We retrospectively studied 116 patients who underwent closure of small PDAs between January 2010 and January 2015. Subjects and Methods: Three types of devices were used: the Amplatzer duct occluder (ADO) II, the cook detachable coil and the Nit Occlud coil (NOC). Immediate and late complications were recorded and patients were followed up for 3 months after the procedure. Statistical Methods: All statistical calculations were performed using Statistical Package for the Social Science software. P <0.05 were considered significant. Results: We successfully deployed ADO II devices in 33 out of 35 cases, cook detachable coils in 36 out of 40 cases and NOCs in 38 out of 41 cases. In the remaining nine cases, the first device was unsuitable or embolized and required retrieval and replacement with another device. Eleven patients (9.5%) developed vascular complications and required anticoagulation therapy. Patients who had hemolysis or vascular complications remained longer in the intensive care unit, with consequently higher total cost (P = 0.016). Also, the need for a second device increased the cost per patient. Conclusions: The cook detachable coil is the most cost-effective device for closure of small-to medium-sized PDAs. Calculations of the incremental cost-effectiveness. (ICE) revealed that the Cook detachable coil had less ICE than the ADO II and NOC. The NOC was more effective with fewer complications. PMID:28566822
Tashiro, Jun; Perez, Eduardo A; Sola, Juan E
To evaluate outcomes after surgical ligation (SL) of patent ductus arteriosus (PDA) in premature, extremely low birth weight (ELBW) infants. Optimal management of PDA in this specialized population remains undefined. Currently, surgical therapy is largely reserved for infants failing medical management. To date, a large-scale, risk-matched population-based study has not been performed to evaluate differences in mortality and resource utilization. Data on identified premature (<37 weeks) and ELBW (<1000 g) infants with PDA (International Classification of Diseases, 9th revision, Clinical Modification, 747.0) and respiratory distress (769) were obtained from Kids' Inpatient Database (2003-2009). Overall, 12,470 cases were identified, with 3008 undergoing SL. Propensity score-matched analysis of 1620 SL versus 1584 non-SL found reduced mortality (15% vs 26%) and more routine disposition (48% vs 41%) for SL (P < 0.001). SL had longer length of stay and higher total cost (P < 0.001). On multivariate analysis, SL mortality predictors were necrotizing enterocolitis (NEC; surgical odds ratio, 5.95; medical odds ratio, 4.42) and sepsis (3.43) (P < 0.006). Length of stay increased with bronchopulmonary dysplasia (BPD; 1.77), whereas total cost increased with surgical NEC (1.82) and sepsis (1.26) (P < 0.04). Non-SL mortality predictors were NEC (surgical, 76.3; medical, 6.17), sepsis (2.66), and intraventricular hemorrhage (1.97) (P < 0.005). Length of stay increased with BPD (2.92) and NEC (surgical, 2.04; medical, 1.28) (P < 0.03). Total cost increased with surgical NEC (2.06), medical NEC (1.57), sepsis (1.43), and BPD (1.30) (P < 0.001). Propensity score-matched analysis demonstrates reduced mortality in premature/ELBW infants with SL for PDA. NEC and sepsis are predictors of mortality and resource utilization.
Bixler, G Michael; Powers, George C; Clark, Reese H; Walker, M Whit; Tolia, Veeral N
To identify changes in the diagnosis, pharmacotherapy, and surgical ligation of patent ductus arteriosus (PDAs) in infants born premature and report on temporal changes in mortality and morbidity from a large volume of neonatal intensive care units (NICUs) in the US. We queried the Pediatrix Clinical Data Warehouse for all inborn infants without major anomalies born between 23 and 30 weeks' gestation from 2006 to 2015 for a diagnosis of PDA, use of indomethacin or ibuprofen, history of ductal ligation, mortality, and major morbidities. There were 829 091 infants entered in the Clinical Data Warehouse; 61 520 infants from 280 NICUs met our inclusion criteria. The diagnosis of PDA declined from 51% to 38% (P < .001), use of indomethacin or ibuprofen decreased from 32% to 18%, and PDA ligation decreased from 8.4% to 2.9% (both P < .001). During the study period, mortality decreased with no increase in any measured morbidity. Of the 163 sites with data for both periods, 128 (79%) showed a decrease in the diagnosis of PDA, and 132 (81%) showed a decrease in the use indomethacin and/or ibuprofen when 2011-2015 was compared with 2006-2010. Of 103 sites with at least 1 PDA ligation, 85 (83%) showed a decrease in PDA ligation in a similar comparison. In this large population of infants <30 weeks' gestation from 280 NICUs across the US, there were significant decreases in the diagnosis and treatment of the PDA. Although there was no evidence of increased morbidities, it remains uncertain how these changes may directly affect infant outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.
Khau Van Kien, Philippe; Mathieu, Flavie; Zhu, Limin; Lalande, Alain; Betard, Christine; Lathrop, Mark; Brunotte, François; Wolf, Jean-Eric; Jeunemaitre, Xavier
Three loci have been shown to be responsible for nonsyndromic familial thoracic aortic aneurysms (TAAs) and aortic dissections (ADs). We recently described a large family in which TAA/AD associates with patent ductus arteriosus (PDA) and provided genetic arguments for a unique pathophysiological entity. Genome-wide scan was performed in 40 subjects belonging to 3 generations in this large pedigree. Using the 7 TAA/AD cases as affected, we observed positive 2-point LOD scores on adjacent markers at chromosome 16p, with a maximum LOD score value of 2.73 at theta=0, a value that increased to 3.56 when 5 PDA cases were included. Multipoint linkage analysis yielded a maximum LOD score of 4.14 in the vicinity of marker D16S3103. Fine mapping allowed the observation of recombinant haplotypes that delimited a critical 20-cM interval at 16p12.2-p13.13. Automatic determination of aortic compliance with cine MRI showed that all subjects bearing the disease haplotype, even asymptomatic, displayed a very low level of aortic compliance and distensibility. Aortic stiffness was strongly associated with disease haplotype with a marked effect of age, indicating subclinical and early manifestation of the disease. Genetic analysis of this family identified a unique locus responsible for both TAA/AD and PDA at chromosome 16p12.2-p13.13 with aortic stiffness as an early hallmark of the disease. TAA/AD with PDA is a new monogenic entity among the genetically heterogeneous group of TAA/AD disease.
Mitra, Souvik; Tamayo, Maria E; Aune, Dagfinn; Mbuagbaw, Lawrence; Veroniki, Areti-Angeliki; Thabane, Lehana
Introduction Management of patent ductus arteriosus (PDA) in preterm infants is one of the most controversial topics in neonatal medicine. The availability of different pharmacotherapeutic options often poses a practical challenge to the practising neonatologist as to which one to choose as a therapeutic option. Our objectives are to determine the relative merits of the available pharmacotherapeutic options for the management of PDA. Methods and Analysis We will conduct a systematic review of all randomised controlled trials evaluating the use of intravenous or oral: indomethacin, ibuprofen and acetaminophen for the treatment of PDA in preterm infants. The primary outcome is failure of closure of the PDA. Secondary outcomes are neonatal mortality, need for surgical closure, duration of ventilator support, chronic lung disease, intraventricular haemorrhage, periventricular leukomalacia, necrotising enterocolitis, gastrointestinal bleeding, time to full enteral feeds and oliguria. We will search Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information, and assess the risk of bias (ROB) and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach). Subgroup analysis according to gestational age, birth weight, different doses of interventions, time of administration of the first dose of the intervention, and echocardiographic definition of haemodynamically significant PDA and ROB are planned. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, if adequate data are available. Ethics and Dissemination The results will help to reduce the uncertainty about the safety and effectiveness of the interventions, will identify knowledge gaps or will encourage further research for
Ali, Safaa; El Sisi, Amel
Aim To assess the challenges, feasibility, and efficacy of device closure of patent ductus arteriosus (PDA) in small children weighing ⩽10 kg for different types of devices used in an initial experience at Sohag University hospital. Methods Between March 2011 and September 2014, 91 patients with PDA underwent transcatheter closure in our institute, among whom 54 weighed ⩽10 kg. All of these patients underwent transcatheter closure of PDA using either a Cook Detachable Coil, PFM Nit-Occlud, or Amplatzer duct occluder. A retrospective review of the treatment results and adverse events was performed. Results Successful device placement was achieved in 53/54 small children (98.1%). The median minimum PDA diameter was 2.4 mm [interquartile range (IQR, 1.8–3.5 mm), median weight 8 kg (IQR, 7–10 kg), and median age 10 months (IQR, 8–17 months)]. Mild aortic obstruction occurred in one case (1.9%), as the device became displaced towards the aorta after release. The device embolized in one case (1.9%) and no retrieval attempt was made. Five cases (9.3%) had minor vascular complications. Conclusion With the current availability of devices for PDA closure, transcatheter closure of PDA is considered safe and efficacious in small children weighing ⩽10 kg with good mid-term outcome. The procedure had a low rate of high-severity adverse events even with the initial experience of the catheterization laboratory. PMID:27053899
El-Mashad, Abd El-Rahman; El-Mahdy, Heba; El Amrousy, Doaa; Elgendy, Marwa
In this prospective study, we compared the efficacy and side effects of indomethacin, ibuprofen, and paracetamol in patent ductus arteriosus (PDA) closure in preterm neonates. Three hundred preterm neonates with hemodynamically significant PDA (hs-PDA) admitted at our neonatal intensive care unit were enrolled in the study. They were randomized into three groups. Group I (paracetamol group) received 15 mg/kg/6 h IV paracetamol infusion for 3 days. Group II (ibuprofen group) received 10 mg/kg IV ibuprofen infusion followed by 5 mg/kg/day for 2 days. Group III (indomethacin group) received 0.2 mg/kg/12 h indomethacin IV infusion for three doses. Laboratory investigations such as renal function test, liver function test, complete blood count, and blood gases were conducted in addition to echocardiographic examinations. All investigations were done before and 3 days after treatment. There was no significant difference between all groups regarding efficacy of PDA closure (P = 0.868). There was a significant increase in serum creatinine levels and serum blood urea nitrogen (BUN) in the ibuprofen and indomethacin groups (P < 0.001). There was a significant reduction in platelet count and urine output (UOP) in both ibuprofen and indomethacin groups (P < 0.001). There was a significant increase in bilirubin levels in only the ibuprofen group (P = 0.003). No significant difference of hemoglobin (HB) level or liver enzymes in all groups (P > 0.05). Ventilatory settings improved significantly in patients with successful closure of PDA than those with failed PDA closure (P < 0.001).
Polat, Tuğçin Bora; Celebi, Ahmet; Hacımahmutoğlu, Sevim; Akdeniz, Celal; Erdem, Abdullah; Fırat, Fatih
Impaired left lung perfusion (LLP) has been described after transcatheter closure of the patent ductus arteriosus (PDA). In this study, we aimed to evaluate lung perfusion scans (LPSs) following occlusion of PDA with two frequently used coils: Cook detachable coil and Gianturco coil. A prospective study of 89 patients who underwent PDA occlusion using the Cook coils in 49 and the Gianturco coils in 40, was conducted. LPSs were performed after a median period of 18 months. The relationships between the LPSs and continuous variables were assessed by Pearson correlation analysis and the cut-off value of the best correlated parameters to predict abnormal LPSs obtained by the Receiver Operating Characteristic (ROC) analysis. Decreased left lung perfusion (LLP) was found in 13 patients including 10 after using Cook coils and 3 after using Gianturco coils (p=0.077). LLP values were significantly correlated with the loops deployed at the pulmonary side, coil/ductal diameter ratio and number of coils deployed (p=0.002, p=0.006 and p=0.009, respectively). Number of loops deployed at the pulmonary side >1.4 (specificity 77%, sensitivity 85%, area under the ROC curve 0.804, 95%CI 0.661-0.947, p<0.001) and first coil/ductal diameter ratio >1.85 (specificity 70%, sensitivity 77%, area under the ROC curve 0.747, 95%CI 0.423-0.790, p<0.005) were the best discriminative cut-off values of decreased LLP. Impaired LLP may appear following transcatheter closure of PDA with either Cook detachable coils or Gianturco coils. This situation may be complicated with loops deployed at the pulmonary side, the use of relatively large size of coil with respect to the ductal diameter and the use of multiple coils.
Incidence of postoperative implant-related bacterial endocarditis in dogs that underwent trans-catheter embolization of a patent ductus arteriosus without intra- and post-procedural prophylactic antibiotics.
Intra- and post-procedural prophylactic antibiotics are routinely administered by veterinary cardiologists to dogs that undergo trans-catheter embolization of a patent ductus arteriosus for prevention of implant-related infective endocarditis. The hypothesis of our study was that primary antibiotic prophylaxis is not necessary to prevent bacterial endocarditis. In this retrospective case series 54 client-owned dogs that underwent trans-catheter occlusion of a patent ductus arteriosus in a single tertiary veterinary referral center between 2004 and 2016 were evaluated. Follow-up information was gained by telephone interviews with the owners or the referring veterinarians, or from the digital archives of the authors' clinic. Inclusion criteria were that at least one metal implant (a coil or an Amplatz duct occluder) had to be delivered in the ductal ampulla, no local or systemic antibiotics were given on the day of the intervention or the week thereafter, at least 3 months of postoperative follow-up information was available, and the author was performing the procedure either as the primary or as the supervising cardiology specialist. None of the 54 dogs developed infective endocarditis in the postoperative 3 months. A study describing a similar population reports 2 of the included 47 dogs having developed infective endocarditis in the postoperative period despite the administration of intra- and post-procedural prophylactic antibiotics. We conclude that intra- and post-procedural antibiotic prophylaxis is not justified in dogs that undergo trans-catheter closure of a patent ductus arteriosus. Proper surgical technique and the use of new sterile catheters and implants are sufficient to prevent infective endocarditis in these dogs. Copyright © 2017 Elsevier B.V. All rights reserved.
Mari, G; Moise, K J; Deter, R L; Kirshon, B; Huhta, J C; Carpenter, R J; Cotton, D B
To investigate the effects of constriction of the ductus arteriosus on the pulsatility index of the middle cerebral artery, maximum velocity waveforms were obtained in 13 fetuses (one set of twins) whose mothers were treated with indomethacin for preterm labor (n = 9) or polyhydramnios (n = 3). Eleven of the fetuses manifested ductal constriction within 48 hours of therapy, whereas two fetuses had constriction after 1 week of therapy. Six of the 13 fetuses also manifested tricuspid insufficiency in association with constriction of the ductus arteriosus. All abnormal cardiac changes resolved in utero after discontinuation of indomethacin. No difference in the pulsatility index values of the middle cerebral artery was observed in the fetuses with ductal constriction but without tricuspid regurgitation (n = 7) when the values were compared with those obtained in absence of ductal constriction (1.87 +/- 0.37 vs. 1.88 +/- 0.33). In the fetuses that manifested both ductal constriction and tricuspid insufficiency (n = 6), the pulsatility index values in the middle cerebral artery were significantly lower in the presence of ductal constriction when compared with the values obtained in the absence of ductal constriction (2.22 +/- 0.26 vs. 1.57 +/- 0.34). These results indicate that a response to indomethacin sufficient to cause both ductal constriction and tricuspid insufficiency decreases the pulsatility index of the middle cerebral artery.
Gallo de Moraes, Alice; Vakil, Abhay; Moua, Teng
Little is known about the presence of patent foramen ovale in idiopathic pulmonary arterial hypertension. While there is suspected worsening of hypoxemia confounding assessment and management of pulmonary hypertension, as well as possible increased morbidity from paradoxical emboli, there may be theoretical relief of worsening right-sided pressures by the same mechanism of right-to-left shunting. Retrospective review of consecutive patients diagnosed with idiopathic pulmonary arterial hypertension (WHO Group 1) via right heart catheterization, from 1998 to 2010. All patients also underwent a four chamber transthoracic echocardiogram with agitated saline contrast for the evaluation of patent foramen ovale. Primary clinical data was collected and compared between patients with and without patent foramen ovale along with univariable and multivariable predictors of long term survival. One hundred and fifty five patients were included in the study, 42 with patent foramen ovale (27%). Patients with patent foramen ovale were younger at pulmonary arterial hypertension diagnosis and trended towards higher right ventricular systolic pressures on echocardiography and mean pulmonary arterial pressures by right heart catheterization. Predictors of mortality included age, diffusing capacity for carbon monoxide, and severe hypoxemia. Only diffusing capacity and age were predictive of mortality after adjustment for a priori covariables. Patent foramen ovale is seen in a quarter of patients with idiopathic pulmonary arterial hypertension and associated with increased prevalence of severe hypoxemia but had no effect on long term survival. Copyright © 2016 Elsevier Ltd. All rights reserved.
Smolich, Joseph J; Penny, Daniel J; Mynard, Jonathan P
Constriction of the fetal ductus arteriosus (DA) has disparate effects on mean and phasic hemodynamics, as mean DA blood flow is preserved until constriction is severe, but DA systolic and diastolic blood velocities change with only mild constriction. To determine the basis of this disparity and its physiological significance, seven anesthetized late-gestation fetal sheep were instrumented with pulmonary trunk (PT), DA, and left pulmonary artery (PA) micromanometer catheters and transit-time flow probes. Blood flow profile and wave intensity analyses were performed at baseline and during mild, moderate, and severe DA constriction (defined as pulmonary-aortic mean pressure differences of 4, 8, and 14 mmHg, respectively), produced with an adjustable snare. With DA constriction, mean DA flow was initially maintained but decreased with severe constriction (P < 0.05) in conjunction with a reduction (P < 0.05) in PT flow (i.e., right ventricular output). By contrast, DA systolic flow fell progressively during DA constriction (P < 0.001), due to decreased transmission of both early and midsystolic proximal flow-enhancing forward-running compression waves into the DA. However, DA constriction was also accompanied by greater systolic storage of blood in the PT and main PA (P < 0.025), and increased retrograde diastolic flow from compliant major branch PA (P < 0.001). Transductal discharge of these central and conduit PA blood reservoirs in diastole offset systolic DA flow reductions. These data suggest that, during DA constriction in the fetus, enhanced central and conduit PA reservoir function constitutes an important compensatory mechanism that contributes to preservation of mean DA flow via a systolic-to-diastolic redistribution of phasic DA flow.
Nwaejike, Nnamdi; Tennyson, Charlene; Mosca, Roberto; Venkateswaran, Rajamiyer
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with previous internal mammary artery/internal thoracic artery (ITA) grafts, can the internal mammary artery/ITA be reused/recycled in redo coronary artery bypass surgery? Fourteen papers were found using the reported search of which 10 represented the best evidence to answer the clinical question. There was variation in patient selection, the number of patients reported, outcome measures recorded, and methods and duration of follow-up. The results were mostly in favour of using a recycled ITA when it could be safely harvested. Most studies were retrospective. One large series of 60 patients who underwent redo coronary artery bypass grafting (CABG) using previously implanted ITAs had a mean time to reoperation of 117 ± 68 months. They reported no operative deaths; no patients required further or subsequent target vessel revascularization; 30-day mortality was 8.3% and myocardial infarction rate was 3%. Another two series of 16 and 12 patients underwent recycling of arterial grafts during coronary artery revascularization with no perioperative deaths in either. Postoperative angiography was performed in 10 patients in one of these studies, which showed excellent flow in all redone left internal thoracic artery (LITA) grafts. One study reported results from a prospective cohort of 9 patients who underwent redo coronary artery bypass grafting. Interval between operations was between 1 and 132 months. There was no perioperative mortality, but 1 patient required reintervention (to an interposition vein graft). A further study of 4 patients who underwent redo CABG using ITAs that were patent but with severe stenosis at the distal anastomosis had no mortality. Postoperative angiography showed patency of all grafts. There have also been 4 case reports on reusing the ITA/ITA in redo CABG with no damage to the reused LITA, no perioperative
Mitra, Souvik; Florez, Ivan D; Tamayo, Maria E; Aune, Dagfinn; Mbuagbaw, Lawrence; Veroniki, Areti-Angeliki; Thabane, Lehana
Management of patent ductus arteriosus (PDA) in preterm infants is one of the most controversial topics in neonatal medicine. The availability of different pharmacotherapeutic options often poses a practical challenge to the practising neonatologist as to which one to choose as a therapeutic option. Our objectives are to determine the relative merits of the available pharmacotherapeutic options for the management of PDA. We will conduct a systematic review of all randomised controlled trials evaluating the use of intravenous or oral: indomethacin, ibuprofen and acetaminophen for the treatment of PDA in preterm infants. The primary outcome is failure of closure of the PDA. Secondary outcomes are neonatal mortality, need for surgical closure, duration of ventilator support, chronic lung disease, intraventricular haemorrhage, periventricular leukomalacia, necrotising enterocolitis, gastrointestinal bleeding, time to full enteral feeds and oliguria. We will search Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information, and assess the risk of bias (ROB) and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach). Subgroup analysis according to gestational age, birth weight, different doses of interventions, time of administration of the first dose of the intervention, and echocardiographic definition of haemodynamically significant PDA and ROB are planned. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, if adequate data are available. The results will help to reduce the uncertainty about the safety and effectiveness of the interventions, will identify knowledge gaps or will encourage further research for other therapeutic options. Therefore, its results will be
Rubin, Lewis J; Galiè, Nazzareno; Grimminger, Friedrich; Grünig, Ekkehard; Humbert, Marc; Jing, Zhi-Cheng; Keogh, Anne; Langleben, David; Fritsch, Arno; Menezes, Flavia; Davie, Neil; Ghofrani, Hossein-Ardeschir
Riociguat is a soluble, guanylate cyclase stimulator, approved for pulmonary arterial hypertension. In the 12-week PATENT-1 study, riociguat was well tolerated and improved several clinically relevant end-points in patients with pulmonary arterial hypertension who were treatment naïve or had been pretreated with endothelin-receptor antagonists or prostanoids. The PATENT-2 open-label extension evaluated the long-term safety and efficacy of riociguat. Eligible patients from the PATENT-1 study received riociguat individually adjusted up to a maximum dose of 2.5 mg three times daily. The primary objective was to assess the safety and tolerability of riociguat; exploratory efficacy assessments included 6-min walking distance and World Health Organization (WHO) functional class. Overall, 396 patients entered the PATENT-2 study and 324 (82%) were ongoing at this interim analysis (March 2013). The safety profile of riociguat in PATENT-2 was similar to that observed in PATENT-1, with cases of haemoptysis and pulmonary haemorrhage also being observed in PATENT-2. Improvements in the patients', 6-min walking distance and WHO functional class observed in PATENT-1 persisted for up to 1 year in PATENT-2. In the observed population at the 1-year time point, mean±sd 6-min walking distance had changed by 51±74 m and WHO functional class had improved in 33%, stabilised in 61% and worsened in 6% of the patients versus the PATENT-1 baseline. Long-term riociguat was well tolerated in patients with pulmonary arterial hypertension, and led to sustained improvements in exercise capacity and functional capacity for up to 1 year. Copyright ©ERS 2015.
Humbert, Marc; Coghlan, J Gerry; Ghofrani, Hossein-Ardeschir; Grimminger, Friedrich; He, Jian-Guo; Riemekasten, Gabriela; Vizza, Carmine Dario; Boeckenhoff, Annette; Meier, Christian; de Oliveira Pena, Janethe; Denton, Christopher P
The 12-week, phase III Pulmonary Arterial hyperTENsion sGC-stimulator Trial (PATENT)-1 study investigated riociguat in patients with pulmonary arterial hypertension (PAH). Here, we present a prospectively planned analysis of the safety and efficacy of riociguat in the subgroup of patients with PAH associated with connective tissue disease (PAH-CTD). Patients with PAH-CTD were further classified post hoc as having PAH associated with systemic sclerosis or PAH-other defined CTD. In PATENT-1, patients received riociguat (maximum 2.5 or 1.5 mg three times daily) or placebo. Efficacy endpoints included change from baseline in 6-minute walking distance (6MWD; primary endpoint), haemodynamics and WHO functional class (WHO FC). In the long-term extension PATENT-2, patients received riociguat (maximum 2.5 mg three times daily); the primary endpoint was safety and tolerability. In patients with PAH-CTD, riociguat increased mean 6MWD, WHO FC, pulmonary vascular resistance and cardiac index. Improvements in 6MWD and WHO FC persisted at 2 years. Two-year survival of patients with PAH-CTD was the same as for idiopathic PAH (93%). Riociguat had a similar safety profile in patients with PAH-CTD to that of the overall population. Riociguat was well tolerated and associated with positive trends in 6MWD and other endpoints that were sustained at 2 years in patients with PAH-CTD. PATENT-1 (NCT00810693), PATENT-2 (NCT00863681). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Han, Heon-Seok; Park, Jeong-Hyun; Kim, Deok Soo; Lee, Seog-Jae; Hong, Jang-Soo; Lee, Geon Kook
We present a rare case of main pulmonary artery stenosis secondary to protruding fibrous material in the main pulmonary artery associated with patent ductus arteriosus. A 1-month-old baby boy manifested cardiac murmur. Echocardiogram showed circumferential high echogenic mass inside the main pulmonary artery with pressure gradient of 49 mmHg and patent ductus arteriosus. The mass did not regress during 3 months' follow-up period. Angiographic images showed that the circular filling defect was located at the main pulmonary artery distal to pulmonary valve, and pulmonary valve and both pulmonary arteries were normal. After surgical removal of the circumferential material and ductus ligation, the pressure gradient became negligible. The material was consisted of scarcely cellular fibrous tissue, abundant coagulum of fibrinous material and dense calcification. PMID:12172057
Moreno, Nuno; da Silva Castro, Alexandra; Pereira, Adriana; Silva, João Carlos; Almeida, Pedro Bernardo; Andrade, Aurora; Maciel, Maria Júlia; Pinto, Paula
Non-occlusion of the internal mammary artery side branches may cause ischemia due to flow diversion after coronary artery bypass grafting. The authors present the case of a 67-year-old man with recurrent angina after undergoing myocardial revascularization with a left internal mammary artery to left anterior descending bypass. He presented with impaired anterior wall myocardial perfusion in the setting of a patent left internal mammary artery side branch. Effective percutaneous treatment was carried out through coil embolization, with improved flow and clinical symptoms, confirmed through ischemia testing. Coronary steal through a patent mammary artery side branch is a controversial phenomenon and this type of intervention should be considered only in carefully selected patients. Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
Lovering, Andrew T; Lozo, Mislav; Barak, Otto; Davis, James T; Lojpur, Mihajlo; Lozo, Petar; Čaljkušić, Krešimir; Dujić, Željko
What is the central question of this study? Does a patent foramen ovale contribute to resting arterial hypoxaemia, defined as arterial oxygen saturation <95%, in subjects with chronic heart failure with or without pulmonary arterial hypertension? What is the main finding and its importance? The presence of a patent foramen ovale contributed to resting arterial hypoxaemia only in subjects with chronic heart failure with pulmonary arterial hypertension. These data suggest that the presence of a patent foramen ovale should be considered in chronic heart failure patients with arterial hypoxaemia and pulmonary hypertension. The roles of intrapulmonary and intracardiac shunt in contributing to arterial hypoxaemia at rest in subjects with chronic heart failure (CHF) have not been well investigated. We hypothesized that blood flow through intrapulmonary arteriovenous anastomoses (Q̇ IPAVA ) and/or patent foramen ovale (Q̇ PFO ) could potentially contribute to arterial hypoxaemia and, with pulmonary hypertension (PH) secondary to CHF, this contribution may be exacerbated. Fifty-six subjects with CHF (New York Heart Association Classes I-III), with (+) or without (-) PH [defined as peak tricuspid regurgitation velocity ≥2.9 m s(-1) (CHF PH+, n = 32) and peak tricuspid regurgitation velocity ≤2.8 m s(-1) (CHF PH-, n = 24)], underwent arterial blood gas analysis and transthoracic saline contrast echocardiography concomitant with transcranial Doppler to detect Q̇ IPAVA and Q̇ PFO . Seventeen of 56 subjects with CHF (30%) had Q̇ PFO , but only four of 56 subjects with CHF had Q̇ IPAVA (7%), both similar to age- and sex-matched control subjects. Mean arterial oxygen saturation (SaO2) was lower in subjects with Q̇ PFO . Only CHF PH+ subjects with Q̇ PFO had arterial hypoxaemia (mean SaO2 <95%). Bubble scores assessed using transthoracic saline contrast echocardiography were correlated with microembolic signals detected with transcranial Doppler in subjects with
Wilson, Simon J; Mitchell, Andrew; Gray, Timothy J M; Loh, Hoe Jun; Cruden, Nick L
A haemostatic technique that maintains radial artery flow ("patent haemostasis") following transradial catheterization reduces rates of radial artery occlusion (RAO) in patients with stable coronary disease. It is unclear whether this benefit extends to patients with an acute coronary syndrome (ACS). Patients undergoing inpatient transradial catheterization for an ACS were prospectively enrolled in a consecutive cohort study (n=300). Radial haemostasis was obtained using standard radial compression (cohort 1; n=150) or patent haemostasis (cohort 2; n=150). An end-of-case activated clotting time (ACT) was recorded and radial artery patency assessed within 24 hours of sheath removal by reverse Barbeau's test. The incidence of RAO was 16.0% following standard radial compression and 5.3% following patent haemostasis (p=0.003). Univariate predictors of RAO were patent haemostasis (OR 0.30; [0.13-0.68], p=0.004), hyperlipidaemia (OR 0.46; [0.21-0.98], p=0.04), history of current smoking (OR 2.86; [1.3-6.0], p=0.015) and longer procedure times (OR 1.03/additional minute; [1.01-1.05], p=0.003). There was no association between the end-of-case ACT and RAO (OR 1.00; [0.9-1.01] p=1.00). After adjusting for covariates, patent haemostasis reduced the risk of RAO by 70% compared to standard compression (OR 0.30; [0.12-0.77], p=0.12). The c-statistic for model discrimination was 0.79 (95% CI [0.71-0.86], p<0.001). Inverse probability treatment weighted analysis also confirmed patent haemostasis as an independent predictor of reduced RAO (OR 0.38 [0.15-0.95], p=0.039). Patent haemostasis is highly effective in preventing early RAO in patients with ACS. Copyright © 2017 Elsevier B.V. All rights reserved.
Kim, Tae Ho; Jung, Jae Jun; Kim, Yong Han; Yang, Ji-Hyuk; Jun, Tae-Gook
An eight-day-old neonate was diagnosed with dextro-transposition of the great arteries, atrial septal defect, patent ductus arteriosus, and a single sinus origin of the coronary arteries. The single coronary artery originated from the left sinus (sinus 2), had a proximal left circumflex arterial branch, and passed anteriorly to the right side of the aorta, further branching into the right coronary and left anterior descending arteries. We successfully performed an arterial switch operation and coronary transfer by tube graft reconstruction with autologous aortic tissue to treat the dextro-transposition of the great arteries and atrial septal defect with a single-sinus origin of the coronary arteries.
Bergwerff, M; Gittenberger-de Groot, A C; Wisse, L J; DeRuiter, M C; Wessels, A; Martin, J F; Olson, E N; Kern, M J
Prx1 (MHox) and Prx2 (S8) are non-clustered homeobox genes that are expressed in a complex, mostly mesenchyme-specific pattern throughout embryogenesis. The expression pattern and gene-targeted mice previously revealed a major role for Prx1 in skeletogenesis. In addition, specific and high expression of both Prx genes was reported in the developing cardiovascular system, predominantly in prospective connective tissues of the heart and in the great arteries and veins. We examined embryos of previously generated gene-targeted mice. Prx2-/- mutants were viable and did not show cardiovascular malformations. Intracardiac morphology of Prxl-/- and Prx1/Prx2-combined null mutants also appeared normal throughout development. However, the Prx1-/- and Prx1/Prx2 double-null mutants showed a vascular abnormality with an abnormal positioning and awkward curvature of the aortic arch in addition to a misdirected and elongated ductus arteriosus, and in two of seven combined mutants, an anomalous retro-oesophageal right subclavian artery. Generally, all great arteries appeared to run somewhat tortuously through the surrounding mesenchyme. The vascular histology and vessel wall thickness were normal in all mutants. Prx1-/- and Prx double-gene-targeted mice revealed similar spectra of vascular anomalies, but double mutants appeared to be more seriously affected. The current findings suggest that other genes may compensate for the loss of Prx in the heart, but, in contrast, our data support a role for Prx in the development of vascular and perivascular matrix.
Smolich, Joseph J; Kenna, Kelly R; Mynard, Jonathan P
Arterial reservoir ("windkessel") function, whereby a part of left ventricular (LV) output is stored in elastic arteries during systole and discharged in diastole, is a well-established physiological phenomenon. However, its role in rapid reversal (to left-to-right) and a systolic-to-diastolic shift of shunting across the ductus arteriosus after birth is unknown. To address this question, ductal and aortic isthmus flows were measured with high-fidelity transit-time probes in six anesthetized preterm fetal lambs before and after cord clamping and subsequent early mechanical ventilation and for 30 min postbirth. Descending aortic flow was calculated as the sum of isthmus and ductal flows. Left-to-right ductal flow profiles were related to those of the isthmus and descending aorta, with upper body arterial reservoir discharge indicated by forward diastolic isthmus flow, and retrograde lower body arterial reservoir discharge by negative diastolic descending aortic flow. Left-to-right ductal shunting appeared immediately after cord clamping (P < 0.001), due entirely to newly emergent retrograde lower body reservoir discharge, and rose with ventilation via increased lower body reservoir discharge (P < 0.005), supplemented by upper body reservoir discharge after 45 s (P < 0.025) and LV systolic flow after 3 min (P = 0.025). The contribution of lower body reservoir discharge to left-to-right ductal shunting fell to 55 ± 8% at ≥15 min (P < 0.001) but remained higher (P < 0.002) than LV systolic flow (33 ± 8%) or upper body reservoir discharge (12 ± 5%). These results suggest that retrograde lower body arterial reservoir discharge plays a key role in rapid reversal and a systolic-to-diastolic shift of ductal shunting after cord clamping and early ventilation at birth.
Schelhorn, Juliane; Ertle, Judith; Schlaak, Joerg F; Mueller, Stefan; Bockisch, Andreas; Schlosser, Thomas; Lauenstein, Thomas
Selective internal radiation therapy (SIRT) using 90-yttrium is a local therapy for unresectable liver malignancies. Non-targeted 90-yttrium diversion via a patent hepatic falciform artery (HFA) is seen as risk for periprocedural complications. Therefore, this study aimed to evaluate the impact of a patent HFA on SIRT. 606 patients with SIRT between 2006 and 2012 were evaluated retrospectively. SIRT preparation was performed by digital subtraction angiography including (99m)Tc-HSAM administration and subsequent SPECT/CT. Patients with an angiographically patent HFA were analyzed for procedural consequences and complications. 19 of 606 patients (3%) with an angiographically patent HFA were identified. Only 11 of these 19 patients received 90-yttrium in the hepatic vessel bed containing the HFA. Initial coil embolization of the HFA succeeded only in three of 11 patients. Out of the eight remaining patients four had no abdominal wall (99m)Tc-HSAM accumulation. The other four patients presented with an abdominal wall (99m)Tc-HSAM accumulation, for those a reattempt of HFA embolization was performed or ice packs were administered on the abdominal wall during SIRT. In summary, all patients tolerated SIRT well. A patent HFA should not be considered a SIRT contraindication. In patients with abdominal wall (99m)Tc-HSAM accumulation HFA embolization or ice pack administration seems to prevent complications.
Sodian, R; Rassoulian, D; Kaczmarek, I; Kozlik-Feldmann, R; Huber, A; Reichart, B; Daebritz, S
Left abnormal subclavian artery and right aortic arch is described as a rare cause of dyspnoea and dysphagia in paediatric patients. The optimal surgical management of such cases is not clearly established. We propose a single-stage repair by transection of the patent ductus arteriosus or ligamentum arteriosum and an additional transection of the left abnormal subclavian artery with reimplantation into the common carotid artery.
Watson, Timothy; Pope, Adele; van Pelt, Niels; Ruygrok, Peter N
In coronary artery bypass grafting, good-quality conduits are needed to maximize the potential for long-term patency. Revascularization has traditionally been achieved with use of the saphenous vein and the internal thoracic arteries. In recent years, total arterial revascularization with use of the radial arteries has been promoted. Meanwhile, use of the transradial approach for coronary angiography has also increased. The long-term effects of previous cannulation in radial artery bypass grafts are not known. Therefore, we used multidetector computed tomographic angiography to investigate radial-artery graft patency in a small series of patients who had undergone transradial angiography. We found a high patency rate, and we discuss those findings here.
Presbitero, P; Bull, C; Haworth, S G; de Leval, M R
Of 12 patients with angiographically absent pulmonary artery, 11 were investigated surgically. The previously occult pulmonary artery was found in 10 patients, in five of whom a vestige of an intrapericardial artery was present and in five the artery was patent only at the hilus, a gap existing between the main pulmonary artery and the hilar vessel, and no artery was found in one. All patients with an intrapericardial artery had right ventricular outflow tract obstruction and a ductus descending vertically from underneath the aortic arch. In those without an intrapericardial vessel the occult artery was on the side opposite the aortic arch, and there was evidence of a ductus coming from the innominate artery on the side of the interruption. The occult pulmonary artery, where identified at operation, was usually joined initially to the systemic circulation. Ultimately, continuity between the hilar and main pulmonary artery may be established surgically. Where no intrapericardial vessel exists, however, a conduit may be required to bridge the gap. It seems advisable to search for the occult artery as early in life as is feasible in the hope that providing a blood supply will ensure development of the vessel and normal lung growth. Images PMID:6743435
Polyakov, V Ya; Nikolaev, Yu A; Pegova, S V; Matsievskaya, T R; Obukhov, I V
The study included 1172 patients (410 men and 762 women) at the mean age of 60.3 ± 10.4 years with grade I-II (stage I-II) arterial hypertension (AH) admitted to the clinic of Institute of Experimental Medicine. The patients were divided into 2 groups based on the results of clinical and laboratory diagnostics. Group 1 (n = 525) included patients with AH and hepatobiliary system (HBS) diseases, group 2 (n = 647) patients with AH without HBS diseases. The patients group 1 had a thicker intima-media complex of carotid arteries, higher peak systolic bloodflow rate in the internal and vertebral carotid arteries, more pronounced coiling of internal carotid arteries than patients of group 2. Patients with AH and HBS diseases exhibited correlation between bloodflow rate in external carotid arteries and atherogenicity coefficient. Duplex scanning of neck vessels of in patients with AH without HBS diseases revealed peculiar changes of the intima-media thickness and hemodynamically significant changes of the blood flow in the internal carotid arteries that may be of prognostic value in this nosological syntropy and require the personified approach to diagnostics, treatment, and prevention of these conditions.
Venkatesh, Vidheya; Lee, Lleona; White, Deborah; Kelsall, Wilf
Our aim was to ascertain the number of neonatal ligations of the patent arterial duct performed in the United Kingdom in 2002, and to determine the survival of the neonates after 30 days. A postal questionnaire was sent to the lead paediatician in every hospital in the United Kingdom possessing a special care or neonatal intensive care unit, requesting information on the number of babies referred for ligation of a persistently patent arterial duct. A separate questionnaire was sent to the paediatric cardiothoracic centres for information on babies who underwent the procedure. Cross-referencing the responses identified neonates who were not reported in the separate questionnaires. Additional information was requested from the central cardiac audit database. The overall response rate was 74%, with 172 forms returned of 234 distributed. From the combined responses, we ascertained that ligation has been performed in 244, with survival at 30 days of 94%. There were problems in identifying some babies because of the incomplete nature of the information received from both referring hospitals and specialist cardiothoracic centres. We would recommend a joint prospective study is conducted by paediatricians and paediatric cardiologists to determine the short and long term outcomes in this population known to be at high risk.
Leong, Quor M; Lai, Hee K; Lo, Richard G H; Teo, Terence K B; Goh, Anthony; Chow, Pierce K H
The most common use of radioembolization is in the treatment of primary and secondary liver tumors, and the most common radioisotope used is yttrium-90. This form of therapy has been proven to be successful in achieving tumor reduction and prolonging survival. Adverse events, although uncommon and usually self-limiting, have been reported. The present report describes a case of radiation dermatitis caused by shunting of (90)Y microspheres to the anterior abdominal wall via a patent falciform artery. When identified, prophylactic embolization of this patent artery may prevent the potential adverse event of radiation-induced dermatitis after radioembolization.
Gnanappa, Ganesh Kumar; Laohachai, Karina; Orr, Yishay; Ayer, Julian
Anomalous origin of a branch pulmonary artery from the aorta is a rare malformation, accounting for 0.12% of all congenital heart defects. Anomalous origin of the left pulmonary artery from the aorta (ALPA) constitutes a small proportion of these cases. ALPA has been reported to arise from the ascending aorta with various embryologic postulates. We report a case of isolated ALPA arising from the descending aorta in association with a patent ductus arteriosus, to emphasize its embryologic ambiguity.
Yaman, C; Arzt, W; Tulzer, G; Tews, G
The case report describes the pre- and postnatal clinical and sonographic findings of a fetus with spontaneous constriction of Ductus arteriosus at 39 weeks gestation. An abnormal four-chamber view due to a hypertrophied and enlarged right ventricle, increased peak systolic (2.39 m/sec), increased peak diastolic (0.88 m/sec) velocities and the decreased pulsatility index of 0.92 were the diagnostic criteria. The flow of the right pulmonary artery was retrograde. After birth estimated pulmonary pressure was 50 mmHg. It is concluded that constriction of the fetal ductus arteriosus may also occur spontaneously in the absence of maternal drugs.
Chatziralli, Irini P; Parikakis, Efstratios A; Mitropoulos, Panagiotis G
To present the case of a man with branch retinal artery occlusion (BRAO) and concomitant patent foramen ovale (PFO), which was first diagnosed during the evaluation of BRAO. A 35-year-old man presented with blurred vision in the left eye for 2 days. His best-corrected visual acuity (BCVA) was 6/6 in the right eye and 6/12 in the left eye. He had no ophthalmic or medical history. Ophthalmologic examination revealed a left inferior BRAO, confirmed by fluorescein angiography. The patient underwent a thorough diagnostic workup. Cardiologic examination with transesophageal echocardiography revealed a right-to-left shunt across a PFO. The patient was treated with clopidogrel and at the 15-day review, BCVA in his left eye was 6/7.5 and the retinal edema was resolved, as detected on optical coherence tomography, but relative afferent pupillary defect was persistent. The patient had developed no other embolic event at the 9-month follow-up, having undergone an operation for PFO repair. Patent foramen ovale, although usually asymptomatic, should be considered among the potential causes of BRAO, especially in young patients. Prompt diagnosis and liaison with cardiologists is important to help prevent ocular or systemic embolic events and associated morbidity.
Artunc Ulkumen, Burcu; Pala, Halil Gursoy; Baytur, Yesim Bulbul; Koyuncu, Faik Mumtaz
We aimed to evaluate ductus venosus Doppler waveforms before and after amniocentesis in order to investigate any effect of amniocentesis on fetal myocardial hemodynamics. We also evaluated the umbilical artery, uterine artery and fetal mid-cerebral artery Doppler waveforms in order to investigate any relationship with ductus venosus Doppler changes. The study population consisted of 56 singleton pregnancies having genetic amniocentesis. Twenty seven of them had transplacental needle insertion; whereas 29 of them had non-transplacental amniocentesis. Uterine artery, umbilical artery, mid-cerebral artery and ductus venosus pulsatiliy index and resistance index were measured just before and after amniocentesis. Amniocentesis does not cause any significant changes in fetal ductus venosus Doppler waveforms. There is also no significant changes in uterine artery, umbilical artery, mid-cerebral artery pulsatility and resistance index. Amniocentesis-whether transplacental or not- does not cause any significant effect on fetal myocardial hemodynamics.
Ulkumen, Burcu Artunc; Pala, Halil Gursoy; Baytur, Yesim Bulbul; Koyuncu, Faik Mumtaz
Objective: We aimed to evaluate ductus venosus Doppler waveforms before and after amniocentesis in order to investigate any effect of amniocentesis on fetal myocardial hemodynamics. We also evaluated the umbilical artery, uterine artery and fetal mid-cerebral artery Doppler waveforms in order to investigate any relationship with ductus venosus Doppler changes. Methods: The study population consisted of 56 singleton pregnancies having genetic amniocentesis. Twenty seven of them had transplacental needle insertion; whereas 29 of them had non-transplacental amniocentesis. Uterine artery, umbilical artery, mid-cerebral artery and ductus venosus pulsatiliy index and resistance index were measured just before and after amniocentesis. Results: Amniocentesis does not cause any significant changes in fetal ductus venosus Doppler waveforms. There is also no significant changes in uterine artery, umbilical artery, mid-cerebral artery pulsatility and resistance index. Conclusion: Amniocentesis-whether transplacental or not- does not cause any significant effect on fetal myocardial hemodynamics. PMID:25225513
Nguyen, Thach; Do, Hoang; Pham, Tri; Vu, Loc T; Zuin, Marco; Rigatelli, Gianluca
New onset of heart failure (HF) is an indication for the assessment of coronary artery disease. The aim of this study was to clarify the mechanistic causes of new onset HF associated with ischemic electrocardiograph (EKG) changes and chest pain in patients with patent or minimally diseased coronary arteries. Twenty consecutive patients (Group A) were retrospectively reviewed if they had an history of new onset of HF, chest pain, electrocardiographic changes indicating ischemia (ST depression or T wave inversion in at least two consecutive leads and a negative coronary angiogram [CA]) and did not require percutaneous coronary intervention or coronary artery bypass grafting. A 1:1 matched cohort (Group B) was adopted to validate the results. All patients had a negative CA. The majority of subjects in Group A had a higher left ventricular end diastolic pressure (LVEDP) when compared to the control group (p<0.05). Similarly, the aortic diastolic (AOD) pressure was lower in Group A than in Group B (p<0.05). In patients with elevated LVEDP and low AOD, with a coronary perfusion pressure (CPP) <20 mmHg, deep T wave inversion in two consecutive leads were more frequently observed. When the CPP was between 20-30 mmHg, a mild ST depression were more frequently recorded (p<0.05). Conversely, when the CPP was >30 mmHg, only mild non-specific ST-T changes or normal EKG were observed. In patients with HF and EKG changes suggestive of ischemia in at least two consecutive leads, a lower AOD could aggravate ischemia in patients with elevated left ventricular end diastolic pressure.
Tang, Liang; Zhou, Shenghua; Shen, Xiangqian
Percutaneous closure of patent arterial ducts with the Amplatzer Ductal Occluder has become an effective and widely accepted alternative to surgical management. Although rarely, the occluder can be dislodged after an initially successful deployment, and with catastrophic consequences. We describe such a case in a 12-month-old girl who underwent transcatheter closure of a patent arterial duct. After device deployment, the occluder embolized in the patient's descending thoracic aorta, and severe spinal cord ischemic injury resulted. To our knowledge, ours is the first report of this complication after the deployment of an Amplatzer Ductal Occluder. We discuss pathophysiologic mechanisms that could expose patients to the risk of device dislodgment, and we review the relevant medical literature.
Petruzzellis, Marco; Fraddosio, Angela; Giorelli, Maurizio; Prontera, Mariapia; Tinelli, Angelica; Lucivero, Vincenzo; Federico, Francesco
Case report. To report the first case of posterior spinal artery (PSA) infarct due to patent foramen ovale (PFO). Infarct in the territories of PSA are very rare: till now 38 cases are reported in the literature. Moreover only 1 case of spinal cord infarction was attributed to paradoxical embolism through PFO, but in the anterior spinal artery territory. A 60-year-old woman was hospitalized for sudden numbness of the right leg. Neurologic examination revealed right leg mild paresis and loss of proprioception and dysesthesia at T11. Spine-MRI showed T5-T7 posterolateral cord ischemia. Transesophageal echocardiography disclosed a PFO with severe right-left shunt confirmed by transcranial Doppler. During the hospitalization she was treated with oral-500 mg ticlopidine, because of a mild allergic reaction to acetylsalicylic acid. No steroids were administrated. Physiotherapy was performed daily. Motor and urinary symptoms disappeared in 20 days. At 1-month clinical follow-up only suspended dysesthesia on the right side was present. At 3 months follow-up spine-MRI showed no signal abnormalities within the spinal cord but the patient still complained of dysesthesia. The therapy was changed to oral 75 mg clopidogrel, cause of leucopoenia. At 1-year follow-up dysesthesia was still present, but less complaining and no recurrence and adverse effect due to clopidogrel therapy were reported. This report describe a case of acute nontraumatic myelopathy. At 4 days after onset, PSA infarct was diagnosed on the basis of neurologic findings and MR images. After extensive diagnostic work-up, we were able to identify only PFO, so it was the first case of PSA due to probable paradoxical embolism. The patient was treated with antiplatelet therapy with good recovery and no recurrence at 1-year follow-up.
... mediastinum) while the child is deep asleep and pain-free (under general anesthesia). For some heart defect repairs, the incision is made on the side of the chest, between the ribs (thoracotomy) instead of through the breastbone. Heart-lung ...
Mehta, SK; Younoszai, A; Pietz, J; Achanti, BP
Pharmacological closure by indomethacin is customary if symptoms of PDA are not controlled adequately with fluid restriction and diuretics. Its use, however, requires a comprehensive clinical assessment of all the vital perinatal factors and a vigilant monitoring of the sick infant. Prophylactic use of indomethacin is discouraged. The decision to use pharmacological versus surgical treatment or both should be individualized based on evidence-based research and clinician's own experience. Surgical ligation remains the primary mode of therapy in cases of pharmacological treatment failure or recurrence. PMID:22368623
... how your family prefers to handle treatment decisions. Medicines Your child's doctor may prescribe medicines to help close your ... with your child's doctors How to give your child medicines at home, if needed When your child goes ...
Qureshi, Muhammad Yasir; Burkhart, Harold M; Julsrud, Paul; Cetta, Frank
Tetralogy of Fallot without pulmonary valve syndrome is almost always associated with an absent ductus arteriosus. Patients with right aortic arch and retroesophageal left subclavian artery have a vascular ring if the left ductus arteriosus or its remnant and the Kommerell diverticulum are present. We report the cases of 2 infants in whom the role of an absent ductus arteriosus or its remnant is noteworthy. Both patients had a combination of tetralogy of Fallot with absent pulmonary valve syndrome and right aortic arch with retroesophageal left subclavian artery without a vascular ring. The absence of the ductus arteriosus has a role in the pathogenesis of tetralogy of Fallot with absent pulmonary valve syndrome. The absence of a ductus arteriosus in the right aortic arch with retroesophageal left subclavian artery precludes a vascular ring.
Kim, Tae Ho; Jung, Jae Jun; Kim, Yong Han; Yang, Ji-Hyuk; Jun, Tae-Gook
An eight-day-old neonate was diagnosed with dextro-transposition of the great arteries, atrial septal defect, patent ductus arteriosus, and a single sinus origin of the coronary arteries. The single coronary artery originated from the left sinus (sinus 2), had a proximal left circumflex arterial branch, and passed anteriorly to the right side of the aorta, further branching into the right coronary and left anterior descending arteries. We successfully performed an arterial switch operation and coronary transfer by tube graft reconstruction with autologous aortic tissue to treat the dextro-transposition of the great arteries and atrial septal defect with a single-sinus origin of the coronary arteries. PMID:25551074
Leonhardt, Andreas; Glaser, Alexander; Wegmann, Markus; Schranz, Dietmar; Seyberth, Hannsjörg; Nüsing, Rolf
Prostaglandins play a major role in maintaining ductal patency in utero. Ductal tone is regulated by both locally released and circulating vasodilatory prostaglandins. In infants with ductus arteriosus-dependent congenital heart disease, ductal patency is maintained by intravenous administration of prostaglandin (PG) E1. Little information is available regarding the expression of prostaglandin receptors in man. By means of RT–PCR and immunohistochemistry we studied the expression of the PGI2 receptor (IP), the four different PGE2 receptors (EP1, EP2, EP3 and EP4), and the receptors for thromboxane (Tx) A2 (TP), PGD2 (DP) and PGF2α (FP) in the ductus arteriosus of three newborn infants with ductus arteriosus-dependent congenital heart disease and intravenous infusion of PGE1 and of one 8 month old child with a patent ductus arteriosus. The EP3, EP4, FP, IP and TP receptor were markedly expressed at the mRNA and protein level, whereas the EP2 receptor was weakly expressed and the EP1 receptor was detected in two out of four tissue specimens only. The DP receptor was not detected in any of the samples. The most pronounced expression, which was located in the media of the ductus arteriosus, was observed for the EP4 and TP receptors followed by IP and FP receptor protein. These data indicate that ductal patency during the infusion of PGE1 in infants with ductus arteriosus-dependent congenital heart disease might be mediated by the EP4 and IP receptor. The data further suggest that a heterogeneous population of prostanoid receptors may contribute to the regulation of ductus arteriosus tone in humans. PMID:12598419
Yokoyama, Utako; Minamisawa, Susumu; Ishikawa, Yoshihiro
The ductus arteriosus (DA), a fetal arterial connection between the main pulmonary artery and the descending aorta, normally closes immediately after birth. The DA is a normal and essential fetal structure. However, it becomes abnormal if it remains patent after birth. Closure of the DA occurs in two phases: functional closure of the lumen within the first hours after birth by smooth muscle constriction, and anatomic occlusion of the lumen over the next several days due to extensive neointimal thickening in human DA. There are several events that promote the DA constriction immediately after birth: (a) an increase in arterial oxygen tension, (b) a dramatic decline in circulating prostaglandinE(2) (PGE(2)), (c) a decrease in blood pressure within the DA lumen, and (d) a decrease in the number of PGE(2) receptors in the DA wall. Anatomical closure of the DA is associated with the formation of intimal thickening, which are characterized by (a) an area of subendothelial deposition of extracellular matrix, (b) the disassembly of the internal elastic lamina and loss of elastic fiber in the medial layer, and (c) migration into the subendothelial space of undifferentiated medial smooth muscle cells. In addition to the well-known vasodilatory role of PGE(2), our findings uncovered the role of PGE(2) in anatomical closure of the DA. Chronic PGE(2)-EP4-cyclic AMP (cAMP)-protein kinase A (PKA) signaling during gestation induces vascular remodeling of the DA to promote hyaluronan-mediated intimal thickening and structural closure of the vascular lumen. A novel target of cAMP, Epac, has an acute promoting effect on smooth muscle cell migration without hyaluronan production and thus intimal thickening in the DA. Both EP4-cAMP downstream targets, Epac and PKA, regulate vascular remodeling in the DA.
Mahony, L; Clyman, R I; Heymann, M A
Delayed closure of the ductus arteriosus after birth has been observed in newborn infants with critical pulmonic stenosis and in newborn lambs with experimental pulmonic stenosis. This delayed ductal closure may be caused by a decreased ability of the muscle to contract when exposed to oxygen or to an increased production of or sensitivity to prostaglandin (PG) E2, the endogenous ductus arteriosus vasodilator. To determine whether the abnormal hemodynamic pattern during fetal life associated with pulmonic stenosis alters the responsiveness of the ductus arteriosus, we operated on 10 fetal lambs of gestational ages 70 to 77 days (term is 148 days) and placed a band around the pulmonary artery. Catheterization at 137 to 142 days showed severe pulmonic stenosis. We then studied isolated rings of ductus arteriosus from these lambs. The oxygen-induced increase in tension in rings of ductus arteriosus from lambs with pulmonic stenosis was significantly decreased (2.55 +/- 0.38; n = 10) compared with rings from control lambs (4.03 +/- 0.51; n = 6, p less than .03). There was no difference between the two groups in either the amount of PGE2 released by the rings or in the sensitivity (expressed as median effective dose) of the rings to PGE2. There was also no difference in the increase in tension when endogenous PGE2 was inhibited by indomethacin. We conclude that delayed closure of the ductus arteriosus in lambs with experimental pulmonic stenosis is not caused by increased sensitivity to or production of PGE2 in the ductus arteriosus (as it is in premature lambs) but rather is the result of a diminished ability of the ductus arteriosus to contract when exposed to oxygen.
Sadiq, Masood; Rehman, Asif U; Hyder, Najam; Qureshi, Ahmad U; Kazmi, Tehmina; Qureshi, Shakeel A
In patients with large patent arterial ducts and severe pulmonary hypertension, the natural history of progression of pulmonary hypertension is very variable. Whether to close or not to close is often a difficult decision, as there are no established haemodynamic parameters predicting reversibility. The objectives of this study were to evaluate the results of device closure of large patent arterial ducts with severe pulmonary hypertension after 2 years of age and to determine haemodynamic variables associated with its regression during long-term follow-up. A total of 45 patients, with median age of 10 (2-27) years, with large patent arterial ducts and severe pulmonary hypertension, were considered. Haemodynamic variables were assessed in air, oxygen, and after occlusion. The follow-up was performed to assess regression of pulmonary hypertension. Device closure was successful in 43 (96%) patients. Pulmonary artery systolic and mean pressures decreased from 79 to 67 mmHg and from 59 to 50 mmHg, respectively (p25% (both in oxygen) (p=0.007). Device closure of large patent arterial ducts with severe pulmonary hypertension is safe and effective. Pulmonary vascular resistance index and systolic and mean pulmonary artery pressures in oxygen are the key prognostic variables predicting regression of pulmonary hypertension.
Tsai, Horng-Der; Chen, Kuanting; Lee, Meng-Luen; Lee, Cheng-Han; Chen, Tze-Ho; Lin, Wen-Hsiang; Chen, Ming
Fetal ductus arteriosus aneurysm (DAA) is a rare but potentially risky congenital heart disease. It is often not diagnosed until the third trimester because of its asymptomatic nature and late onset. In rare occasions, DAA may result in serious complications; therefore, prenatal diagnosis is helpful. Herein, we report the case of a foetus with cystic hygroma and increased nuchal translucency in the first trimester (but regressed at 20-week anomalous scan). Karyotyping indicated a 46 XY genotype. A large vascular mass was noted at the apex of the left lung by Doppler ultrasound at 38 weeks of gestation, with a diameter of 12.5 mm. After birth, echocardiography showed a patent ductus arteriosus with aneurysmal dilatation (17 mm as the largest diameter); thus, DAA was impressed. Chest computed tomography and three-dimensional angiography confirmed the large aneurysmal dilatation of the ductus arteriosus with a closed end at the pulmonary arterial side. The male infant survived, but presented mild respiratory distress at birth. He was discharged at 24 days of age. At that time, DAA had regressed partially (diameter of 8.5 mm and much less blood flow), and it fully regressed at 40 days of age. Copyright © 2016. Published by Elsevier B.V.
Kawahito, Tomohisa; Takano, Shinji; Egawa, Yoshiyasu; Iwamura, Yoshinobu; Nakahara, Yasuo; Nii, Akira; Ohnishi, Tatsuya; Miyagi, Yuhichi; Terada, Kazuya; Ohta, Akira
Pulmonary artery sling is frequently combined with tracheal stenosis, and occasionally combined with congenital heart defects. However, there are few reports of successfully treated cases that were combined with single ventricle. In this article, we report a successfully treated case of pulmonary artery sling combined with tracheal stenosis, single ventricle, pulmonary atresia, vascular ring, and bilateral superior vena cava. A male infant was referred to our hospital for central cyanosis, and was diagnosed with single ventricle (tricuspid stenosis, multiple ventricular septal defect, and hypoplastic right ventricle)with pulmonary atresia by echocardiogram. Tracheal stenosis was shown at cardiac catheterization. Pulmonary artery sling and tracheal diverticulum were diagnosed by computed tomography (CT) and magnetic resonance imaging(MRI)examination. Furthermore, the patient was complicated by vascular ring, which consisted of right aortic arch, an aberrant left subclavian artery, and patent ductus arteriosus, and this ductus arteriosus was connected to the left subclavian artery and pulmonary arterial trunk. After 6 months of medical treatment, including continuous infusion of prostaglandin, re-evaluation was performed by cardiac catheterization. We considered that bidirectional cavo-pulmonary shunt was appropriate for the patient since his pulmonary vasculature had matured well. An operation was performed under the use of cardio-pulmonary bypass. Release of vascular ring by division of the ductus, bilateral bidirectional cavo-pulmonary shunt, and a slide tracheoplasty for tracheal stenosis were performed simultaneously. His recovery was uneventful, and he is currently waiting to receive a Fontan-type operation.
Coto, E O; Raggio, J M; Malo, P; Sainz, C; Aparisi, R; Gomez-Ullate, J M
A child aged 2 years and 9 months was angiocardiographically diagnosed to have a single ventricle with normally related great arteries and atresia of the left A-V valve. A Blalock-Hanlon procedure and division of a large patent ductus arteriosus were followed by reduction in pulmonary artery pressure, but after operation the patient showed signs of left ventricular failure unresponsive to medical treatment, necessitating pulmonary artery banding. We have found only three similar published cases, and this is the only one with full angiographic documentation. Images PMID:725830
Tamayo-Espinosa, Tania; Erdmenger-Orellana, Julio; Becerra-Becerra, Rosario; Balderrabano-Saucedo, Norma; Segura-Standford, Begoña
The right-side aortic arch may be associated with aberrant left subclavian artery, in some cases this artery originates from an aneurismal dilatation of the aorta called Kommerell diverticulum. We report 2 cases of vascular ring formed by a right-side aortic arch, anomalous left subclavian artery, Kommerell's diverticulum and left patent ductus arteriosus. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.
Nakahara, Yoshinori; Yoshida, Shigehiko; Yamamoto, Yosuke; Uemura, Hisashi; Yamagishi, Shunsuke; Furuhata, Ken; Hanzawa, Yoshikatu; Kanemura, Takeyuki; Osaka, Shinichi
We report a rare case of a giant right coronary artery aneurysm 13 years after coronary artery bypass grafting. Coronary angiography at the time of primary surgery demonstrated irregular aneurysmal dilatation in the mid-right coronary artery that expanded greatly over a 13-year period to a maximum diameter of 80 mm. The patient underwent aneurysmectomy and interposition using a saphenous vein graft through a right lateral thoracotomy. The patient did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalaemia in addition to continuous antegrade cardioplegia. Postoperatively, coronary computed tomography showed a lack of residual aneurysm and good flow in the saphenous vein graft. The patient made an uneventful recovery.
Gittenberger-de Groot, A C; Strengers, J L; Mentink, M; Poelmann, R E; Patterson, D F
The process of anatomic closure of the ductus arteriosus was studied at the ultrastructural level in 15 normal beagles (age 0 hour to 13 days) and in 18 specimens from a strain of dogs with hereditary persistent ductus arteriosus (age 4 hours to 27 days). Normal ductal closure takes place from the pulmonary artery to the aortic end. It is accompanied by a series of histologic changes: 1) separation of the endothelial cells from the internal elastic lamina resulting in a wide region of subendothelial edema; 2) ingrowth and infolding of endothelial cells and migration of undifferentiated smooth muscle cells from the inner media into the subendothelial region; 3) apposition of endothelial cells bordering the lumen; and 4) degenerative changes. In persistent ductus arteriosus, these changes do not occur. The endothelial cells remain closely adhered to the internal elastic lamina and the underlying media is abnormal in structure. In the case of partial persistent ductus arteriosus (ductus diverticulum), both the normal and the abnormal type of wall are found in a single ductus arteriosus. The histologic features of the normal and the persistent ductus arteriosus in the dog resemble those of the normal and the persistent ductus arteriosus in humans, suggesting a similar pathogenesis.
Trong Thach, Than; Duy Quan, Vo; Diem Nghi, Tran; Hoang Anh, Nguyen; Phi Hung, Le; Thien Luan, Nguyen; Phuoc Long, Nguyen
Patent urachus is a rare congenital abnormality. Since its first description by Cabriolus in 1550, few cases have been reported. A 26-year-old Vietnamese primigravida presented at 20 weeks of gestation for evaluation of a cystic mass in the umbilical cord, which was first discovered at week 13 of pregnancy by ultrasound scan. The cystic mass originated from the root of the umbilical cord, connected to the urinary bladder, and no intestinal contents were enclosed within. Doppler ultrasound assessment showed that the single umbilical artery existed within the normal range. The progression of the umbilical cyst continued to be screened, but the mass disappeared on ultrasound images at 27 weeks of gestation. This led to the consideration of the cyst’s rupture. After 38 gestational weeks, the pregnant woman delivered a 3350g male infant via cesarean section because of an obstructed vaginal labor. The following days, a stream of urine was recorded leaking out from the umbilical mass whenever he cried. Seven weeks after delivery, an open surgical approach was successfully performed. The baby is now 43 months of age, growing and developing normally. Since an allantoic cyst with patent urachus is a rare clinical entity, early discovery, close monitoring and accurate diagnosis through ultrasound in the prenatal period may consequently allow clinicians to have suitable attitudes towards management when the infant is born. PMID:26213613
Piskin, Senol; Unal, Gozde; Arnaz, Ahmet; Sarioglu, Tayyar; Pekkan, Kerem
In this study, hemodynamic performance of three novel shunt configurations that are considered for the surgical repair of tetralogy of Fallot (TOF) disease are investigated in detail. Clinical experience suggests that the shunt location, connecting angle, and its diameter can influence the post-operative physiology and the neurodevelopment of the neonatal patient. An experimentally validated second order computational fluid dynamics (CFD) solver and a parametric neonatal diseased great artery model that incorporates the ductus arteriosus (DA) and the full patient-specific circle of Willis (CoW) are employed. Standard truncated resistance CFD boundary conditions are compared with the full cerebral arterial system, which resulted 21, -13, and 37% difference in flow rate at the brachiocephalic, left carotid, and subclavian arteries, respectively. Flow splits at the aortic arch and cerebral arteries are calculated and found to change with shunt configuration significantly for TOF disease. The central direct shunt (direct shunt) has pulmonary flow 5% higher than central oblique shunt (oblique shunt) and 23% higher than modified Blalock Taussig shunt (RPA shunt) while the DA is closed. Maximum wall shear stress (WSS) in the direct shunt configuration is 9 and 60% higher than that of the oblique and RPA shunts, respectively. Patent DA, significantly eliminated the pulmonary flow control function of the shunt repair. These results suggests that, due to the higher flow rates at the pulmonary arteries, the direct shunt, rather than the central oblique, or right pulmonary artery shunts could be preferred by the surgeon. This extended model introduced new hemodynamic performance indices for the cerebral circulation that can correlate with the post-operative neurodevelopment quality of the patient.
Michel-Behnke, I; Akintuerk, H; Marquardt, I; Mueller, M; Thul, J; Bauer, J; Hagel, K J; Kreuder, J; Vogt, P; Schranz, D
Objective: To present an institutional experience with stent placement in the arterial duct combined with bilateral banding of the pulmonary artery branches as a basis for various surgical strategies in newborns with hypoplastic left heart obstructive lesions. Design: Observational study. Setting: Paediatric heart centre in a university hospital. Patients: 20 newborns with various forms of left heart obstructive lesions and duct dependent systemic blood flow. Interventions: Patients underwent percutaneous ductal stenting and surgical bilateral pulmonary artery banding. Atrial septotomy by balloon dilatation was performed as required, in one premature baby by the transhepatic approach. Main outcome measures: Survival; numbers of and reasons for palliative and corrective cardiac surgery. Results: One patient died immediately after percutaneous ductal stenting. One patient died in connection with the surgical approach of bilateral pulmonary banding. Stent and ductal patency were achieved for up to 331 days. Two patients underwent heart transplantation and two patients died on the waiting list. Ten patients had a palliative one stage procedure with reconstruction of the aortic arch and bidirectional cavopulmonary connection at the age of 3.5–6 months. There was one death. One patient is still awaiting this approach. Two patients received biventricular repair. In one, biventricular repair will soon be provided. Conclusions: Stenting the arterial duct combined with bilateral pulmonary artery banding in newborns with hypoplastic left heart or multiple left heart obstructive lesions allows a broad variation of surgical strategies depending on morphological findings, postnatal clinical conditions, and potential ventricular growth. PMID:12748222
Stoller, Jason Z.; DeMauro, Sara B.; Dagle, John M.; Reese, Jeff
The ductus arteriosus (DA) shunts blood away from the lungs during fetal life, but at birth this shunt is no longer needed and the vessel rapidly constricts. Postnatal persistence of the DA, patent ductus arteriosus (PDA), is predominantly a detrimental condition for preterm infants but is simultaneously a condition required to maintain systemic blood flow for infants born with certain severe congenital heart defects. Although PDA in preterm infants is associated with significant morbidities, there is controversy regarding whether PDA is truly causative. Despite advances in our understanding of the pathobiology of PDA, the optimal treatment strategy for PDA in preterm infants is unclear. Here we review recent studies that have continued to elucidate the fundamental mechanisms of DA development and pathogenesis. PMID:23519783
Dunham-Snary, Kimberly J; Hong, Zhigang G; Xiong, Ping Y; Del Paggio, Joseph C; Herr, Julia E; Johri, Amer M; Archer, Stephen L
The mammalian homeostatic oxygen sensing system (HOSS) initiates changes in vascular tone, respiration, and neurosecretion that optimize oxygen uptake and tissue oxygen delivery within seconds of detecting altered environmental or arterial PO2. The HOSS includes carotid body type 1 cells, adrenomedullary cells, neuroepithelial bodies, and smooth muscle cells (SMC) in pulmonary arteries (PA), ductus arteriosus (DA) and fetoplacental arteries. Hypoxic pulmonary vasoconstriction (HPV) optimises ventilation-perfusion matching. In utero, HPV diverts placentally-oxygenated blood from the non-ventilated lung through the DA. At birth, increased alveolar and arterial oxygen tension dilate the pulmonary vasculature and, constrict the DA, respectively, thereby transitioning the newborn to an air-breathing organism. Though modulated by endothelial-derived relaxing and constricting factors, O2-sensing is intrinsic to PA- and DASMCs. Within the SMC’s dynamic mitochondrial network, changes in PO2 alter the reduction-oxidation state of redox couples (NAD+/NADH, NADP+/NADPH) and the production of reactive oxygen species, ROS (e.g. H2O2) by Complexes I and III of the electron transport chain (ETC). ROS and redox couples regulate ion channels, transporters, and enzymes, changing intracellular calcium [Ca2+]i and calcium sensitivity and eliciting homeostatic responses to hypoxia. In PASMC, hypoxia inhibits ROS production and reduces redox couples, thereby inhibiting O2-sensitive voltage-gated potassium (Kv) channels, depolarizing the plasma membrane, activating voltage-gated calcium channels (CaL), increasing [Ca2+]i and causing vasoconstriction. In DASMC, elevated PO2 causes mitochondrial fission, increasing ETC Complex I activity and ROS production. The DASMC’s downstream response to elevated PO2 (Kv channel inhibition, CaL activation, increased [Ca2+]i and rho kinase activation) is similar to the PASMC’s hypoxic response. Impaired O2-sensing contributes to human diseases
Dunham-Snary, Kimberly J; Hong, Zhigang G; Xiong, Ping Y; Del Paggio, Joseph C; Herr, Julia E; Johri, Amer M; Archer, Stephen L
The mammalian homeostatic oxygen sensing system (HOSS) initiates changes in vascular tone, respiration, and neurosecretion that optimize oxygen uptake and tissue oxygen delivery within seconds of detecting altered environmental or arterial PO2. The HOSS includes carotid body type 1 cells, adrenomedullary cells, neuroepithelial bodies, and smooth muscle cells (SMCs) in pulmonary arteries (PAs), ductus arteriosus (DA), and fetoplacental arteries. Hypoxic pulmonary vasoconstriction (HPV) optimizes ventilation-perfusion matching. In utero, HPV diverts placentally oxygenated blood from the non-ventilated lung through the DA. At birth, increased alveolar and arterial oxygen tension dilates the pulmonary vasculature and constricts the DA, respectively, thereby transitioning the newborn to an air-breathing organism. Though modulated by endothelial-derived relaxing and constricting factors, O2 sensing is intrinsic to PASMCs and DASMCs. Within the SMC's dynamic mitochondrial network, changes in PO2 alter the reduction-oxidation state of redox couples (NAD(+)/NADH, NADP(+)/NADPH) and the production of reactive oxygen species, ROS (e.g., H2O2), by complexes I and III of the electron transport chain (ETC). ROS and redox couples regulate ion channels, transporters, and enzymes, changing intracellular calcium [Ca(2+)]i and calcium sensitivity and eliciting homeostatic responses to hypoxia. In PASMCs, hypoxia inhibits ROS production and reduces redox couples, thereby inhibiting O2-sensitive voltage-gated potassium (Kv) channels, depolarizing the plasma membrane, activating voltage-gated calcium channels (CaL), increasing [Ca(2+)]i, and causing vasoconstriction. In DASMCs, elevated PO2 causes mitochondrial fission, increasing ETC complex I activity and ROS production. The DASMC's downstream response to elevated PO2 (Kv channel inhibition, CaL activation, increased [Ca(2+)]i, and rho kinase activation) is similar to the PASMC's hypoxic response. Impaired O2 sensing contributes to
Sondheimer, H.M.; Oliphant, M.; Schneider, B.; Kavey, R.E.W.; Blackman, M.S.; Parker, F.B. Jr.
To expand the search for central pulmonary arteries in six patients with absence of cardiac-pulmonary continuity, computerized axial tomography (CAT) of the chest was performed. The CAT scans were compared with previous arteriograms and pulmonary vein wedge angiograms. Three patients with type IV truncus arteriosus were studied, and none had a central, right or left pulmonary artery on CAT scan. However, two patients with tetralogy of Fallot with pulmonary atresia and a patent ductus arteriosus to the right lung demonstrated the presence of a left pulmonary artery. In addition, one child with truncus arteriosus with ''absent'' left pulmonary artery demonstrated a left pulmonary artery on the CAT scan. The CAT scan may therefore enhance our ability to search for disconnected pulmonary arteries in children with complex cyanotic congenital heart disease.
Rosenbaum, Daniel G; Kasdorf, Ericalyn; Renjen, Pooja; Brill, Paula; Kovanlikaya, Arzu
We present a 3-month-old boy with a type IIA sling left pulmonary artery associated with imperforate anus and rectourethral fistula. Tracheobronchial abnormalities are demonstrated using multidetector CT with 3-D volume rendering of the airways. This case represents a novel variant of an already rare entity with an unusually high right upper lobe bronchus and no evidence of associated tracheobronchial stenosis. Copyright © 2014 Elsevier Inc. All rights reserved.
Successful aortic root replacement and shunt closure in a case with rare coexistence of congenital cardiac malformations: bicuspid aortic valve with annuloaortic ectasia, single coronary artery, and patent foramen ovale.
Egashira, Toru; Shimizu, Hideyuki; Yamada, Yoshitake; Fukuda, Keiichi
This is the first report of rare simultaneous complication of three cardiac malformations: bicuspid aortic valve with annuloaortic ectasia, single coronary artery, and patent foramen ovale. We successfully operated to replace the aortic valve and ascending aorta, and to close the patent foramen ovale.
Pancholy, Samir B; Bertrand, Olivier F; Patel, Tejas
Systemic anticoagulation decreases the risk of radial artery occlusion (RAO) after transradial catheterization and standard occlusive hemostasis. We compared the efficacy and safety of provisional heparin use only when the technique of patent hemostasis was not achievable to standard a priori heparin administration after radial sheath introduction. Patients referred for coronary angiography were randomized in 2 groups. In the a priori group, 200 patients received intravenous heparin (50 IU/kg) immediately after sheath insertion. In the provisional group, 200 patients did not receive heparin during the procedure. After sheath removal, hemostasis was obtained using a TR band (Terumo corporation, Tokyo, Japan) with a plethysmography-guided patent hemostasis technique. In the provisional group, no heparin was given if radial artery patency could be obtained and maintained. If radial patency was not achieved, a bolus of heparin (50 IU/kg) was given. Radial artery patency was evaluated at 24 hours (early RAO) and 30 days after the procedure (late RAO) by plethysmography. Patent hemostasis was obtained in 67% in the a priori group and 74% in the provisional group (p = 0.10). Incidence of RAO remained similar in the 2 groups at the early (7.5% vs 7.0%, p = 0.84) and late (4.5% vs 5.0%, p = 0.83) evaluations. Women, patients with diabetes, patients having not received heparin, and patients without radial artery patency during hemostasis had more RAO. By multivariate analysis, patent radial artery during hemostasis (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.004 to 0.28, p = 0.002) and diabetes (OR 11, 95% CI 3 to 38,p <0.0001) were independent predictors of late RAO, whereas heparin was not (OR 0.45 95% CI 0.13 to 1.54, p = 0.20). In conclusion, our results suggest that maintenance of radial artery patency during hemostasis is the most important parameter to decrease the risk of RAO. In selected cases, provisional use of heparin appears feasible and safe when
Novo García, E; Bermúdez, R; Herraiz, I; Salgado, A; Balaguer, J; Moya, J L; Pinto, J
Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demonstrated in children, however a few results have been reported of occlusion in adults. From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Raskind device. Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were studied retrospectively. The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echocardiograms. The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus. Similar QP/QS (1.61 +/- 0.47 in adults vs 1.49 +/- 0.51) was calculated although pulmonary pressure was superior in children (12.50 +/- 2.97 vs 16.84 +/- 5.88 mmHg; p = 0.003). In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 +/- 1.50 vs 2.41 +/- 0.96 mm; p = 0.009). In adults 17 mm umbrella were used more frequently (91 vs 61%; p = 0.02). Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children. The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77% and 95% vs 83% (p > 0.10). Multivariate analysis identified age as an independent predictor of complete occlusion. Our experience in transcatheter occlusion of persistent ductus arteriosus with Rashkind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.
AOKI, Takuma; SUNAHARA, Hiroshi; SUGIMOTO, Keisuke; ITO, Tetsuro; KANAI, Eiichi; FUJII, Yoko
Case 1 involved a 4-month-old intact male Somali cat in which peripheral pulmonary artery stenosis (PPS) was recognized after a cardiac murmur remained following patent ductus arteriosus ligation. Case 2, which involved a 1-year-old neutered male Norwegian Forest cat, and Case 3, which involved a 6-month-old intact female American Curl cat, were referred, because of cardiac murmurs. Grades III to IV/VI systolic heart murmurs were auscultated at the left heart base in all 3 cats. All cases showed bilateral pulmonary artery stenosis, although there were no associated clinical signs. In Cases 1 and 2, the pressure gradient through the stenosis decreased after treatment with atenolol. PMID:25650057
Introduction: Preterm infants are at increased risk of having a patent arterial duct (PAD). PADs may cause congestive heart failure, respiratory distress, necrotizing enterocolitis, and renal impairment. Consequently, in some infants, it becomes necessary to attempt closure of the PAD. Surgical closure can be difficult in small infants and is not without its risks; thus, medical closure offers advantages. Cyclooxygenase inhibitors have been used for medical closure of the PAD with both ibuprofen and indomethacin having been used clinically. Methods: We performed a systematic review of the literature to identify all studies comparing ibuprofen and indomethacin. Studies comparing ibuprofen and indomethacin for closure of the PAD in premature infants were included in the meta-analysis. A subanalysis was performed to compare the route of administration. Efficacy endpoints studied were PAD closure and surgical ligation while adverse effects studied were death in the first month of life, necrotizing enterocolitis, gastrointestinal bleeding, intestinal perforation, bronchopulmonary dysplasia in the first month of life, Grade 3 or 4 intraventricular hemorrhage, and change in the serum creatinine after treatment. Results: Ibuprofen and indomethacin were equally effective in closing the PAD in premature infants and demonstrated no difference in the incidence of adverse events. In respect to the route of administration, oral ibuprofen was as effective as intravenous indomethacin. When comparing both drugs via the intravenous route, the only difference noted between the ibuprofen and indomethacin was that ibuprofen was associated with a lesser increase in serum creatinine after treatment. Conclusion: Ibuprofen and indomethacin are equally effective in PAD closure without any difference in the incidence of adverse events. Importantly, oral ibuprofen was as effective as intravenous indomethacin. PMID:26180698
Loomba, Rohit; Nijhawan, Karan
Preterm infants are at increased risk of having a patent arterial duct (PAD). PADs may cause congestive heart failure, respiratory distress, necrotizing enterocolitis, and renal impairment. Consequently, in some infants, it becomes necessary to attempt closure of the PAD. Surgical closure can be difficult in small infants and is not without its risks; thus, medical closure offers advantages. Cyclooxygenase inhibitors have been used for medical closure of the PAD with both ibuprofen and indomethacin having been used clinically. We performed a systematic review of the literature to identify all studies comparing ibuprofen and indomethacin. Studies comparing ibuprofen and indomethacin for closure of the PAD in premature infants were included in the meta-analysis. A subanalysis was performed to compare the route of administration. Efficacy endpoints studied were PAD closure and surgical ligation while adverse effects studied were death in the first month of life, necrotizing enterocolitis, gastrointestinal bleeding, intestinal perforation, bronchopulmonary dysplasia in the first month of life, Grade 3 or 4 intraventricular hemorrhage, and change in the serum creatinine after treatment. Ibuprofen and indomethacin were equally effective in closing the PAD in premature infants and demonstrated no difference in the incidence of adverse events. In respect to the route of administration, oral ibuprofen was as effective as intravenous indomethacin. When comparing both drugs via the intravenous route, the only difference noted between the ibuprofen and indomethacin was that ibuprofen was associated with a lesser increase in serum creatinine after treatment. Ibuprofen and indomethacin are equally effective in PAD closure without any difference in the incidence of adverse events. Importantly, oral ibuprofen was as effective as intravenous indomethacin.
Approximately two billion people worldwide are chronically infected with T. gondii and yet with largely unknown consequences. On the other hand, several authors reported an association between migraine and patent foramen ovale (PFO), and different types of headaches, including migraine, may be precipitated by various diseased states or medications associated with marked immune irregularities, which sometimes cause reactivation of latent cerebral toxoplasmosis (CT). Recently, in a group of 104 subjects with migraine, 46 individuals (44.2%) were found to be seropositive for T. gondii. PFO, atrial septal defects, as well as pulmonary right-to-left shunts are usually associated with a various degree of arterial blood oxygen desaturation. Hypoxia is associated with an increase in the generation of several proinflammatory cytokines and other inflammation mediators, such as TNF-alpha, IL-1-beta, IL-6, IL-8, chemokines (monocyte chemoattractant protein-1, CC-chemokine receptor 2, macrophage inflammatory protein-1alpha, intercellular adhesion molecule-1), acute-phase protein gene expressions, COX-2 gene transcription, induction of iNOS, and reactive oxygen species. Moreover, hypoxia markedly decreased T-lymphocyte IL-2 mRNA, a key cytokine responsible for B-cell proliferation and immunoglobulin secretion, and ischemic tissues demonstrated intravascular neutrophil accumulation, vascular damage, and increased vascular wall permeability. Interestingly, T. gondii activates hypoxia-inducible factor 1 already at physiologically relevant oxygen levels and requires HIF1 for growth and survival. These abnormalities may cause imbalance in the host/T. gondii immune system, which finally results in the reactivation of CT. In addition, hypoxia may participate in paradoxical microembolism because arterial oxygen desaturation enhances expression of plasminogen activator inhibitor-1, an important factor which suppresses fibrinolysis, and this effect may be further amplified by a decreased
Jacobs, Kimberley; Goy, Sarah K; Dzialowski, Edward M
The ductus arteriosi (DA) are embryonic blood vessels found in amniotic vertebrates that shunt blood away from the pulmonary artery and lungs and toward the aorta. Here, we examine changes in morphology of the right and left DA (LDA), and right and left aorta (LAo) from embryonic and hatchling alligators. The developing alligator has two-patent DA that join the right and LAo. Both DA exhibit a muscular phenotype composed of an internal smooth muscle layer (2-4 cells thick). At hatching, the lumen diameter of both DA decreases as the vessels begin to close within the first 12 h of posthatch life. Between day 1 and day 12 posthatching, the vessel becomes fully occluded with endothelial and smooth muscle cells filling the lumen. A number of DA from hatchlings contained blood clots along their length. The lumen of the full term alligator DA is reduced in comparison with the full term chicken DA. The developing alligator embryo has an additional right-to-left shunt pathway in the LAo arising from the right ventricle. The embryonic LAo diameter is twice the diameter of either the right DA or LDA, providing a lower resistance pathway for blood leaving the right ventricle. On the basis of these findings, we propose that the paired DA of the embryonic alligator have a reduced role in the embryonic right-to-left shunt of blood from the right ventricle when compared with the avian DA.
Burke, Edmund B.
Outlines basic patent law information that pertains to computer software programs. Topics addressed include protection in other countries; how to obtain patents; kinds of patents; duration; classes of patentable subject matter, including machines and processes; patentability searches; experimental use prior to obtaining a patent; and patent…
Marshall, T A; Marshall, F; Reddy, P P
Cardiorespiratory and transcutaneous oxygen monitors were used on 13 preterm neonates to examine physiologic changes during ductus arteriosus ligation. Transcutaneous oxygen decreased 30 seconds after left lung deflation; all infants required increases in inspired oxygen and ventilation to correct abnormal values after the left lung was compressed. Transcutaneous oxygen decreased 30 seconds after ductus arteriosus ligation (mean delta tcPO2 = -17 mm Hg +/- 11.4) but increased 150 seconds after left lung inflation (mean delta tcPO2 = 46.9 mm Hg +/- 28.8). Arterial blood pressure increased (mean delta systolic BP = 17.9 mm Hg +/- 9.5) and heart rate decreased 10 seconds after ductus arteriosus ligation. In five neonates, gradual closure of the ductus arteriosus over 40 to 75 seconds resulted in a more gradual increase in blood pressure. Intraventricular hemorrhage was confirmed in two patients after surgery. Ligation of the ductus arteriosus results in an abrupt increase in blood pressure, which may be related to the pathogenesis of intraventricular hemorrhage. We suggest that the ductus arteriosus be closed gradually to allow a more gradual increase in blood pressure.
Bornak, Arash; Baqai, Atif; Li, Xiaoyi; Rey, Jorge; Tashiro, Jun; Velazquez, Omaida C
Enlarging aneurysms in the thoracic aorta frequently remain asymptomatic. Fistulization of thoracic aortic aneurysms (TAA) to adjacent structures or the presence of a patent ductus arteriosus and TAA may lead to irreversible cardiopulmonary sequelae. This article reports on a large aneurysm of the thoracic aorta with communication to the pulmonary artery causing pulmonary edema and cardiorespiratory failure. The communication was ultimately closed after thoracic endovascular aortic aneurysm repair allowing rapid symptom resolution. Early diagnosis and closure of such communication in the presence of TAA are critical for prevention of permanent cardiopulmonary damage. Copyright © 2016 Elsevier Inc. All rights reserved.
Díaz-Gómez, José L.; Rodrigues, Eduardo; Mordecai, Monica; Moss, John; Agnew, Richard C.; Oken, Keith R.
We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option. PMID:25566718
DIaz-Gómez, Jos L; Rodrigues, Eduardo; Mordecai, Monica; Moss, John; Agnew, Richard C; Oken, Keith R
We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option.
Removal of an introducer-sheath from a femoral artery after completing transarterial embolization of a patent ductus arteriosus can cause life-threatening hemorrhage in dogs. In the present study, the effectiveness of chitosan acetate dressing in 10 experimental dogs was tested. Under general anesthesia, an introducer-sheath was placed into the femoral artery with percutaneous puncture using Seldinger's technique. The outer diameter of the introducer-sheaths varied from 3.0 to 4.0 mm with an introducer/artery ratio of 80 to 123%. The artery's diameter was measured using ultrasonography. Following removal of the introducer-sheath, a chitosan acetate dressing was applied to the wound and held in place with manual compression for 10 min. Successful hemostasis was reached on 12 arteries. However, on two arteries, hemorrhage was uncontrollable and led to a hypovolemic shock during 10 min of manual compression. Possible causes of the negative outcome in two dogs were their old age and an introducer-sheath with a too large diameter. The chitosan acetate dressing was easy to use and the artery remained patent. Dogs could walk directly after recovery from anesthesia and their femoral arteries were saved. In conclusion, the outer diameter of the introducer-sheath should not exceed 3 mm or the inner diameter of the artery.
Removal of an introducer-sheath from a femoral artery after completing transarterial embolization of a patent ductus arteriosus can cause life-threatening hemorrhage in dogs. In the present study, the effectiveness of chitosan acetate dressing in 10 experimental dogs was tested. Under general anesthesia, an introducer-sheath was placed into the femoral artery with percutaneous puncture using Seldinger's technique. The outer diameter of the introducer-sheaths varied from 3.0 to 4.0 mm with an introducer/artery ratio of 80 to 123%. The artery's diameter was measured using ultrasonography. Following removal of the introducer-sheath, a chitosan acetate dressing was applied to the wound and held in place with manual compression for 10 min. Successful hemostasis was reached on 12 arteries. However, on two arteries, hemorrhage was uncontrollable and led to a hypovolemic shock during 10 min of manual compression. Possible causes of the negative outcome in two dogs were their old age and an introducer-sheath with a too large diameter. The chitosan acetate dressing was easy to use and the artery remained patent. Dogs could walk directly after recovery from anesthesia and their femoral arteries were saved. In conclusion, the outer diameter of the introducer-sheath should not exceed 3 mm or the inner diameter of the artery. PMID:26119165
Hutchinson, DP; Sampson, AJ
The ductus arteriosus holds major functional importance within the fetal circulation, and anomalies within the ductus arteriosus may interfere with the integrity of the fetal circulation. Ductus arteriosus aneurysm, previously considered a rare lesion, is now a well-reported finding in infancy with some reports describing this finding in the prenatal period. Postnatally, most ductus arteriosus aneurysms resolve spontaneously; however, a small group of infants show complications such as connective-tissue disorders, thrombo-embolism, compression of surrounding thoracic structures and life-threatening spontaneous rupture requiring surgical correction. As such, postnatal assessment in this group is recommended. PMID:27433265
Mijangos-Vázquez, Roberto; Patiño-Bahena, Emilia; Martínez-García, Alfonso; Herrera, Juan; Calderón-Colmenero, Juan; Buendía-Hernández, Alfonso; Soto-López, María Elena
Congenital vascular malformations of the major arteries in the chest have been classified into 5 groups: 1) double aortic arch; 2) right aortic arch with left ligament or persistent ductus arteriosus; 3) aberrant subclavian artery; 4) aberrant left pulmonary artery, and 5) anomalous innominate artery. We reviewed the patients with aberrant right subclavian artery and their treatment. We studied retrospectively the records of 29 patients with aberrant right subclavian artery in childhood, from January 1992 to December 2012, analyzing the following variables: age at onset, clinical manifestations, associated cardiovascular defects, diagnosis and surgical approach method. We found that most patients have an asymptomatic course, only 31% of them course with symptoms during the first year of life, with an incidental diagnosis of 35% during catheterization or other imaging studies. Patent ductus arteriosus was the most frequently associated congenital malformation, with 13%. Down's syndrome was found in 21%. The most common treatment was surgical section of the aberrant subclavian artery to release the esophagus. This vascular abnormality must be suspected in those patients with dysphagia, dyspnea, chest pain during feeding or breathing difficulties. A significant number of patients are not diagnosed in time, some reach adulthood without a diagnosis. This malformation is often found in imaging studies when evaluating the aorta or in a gastroesophageal reflux study, in which the barium bolus reveals the extrinsic compression of the esophagus. Copyright © 2013 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.
Pappalardo, Federico; Ancona, Marco B; Giannini, Francesco; Regazzoli, Damiano; Mangieri, Antonio; Montorfano, Matteo; De Bonis, Michele; Alfieri, Ottavio; Zangrillo, Alberto; Scandroglio, Anna Mara; Colombo, Antonio; Latib, Azeem
Pressure-controlled Intermittent Coronary Sinus Occlusion (PICSO) intermittently increases the pressure in the cardiac venous outflow tract using a balloon-tipped catheter introduced percutaneously into the coronary sinus. It aims to improve microvascular perfusion in STEMI patients during PCI, thus improving infarct healing. Its successful administration was associated with an improvement in myocardial recovery four months after primary-PCI as compared to control. However, it has never been used in other settings or for a prolonged period. The aim of this study was to report on the feasibility and efficacy of prolonged PICSO to treat refractory LV dysfunction and ischemia. Two patients with refractory LV dysfunction and ongoing ischemia with patent epicardial coronary artery and suspected underlying microvascular dysfunction were treated with prolonged off-label PICSO utilization. A medium of 23,990mmHg PICSO quantity (a marker of PICSO therapy performance) was achieved: it was almost fifty times the PICSO quantity previously reported in in short-term PICSO utilization. After PICSO placement, both patients showed significant improvement of myocardial ischemia and recovery of LV systolic function. Prolonged PICSO utilization was feasible and effective in two patients. These cases highlight a novel application of PICSO technology: redistribution of venous blood and improvement in microvascular perfusion that might be a new target in cases of refractory LV dysfunction and ongoing ischemia in the setting of patent epicardial coronary arteries. Copyright © 2017 Elsevier B.V. All rights reserved.
Moza, Ankush; Moukarbel, George V; Cooper, Christopher J; Bhat, Pradeep K
Patients with coronary artery disease often have concurrent peripheral vascular disease. The presence of concurrent vascular pathologies can pose unique challenges among patients who have undergone coronary artery bypass grafting utilizing the left internal mammary artery. We describe a patient with peripheral vascular disease and prior history of coronary artery bypass grafting, who presented with recurrent anginal symptoms and an abnormal stress test despite the absence of significant residual unrevascularized coronary artery disease. Additional evaluation led to the identification of an ipsilateral severe subclavian stenosis with a concomitant ipsilateral upper extremity arteriovenous fistula. Patient's symptoms resolved with the treatment of the underlying vascular lesions.
Bronshtein, Moshe; Zimmer, Etan Z; Blazer, Shraga; Blumenfeld, Zeev
To report fetal right-sided persistent ductus arteriosus (RPDA) in association with right aortic arch (RAA). Extensive sonographic fetal anatomical scans were consecutively performed on 19,874 private, self-referred pregnant women who wanted early sonographic detection of fetal anomalies. Of 19,874 transvaginal (TVS) sonographic examinations 40 fetuses had right aortic arch (RAA) and four of them (10%) had RPDA. We also diagnosed seven cases of RPDA with involvement of the left aortic arch where a right-curving pattern ("L" shape) parallel to the right pulmonary artery was suggestive of Rt. DA with left aortic arch. Only one (9%) of the RPDA cases was associated with a cardiac anomaly (double outlet right ventricle). None of the other eight RPDA cases had any discernible anomalies, and all of the fetuses with RPDA had normal karyotypes. In 10% of the fetuses with right aortic arch the ductal arch was also on the right side. An unusual-looking DA may be a RPDA associated with the left aortic arch. In most cases, the RPDA is a normal variant not associated with other anomalies. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Visconti, Luiza Fortunato; Morhy, Samira Saady; Deutsch, Alice D'Agostini; Tavares, Gláucia Maria Penha; Wilberg, Tatiana Jardim Mussi; Rossi, Felipe de Souza
ABSTRACT Objective: To identify clinical and echocardiographic parameters associated with the evolution of the ductus arteriosus in neonates with birth weight lower than 1,500g. Methods: Retrospective study of 119 neonates in which clinical parameters (Prenatal: maternal age, risk of infection and chorioamnionitis, use of corticosteroid, mode of delivery and gestational age. Perinatal: weight, Apgar score, gender and birth weight/gestational age classification; Postnatal: use of surfactant, sepsis, fluid intake, heart murmur, heart rate, precordial movement and pulses, use of diuretics, oxygenation index, desaturation/apnea, ventilatory support, food intolerance, chest radiography, renal function, hemodynamic instability, and metabolic changes) and echocardiographic parameters (ductus arteriosus diameter, ductus arteriosus/weight ratio, left atrium/ aorta ratio, left ventricular diastolic diameter, and transductal flow direction, pattern and velocity) were analyzed. The clinical and echocardiographic parameters analyzed were considered statistically significant when p<0.05. Results: In the 119 neonates, the incidence of patent ductus arteriosus was 61.3%; 56 received treatment (46 pharmacological and 10 surgical treatment), 11 had spontaneous closure, 4 died, and 2 were discharged with patent ductus arteriosus. A higher incidence of chorioamnionitis, use of surfactant, lower weight and gestational age, sepsis, heart murmur, ventilatory support and worse oxygenation indices were observed in the neonates receiving treatment. The group with spontaneous closure had a smaller ductus arteriosus diameter, lower ductus arteriosus/weight ratio, and higher transductal flow velocity. Conclusion: Based on clinical and echocardiographic parameters, the neonates with spontaneous closure of the ductus arteriosus could be differentiated from those who required treatment. PMID:24136758
Hofstadler, G; Tulzer, G; Altmann, R; Schmitt, K; Danford, D; Huhta, J C
Closure of the fetal ductus arteriosus, which is usually due to nonsteroidal antiinflammatory agents, may be detrimental. Therefore prenatal and postnatal clinical and echocardiographic findings in four human fetuses with spontaneous ductus arteriosus occlusion are reported. Echocardiographic and clinical data were retrospectively analyzed. Spontaneous closure of the ductus arterious was discovered in four fetuses (gestational age 34 to 38 weeks). No mother had received nonsteroidal antiinflammatory agents. Enlargement of the right heart and pulmonary arteries and tricuspid and pulmonary regurgitation were present in all cases. Two fetuses had right ventricular hypertension. Postnatally their right ventricular function recovered promptly. The others had severe right heart failure with abnormal umbilical venous pulsations. After immediate delivery none had signs of persistent pulmonary hypertension. However, they have echocardiographic evidence of right ventricular dysfunction 2 to 6 months after delivery. Occlusion of the fetal ductus arteriosus may also occur in the absence of treatment with nonsteroidal antiinflammatory agents. Immediate delivery resulted in good clinical outcome, although right ventricular dysfunction may persist.
Levet, Sandrine; Ouarné, Marie; Ciais, Delphine; Coutton, Charles; Subileau, Mariela; Mallet, Christine; Ricard, Nicolas; Bidart, Marie; Debillon, Thierry; Faravelli, Francesca; Rooryck, Caroline; Feige, Jean-Jacques; Tillet, Emmanuelle; Bailly, Sabine
The transition to pulmonary respiration after birth requires rapid alterations in the structure of the mammalian cardiovascular system. One dramatic change that occurs is the closure of the ductus arteriosus (DA), an arterial connection in the fetus that directs blood flow away from the pulmonary circulation. Two members of the TGFβ family, bone morphogenetic protein 9 (BMP9) and BMP10, have been recently involved in postnatal angiogenesis, both being necessary for remodeling of newly formed microvascular beds. The aim of the present work was to study whether BMP9 and BMP10 could be involved in closure of the DA. We found that Bmp9 knockout in mice led to an imperfect closure of the DA. Further, addition of a neutralizing anti-BMP10 antibody at postnatal day 1 (P1) and P3 in these pups exacerbated the remodeling defect and led to a reopening of the DA at P4. Transmission electron microscopy images and immunofluorescence stainings suggested that this effect could be due to a defect in intimal cell differentiation from endothelial to mesenchymal cells, associated with a lack of extracellular matrix deposition within the center of the DA. This result was supported by the identification of the regulation by BMP9 and BMP10 of several genes known to be involved in this process. The involvement of these BMPs was further supported by human genomic data because we could define a critical region in chromosome 2 encoding eight genes including BMP10 that correlated with the presence of a patent DA. Together, these data establish roles for BMP9 and BMP10 in DA closure. PMID:26056270
Phase analysis of gated myocardial perfusion single-photon emission computed tomography after coronary artery bypass graft surgery: reflection of late reverse remodeling in patients with patent grafts after coronary artery bypass graft surgery.
Park, Sohyun; Cheon, Gi Jeong; Paeng, Jin Chul; Won, Kyoung Sook; Kang, Keon Wook; Kim, Ki-Bong; Chung, June-Key; Lee, Dong Soo
Phase analysis using gated myocardial perfusion single-photon emission computed tomography (GMPS) is a tool used to assess left ventricular (LV) dyssynchrony. We attempted to investigate the role of LV dyssynchrony assessed by GMPS using phase analysis for the late LV function after coronary artery bypass graft surgery (CABG) in patients with patent grafts. A total of 45 patients who received off-pump CABG with patent graft 1 year after CABG and preserved perfusion reserve were enrolled retrospectively. All patients underwent GMPS before and 3 months and 1 year after CABG. Using the Emory Cardiac Toolbox, both phase histogram bandwidth (PBW) and phase SD derived by phase analysis were used for the analysis, in addition to the conventional perfusion parameters. For the evaluation of LV function, transthoracic echocardiography was also performed. All of the patients showed perfusion improvement (paired t-test, P<0.05) after CABG. Nonetheless, 30 of 45 patients showed LV dyssynchrony 3 months after CABG. One year after CABG, however, 25 out of 45 patients showed reverse remodeling. Among those patients with reverse remodeling, 19 patients had shown LV 3 months after CABG. Using stepwise logistic regression with forward selection, PBW 3 months after CABG could predict reverse remodeling 1 year after CABG (odds ratio 1.03, P<0.05). Using receiver operating characteristic analysis, PBW 3 months after CABG had the largest area under the curve to detect reverse remodeling 1 year after CABG with a cut-off value of 82 (sensitivity 0.95, specificity 0.56, P<0.001). Postoperative LV dyssynchrony assessed by GMPS using phase analysis may reflect late reverse remodeling and potential of further functional improvement in patients with patent grafts and preserved perfusion reserve after CABG.
Ghofrani, Hossein-Ardeschir; Grimminger, Friedrich; Grünig, Ekkehard; Huang, Yigao; Jansa, Pavel; Jing, Zhi-Cheng; Kilpatrick, David; Langleben, David; Rosenkranz, Stephan; Menezes, Flavia; Fritsch, Arno; Nikkho, Sylvia; Humbert, Marc
Pulmonary arterial hypertension is a chronic disease associated with poor long-term outcomes. Identifying predictors of long-term outcome in pulmonary arterial hypertension is important to assess disease severity and guide treatment. We investigate associations between efficacy parameters and long-term outcomes in patients with pulmonary arterial hypertension receiving riociguat in the PATENT-2 study. We also present safety and efficacy data from the final data cutoff of PATENT-2, where most patients had received at least 2 years of riociguat treatment. Eligible patients from the PATENT-1 study entered the PATENT-2 open-label extension, which will continue until all patients transition to the commercial drug. All patients received riociguat individually adjusted to a maximum dose of 2·5 mg three times a day. The primary endpoint was safety and tolerability, assessed with recording adverse events, serious adverse events, discontinuations, and deaths; exploratory assessments included 6-min walking distance (6MWD), WHO functional class, N-terminal prohormone of brain natriuretic peptide (NT-proBNP)concentrations, Borg dyspnoea score, health-related quality of life (EQ-5D score), survival, and clinical worsening-free survival. Association between efficacy parameters and long-term outcomes was assessed using Kaplan-Meier analyses and a Cox proportional-hazards regression model. PATENT-2 is registered at ClinicalTrials.gov, number NCT00863681. 396 patients entered PATENT-2, of whom 197 patients were receiving riociguat monotherapy and 199 were receiving riociguat in combination with endothelin receptor antagonists or prostanoids, or both. A significant association was noted between 6MWD, NT-proBNP concentration, and WHO functional class and overall survival at baseline (p=0·0006, 0·0225, and 0·0191, respectively), and at follow-up (p=0·021, 0·0056, and 0·0048, respectively). Riociguat was well tolerated in PATENT-2. Serious adverse events were recorded in 238 (60
Hepatic falciform ligament Tc-99m-macroaggregated albumin activity on SPECT/CT prior to Yttrium-90 microsphere radioembolization: prophylactic measures to prevent non-target microsphere localization via patent hepatic falciform arteries.
Kao, Yung Hsiang; Tan, Andrew E H; Khoo, Li Ser; Lo, Richard H G; Chow, Pierce K H; Goh, Anthony S W
Yttrium-90 (Y-90) selective internal radiation therapy (SIRT) is increasingly used to treat inoperable hepatocellular carcinoma. We describe two patients where hepatic falciform ligament Technetium-99m-macroaggregated albumin (Tc-99m-MAA) activity was identified on single photon emission computed tomography with integrated low-dose CT (SPECT/CT) scan during pre-therapy planning, and the steps taken to prevent radiation dermatitis. The first patient underwent prophylactic coil embolization of the patent hepatic falciform artery; the second patient underwent super-selective infusion of Y-90 resin microspheres to avoid the patent hepatic falciform artery. The incidence of falciform ligament Tc-99m-MAA activity detected on SPECT/CT at our institution is 10%. Tc-99m-MAA SPECT/CT scan provides valuable diagnostic information for treatment planning prior to Y-90 SIRT.
Pozzi, Marco; Quarti, Andrea; Iezzi, Federica
There are cases in which ligation of the ductus arteriosus is part of a palliative or reparative procedure where the opportunity to reopen the ductus in the early period after surgery could be beneficial. This applies, particularly, to patients with borderline left ventricle in whom a biventricular repair is performed or in small babies in whom a modified Blalock-Taussig shunt is performed, particularly when a very small polytetrafluoroethylene graft is used. Conventional ductal ligation is generally irreversible. We describe a technique of ductal closure that allows easy reopening of the duct in the early postoperative period.
... artery and blood reaches the aorta through a patent ductus arteriosus (see diagram). How does the defect ... only source of lung blood flow is the patent ductus arteriosus (PDA), an open passageway between the ...
Bobrow, Martin; Thomas, Sandy
The protection of inventions based on human DNA sequences has been achieved mainly through application of the patent system. Over the past decade, there has been continuing debate about whether this use of intellectual property rights is acceptable. Companies and universities have been active during this period in filing thousands of patent applications. Although many have argued that to claim a DNA sequence in a patent is to claim a discovery, patent law allows discoveries that are useful to be claimed as part of an invention. As the technology to isolate DNA sequences has advanced, the criterion for inventiveness, necessary for any invention to be eligible for filing, has become more difficult to justify in the case of claims to DNA sequences. Moreover, the discovery that a gene is associated with a particular disease is, it is argued, to discover a fact about the world and undeserving of the status of an invention. Careful examination of the grounds for allowing the patenting of DNA sequences as research tools suggests such rewards will rarely be justified. The patenting of DNA sequences as chemical intermediates necessary for the manufacture of therapeutic proteins is, however, reasonable given that the information within the sequence is applied to produce a tangible substance which has application as a medicine. Despite the legal, technical and political complexities of applying the flexibilities with the current law, it is argued that much could be achieved in the area of patenting DNA by raising the thresholds for patentability.
Härkin, Pia; Härmä, Antti; Aikio, Outi; Valkama, Marita; Leskinen, Markku; Saarela, Timo; Hallman, Mikko
To study the biologic effect of paracetamol, an inhibitor of prostaglandin synthase, on early closure of ductus arteriosus, and to evaluate possible adverse effects associated with the drug. In a controlled, double-blind, phase I-II trial, very low gestational age (<32 weeks) infants requiring intensive care were randomly assigned to intravenous paracetamol or placebo (0.45% NaCl). A loading dose of 20 mg/kg was given within 24 hours of birth, followed by 7.5 mg/kg every 6 hours for 4 days. Daily cardiac ultrasound examinations of ductal calibers were performed before the first dose, and until 1 day after the last dose. The main outcome was a decrease in the ductal caliber without side effects. Of 63 screened infants, 48 were randomized: 23 were assigned to paracetamol and 25 to placebo. Before the intervention, their ductal calibers were similar. During the intervention, the ductus closed faster in the paracetamol group (hazard ratio 0.49, 95% CI 0.25-0.97, P = .016). The mean (95% CI) postnatal ages for ductal closure were 177 hours (31.1-324) for the paracetamol-treated vs 338 hours (118-557) for controls (P = .045). Paracetamol serum levels were within the therapeutic range, and no adverse effects were evident. Prophylactic paracetamol induced early closure of the ductus arteriosus without detectable side effects. Further trials are required to determine whether intravenous paracetamol may safely prevent symptomatic patent ductus arteriosus. ClinicalTrials.gov: NCT01938261; European Clinical Trials Database: EudraCT 2013-008142-33. Copyright © 2016 Elsevier Inc. All rights reserved.
David, Jane Jackie; Mohanlal, Smilu; Sankhe, Punam; Ghildiyal, Radha
We report a 2.5-year-old girl who presented with hoarseness of voice since 3 months of age and failure to thrive. Chest X-ray showed cardiomegaly with a deviation of the trachea and mediastinum to the right side. Two-dimensional echocardiography showed decreased flow across the right pulmonary artery, a small atrial septal defect (ASD) with a right-to-left shunt, and a dilated right atrium and right ventricle with severe tricuspid regurgitation suggestive of severe pulmonary hypertension. A silent large patent ductus arteriosus was also seen. Multiple detector computerized tomography aortogram confirmed the findings of absent right pulmonary artery and hypoplastic right lung with small cystic lesions suggestive of congenital cystic adenomatoid malformation in the right lower lobe. Hoarseness of voice was due to the left vocal cord palsy probably secondary to severe pulmonary hypertension (Ortner's syndrome).
Bökenkamp, Regina; Gittenberger-De Groot, Adriana C; Van Munsteren, Conny J; Grauss, Robert W; Ottenkamp, Jaap; Deruiter, Marco C
Persistent ductus arteriosus (PDA) is a common cardiovascular anomaly in children caused by the pathologic persistence of the left sixth pharyngeal arch artery. The inbred Brown-Norway (BN) rat presents with increased vascular fragility due to an aortic elastin deficit resulting from decreased elastin synthesis. The strikingly high prevalence of PDA in BN rats in a pilot study led us to investigate this vascular anomaly in 12 adolescent BN rats. In all BN rats, a PDA was observed macroscopically, whereas a ligamentum arteriosum was found in adult controls. The macroscopic appearance of the PDA was tubular (n = 2), stenotic (n = 8), or diverticular (n = 2). The PDA had the structure of a muscular artery with intimal thickening. In the normal closing ductus of the neonatal controls, the media consisted of layers of smooth muscle cells (SMCs) intermingled with layers of elastin. The intima was thin and poor in elastin. By contrast, the media of PDA in BN rats elastin lamellae were absent and the intima contained many elastic fibers. The abnormal distribution of elastin in the PDA of BN rats suggests that impaired elastin metabolism is related to the persistence of the ductus and implicates a genetically determined factor that may link the PDA with aortic fragility.
Clyman, R I; Teitel, D; Padbury, J; Roman, C; Mauray, F
A model of patent ductus arteriosus in premature lambs was created to study the relative importance of beta-adrenoreceptor stimulation and increased myocardial contractility. In 39 fetal lambs (133 +/- 2, +/- SD days gestation, term 145 days), the ductus arteriosus was infiltrated with formalin, and a snare was placed around it to regulate its patency. One day later, the lambs were delivered, given sheep surfactant, paralyzed, and mechanically ventilated. Microsphere measurements of left ventricular output were made between 4 and 6 h after delivery. When the ductus was opened, there was no change in heart rate, but there were significant increases in left ventricular output, stroke volume, left ventricular end-diastolic pressure, and peak dP/dt. The increase in peak dP/dt due to opening the ductus was greater than that due to an increase in left ventricular end-diastolic pressure alone and was accompanied by an increase in norepinephrine secretion from the left ventricle. Propranolol (1 mg/kg) was used to evaluate the effect of beta-adrenergic tone on left ventricular output and contractility. The left atrium was paced in both control and propranolol-treated lambs. When the ductus was closed, propranolol significantly decreased stroke volume and peak dP/dt without changing left ventricular end-diastolic pressure or systemic vascular resistance. During a saline volume load (50 ml/kg over a 3-min period), propranolol-treated lambs had a reduced stroke volume and peak dP/dt despite similar values of left ventricular end-diastolic pressure and resistance as those of control lambs.(ABSTRACT TRUNCATED AT 250 WORDS)
Tan, T H; Heng, J T; Wong, K Y
The aim of this study is to establish the norms for pulmonary arterial diameters in the premature infants. One hundred and thirty cross-sectional echocardiograms were performed on 62 premature neonates (23.4 weeks to 36 weeks gestation) in the Neonatal Intensive Care Unit. Except for small atrial septal defects/patent foremen ovale (< or =3 mm) or patent ductus arteriosus (PDA), babies with structural heart defects were excluded. The weight at echocardiography ranges from 470 grams to 2,445 grams, with a mean of 1,157 grams. The diameter of the pulmonary annulus (PA), left pulmonary artery (LPA) and right pulmonary artery (RPA) were measured at peak systole at predetermined sites. Sizes of the atrial septal defect and PDA were also measured, if present. There was no difference in the diameter between the left and right pulmonary arteries (p=0.254, paired t-test) in the same patient. After controlling for weight, the mean diameters of the LPA and RPA were larger in patients with PDA (p=0.002) compared to those without PDA (p=0.002), while their pulmonary annulus were comparable in size (p=0.691). Between the gestational ages of 23 and 36 weeks, the diameter of PA, LPA and RPA correlated linearly with weight (Pearson R = 0.84, 0.82, 0.65 and 0.71, respectively; p<0.0005). Prediction graphs and regression equations are given. These normal ranges can be used for assessment of pulmonary artery diameters in premature neonates.
Laser, Kai T; Haas, Nikolaus A; Fischer, Markus; Habash, Sheeraz; Degener, Franziska; Prinz, Christian; Körperich, Hermann; Sandica, Eugen; Kececioglu, Deniz
Left ventricular rotation is physiologically affected by acute changes in preload. We investigated the acute effect of preload changes in chronically underloaded and overloaded left ventricles in children with shunt lesions. A total of 15 patients with atrial septal defects (Group A: 7.4 ± 4.7 years, 11 females) and 14 patients with patent arterial ducts (Group B: 2.7 ± 3.1 years, 10 females) were investigated using 2D speckle-tracking echocardiography before and after interventional catheterisation. The rotational parameters of the patient group were compared with those of 29 matched healthy children (Group C). Maximal torsion (A: 2.45 ± 0.9°/cm versus C: 1.8 ± 0.8°/cm, p < 0.05), apical peak systolic rotation (A: 12.6 ± 5.7° versus C: 8.7 ± 3.5°, p < 0.05), and the peak diastolic torsion rate (A: -147 ± 48°/second versus C: -110 ± 31°/second, p < 0.05) were elevated in Group A and dropped immediately to normal values after intervention (maximal torsion 1.5 ± 1.1°/cm, p < 0.05, apical peak systolic rotation 7.2 ± 4.1°, p < 0.05, and peak diastolic torsion rate -106 ± 35°/second, p < 0.05). Patients in Group B had decreased maximal torsion (B: 1.8 ± 1.1°/cm versus C: 3.8 ± 1.4°/cm, p < 0.05) and apical peak systolic rotation (B: 8.3 ± 6.1° versus C: 13.9 ± 4.3°, p < 0.05). Defect closure was followed by an increase in maximal torsion (B: 2.7 ± 1.4°/cm, p < 0.05) and the peak diastolic torsion rate (B: -133 ± 66°/second versus -176 ± 84°/second, p < 0.05). Patients with chronically underloaded left ventricles compensate with an enhanced apical peak systolic rotation, maximal torsion, and quicker diastolic untwisting to facilitate diastolic filling. In patients with left ventricular dilatation by volume overload, the peak systolic apical rotation and the maximal torsion are decreased. After normalisation of the preload, they immediately return to normal and diastolic untwisting rebounds. These mechanisms are important for
Schiessl, B; Schneider, K T; Zimmermann, A; Kainer, F; Friese, K; Oberhoffer, R
Physiological fetal circulation requires patency of the ductus arteriosus. As gestation proceeds, the sensitivity of the ductus to dilating prostaglandins diminishes. The sensitivity to constricting agents like PGE-synthetase inhibitors, present in many analgetics, however, increases. Fetuses affected by an antenatal constriction of the ductus arteriosus (DC) may present with different signs of cardiac failure including dilated right ventricle, tricuspid regurgitation and abnormal venous Doppler. We report on four cases with prenatal DC, presenting at 34, 35, 36 and 37 weeks of gestation. They were referred to fetal echocardiography because of abnormal routine echo scans with unexplained signs of right heart decompensation. Three patients were medicated during pregnancy with either aspirin (low dose), metamizole or ibuprofen. One patient did not take any drugs, especially no pain medication drug in pregnancy. Immediate delivery was performed in all cases. The neonates were in a good condition; echocardiography showed different degrees of right heart hypertrophy which disappeared in all infants by the age of 3 months except in case 2. Unexplained fetal right heart decompensation requires detailed echocardiographic evaluation of the ductus arteriosus and a sophisticated medical history with regard to analgesics. In contrast to ibuprofen and high-dose aspirin, metamizole and low-dose aspirin have not yet been reported as possible agents constricting the fetal arterial duct. In any suspected context, early delivery as in our cases may save babies life. Any application of non-steroidal anti-inflammatory drugs in pregnancy requires close fetal follow-up due to their potentially life-threatening effect.
Simmons, Edlyn S.
Reports on retrieval of patent information online and includes definition of patent family, basic and equivalent patents, "parents and children" applications, designated states, patent family databases--International Patent Documentation Center, World Patents Index, APIPAT (American Petroleum Institute), CLAIMS (IFI/Plenum). A table…
Our studies and those of others have shown that changes in the extracellular matrix have profound effects on vascular remodeling. In the ductus, increased production of endothelial hyaluronan and smooth muscle cell chondroitin sulfate and fibronectin and impaired elastin fiber assembly are features critical to smooth muscle cell migration into the subendothelium and intimal cushion formation. There is a developmentally orchestrated process that involves post-transcriptional mechanisms of gene regulation. Closure of the ductus arteriosus is associated with further changes in matrix expression and programmed cell death. The changes in the extracellular matrix that induce neointimal formation are also observed in pathological conditions in pulmonary and coronary arteries. Plasticity of the pulmonary circulation in the perinatal period also involves matrix regulation, and processes that prevent the normal decrease in pulmonary vascular resistance will result in impaired matrix regulation, and in the development of structural changes in the pulmonary arteries, including abnormal smooth muscle cell differentiation, hypertrophy and proliferation, which sustain the elevation in pulmonary artery pressure.
Kiliç, Esra; Alanay, Yasemin; Utine, Eda; Ozgen-Mocan, Burçe; Robinson, Peter N; Boduroğlu, Koray
We report a 13-year-old girl with Loeys-Dietz syndrome (LDS) caused by a known transforming growth factor beta receptor II (TGFBR2) gene mutation, who developed aortic root dilatation and saccular aneurysm of the internal carotid artery. LDS is a rare, autosomal dominant aortic aneurysm syndrome with multisystem involvement. The disease is typically characterized by the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula/cleft palate. The characteristic LDS symptoms observed in the reported case included craniofacial dysmorphism (hypertelorism, cleft palate, blue sclerae, malar hypoplasia, retrognathia), skeletal deformities (scoliosis, talipes equinovarus, pectus deformity, arachnodactyly), congenital heart defects (patent ductus arteriosus, PDA), and arterial tortuosity and aneurysms. Molecular genetic testing revealed a heterozygous mutation (c.1610 G>C, p.R528C) in the serine-threonine kinase domain of the TGFBR2 gene. Magnetic resonance (MR) angiography showed aortic dilatation, tortuosity of bilateral supraaortic arteries, and saccular aneurysm on the right cervical internal carotid artery. LDS resembles Marfan-related disorders (Marfan, Shprintzen-Goldberg and vascular Ehlers-Danlos syndrome), but arterial tortuosity and aneurysms are characteristic for LDS, so a timely diagnosis of LDS is important for early diagnosis and intervention of aneurysms to prevent vascular events. Here, we describe a LDS patient who presented with arterial tortuosity and saccular aneurysm.
Sanatani, Shubhayan; Potts, James E.; Ryan, Angela; Sandor, George G. S.; Human, Derek G.; Culham, J. A. Gordon
Purpose: To review the clinical outcomes of catheter-directed coil occlusion (coil occlusion) of persistently patent ductus arteriosus (PDA) at a pediatric tertiary care hospital.Methods: A retrospective review of all patients referred to the Cardiac Catheterization Laboratory for coil occlusion at our institution was performed. Twenty-one consecutive patients (12 female) underwent coil occlusion and follow-up between May 1995 and December 1997. We undertook PDA occlusion if: (a) the PDA narrowed to less than 4 mm on echocardiogram and (b) the minimum body weight was approximately 10 kg. Standard right and retrograde left heart catheterization was performed, followed by coil occlusion. Color-flow mapping (CFM) was used intra-procedurally to confirm occlusion of the PDA with a follow-up study several weeks later.Results: The median age and weight of the patients were 33 months and 13.2 kg, respectively. Fourteen patients received one coil, with six requiring a second coil and one requiring multiple coils. Initial follow-up was at a median of 2.4 months. At latest follow-up, 2 patients still have persistent How at the ductal level. The coils were deployed without complication or embolization.Conclusions: A review of our first 21 cases demonstrated three important lessons: (1) the maximum diameter of the PDA suitable for coil occlusion is approximately 3 mm; (2) CFM must show complete obliteration of flow in the catheterization lab in order to ensure occlusion of the PDA at follow-up; and (3) the Jackson detachable system allows for precise placement of the coil, often within another coil.
Miranda, Carlos D; Kenny, Damien
We report our experience with stenting a right ductus arteriosus in a neonate with ductal origin of the right pulmonary artery (PA), who subsequently developed severe pulmonary hypertension in the left PA requiring decompression of the right ventricle with stenting of the left ductus. © 2015 Wiley Periodicals, Inc.
Kim, Hyungtae; Chang, Yun Hee; Jung, Wonkil; Lee, Hyoung Doo; Park, Ji Ae; Huh, Up
Background The tetralogy of Fallot (TOF) with pulmonary atresia (PA) and a ductus-dependent pulmonary circulation (no major aorto-pulmonary collateral arteries (MAPCAs)) has been treated with staged repair or primary repair depending on the preference of surgeons or institutions. We evaluated the 19-year outcome of staged repair for this anomaly to find out whether our surgical strategy should be changed. Materials and Methods Forty-four patients with TOF/PA with patent ductus arteriosus (PDA) who underwent staged repair from June 1991 to October 2010 were included in this retrospective study. The patients with MAPCAs were excluded. The average age at the first palliative shunt surgery was 40.8±67.5 days (range: 0~332 days). Thirty-one patients (31/44, 70%) were neonates. The average weight was 3.5±1.6 kg (range: 1.6~8.7 kg). A modified Blalock-Taussig (BT) shunt was performed in 38 patients, classic BT shunt in 4 patients, and central shunt in 2 patients. Six patients required concomitant procedures: pulmonary artery angioplasty was performed in 4 patients, pulmonary artery reconstruction in one patient, and re-implantation of the left pulmonary artery to the main pulmonary artery in one patient. Four patients required a second shunt operation before the definitive repair was performed. Thirty-three patients underwent definitive repair at 24.2±13.3 months (range: 7.3~68 months) after the first palliative operation. The average age at the time of definitive repair was 25.4±13.5 months (range: 7.6~68.6 months) and their average weight was 11.0±2.1 kg. For definitive repair, 3 types of right ventricular outflow procedures were used: extra-cardiac conduit was performed in 30 patients, trans-annular patch in 2 patients, and REV operation in 1 patient. One patient was lost to follow-up after hospital discharge. The mean follow-up duration for the rest of the patients was 72±37 months (range: 4~160 months). Results Ten patients (10/44, 22.7%) died before the
Tefft, Robert G
This study sought to determine whether early treatment of premature infants with ibuprofen would result in a reduced incidence of surgical ligation of patent ductus arteriosus. Secondary outcomes included duration of hospitalization, assisted ventilation and supplemental oxygen, mortality rate, persistent patent ductus arteriosus (PDA), hypotension, intraventricular hemorrhage, and intestinal perforation. Outcomes among 105 very low-birth-weight (VLBW) infants managed by clinical use of indomethacin were compared with outcomes of 80 infants treated under a standardized protocol for ibuprofen therapy on the first day of life among infants <25 weeks estimated gestational age (EGA) and among infants of 25 to 28 weeks EGA with respiratory distress syndrome or history of antenatal steroids. The incidence of PDA ligation was significantly lower among the early ibuprofen group than among the clinical indomethacin group (0/80 versus 9/105, P = 0.0056). No differences were found in secondary outcomes. The effect persisted (P = 0.0100 to 0.0153) when corrected for birth weight, EGA, gender, Apgar scores, initial pH and base deficit, transport from another hospital, surfactant treatment, and need for assisted ventilation. In our neonatal intensive care unit, the incidence of PDA ligation among VLBW infants decreased after adoption of an early ibuprofen treatment protocol. Thieme Medical Publishers.
Sherer, D M; Divon, M Y
To review current data pertaining to prenatal ultrasonography of the ductus arteriosus. We reviewed manuscripts published in the English language regarding prenatal ultrasonography and the fetal ductus arteriosus obtained from a MEDLINE search for 1966 onward. Additional sources were identified through cross-referencing. Data regarding morphology, physiology, pathophysiology of fetal disease, and hemodynamic changes after administration of various maternal medications and structural congenital anomalies of the ductus arteriosus were selected. Knowledge of the function of the ductus arteriosus in both normal and abnormal fetal conditions is enhanced by prenatal ultrasonographic findings. Detailed analyses of ductus arteriosus hemodynamics are indicated in well-defined medical conditions, including maternal medication and established structural or functional fetal cardiac disease. The fetal ductus arteriosus is a vascular structure of major functional importance. Knowledge of physiologic hemodynamic changes of blood flow in this vessel obtained by prenatal ultrasonography in conjunction with increasing gestational age, maternal medication, fetal growth restriction, as well as the detection of structural anomalies, may assist in clinical management of complicated pregnancies.
Dyamenahalli, U; Smallhorn, J F; Geva, T; Fouron, J C; Cairns, P; Jutras, L; Hughes, V; Rabinovitch, M; Mason, C A; Hornberger, L K
The purpose of this study was to describe the clinical characteristics and outcome and to elucidate the pathogenesis of ductus arteriosus aneurysm (DAA). Ductus arteriosus aneurysm is a rare lesion that can be associated with severe complications including thromboembolism, rupture and death. We reviewed the clinical records, diagnostic imaging studies and available histology of 24 cases of DAA, diagnosed postnatally (PD) in 15 and antenatally (AD) in 9 encountered in five institutions. Of PD cases, 13 presented at <2 months, and all AD cases were detected incidentally after 33 weeks of gestation during a late trimester fetal ultrasound study. Of the 24, only 4 had DAA-related symptoms and 6 had associated syndromes: Marfan, Smith-Lemli-Opitz, trisomies 21 and 13 and one possible Ehlers-Danlos. Three had complications related to the DAA: thrombus extension into the pulmonary artery, spontaneous rupture, and asymptomatic cerebral infarction. Six underwent uncomplicated DAA resection for ductal patency, DAA size or extension of thrombus. In the four examined, there was histologic evidence of reduced intimal cushions in two and abnormal elastin expression in two. Five of the 24 died, with only one death due to DAA. Of 19 survivors, all but one remain clinically asymptomatic at a median follow-up of 35 months; however, two have developed other cardiac lesions that suggest Marfan syndrome. A review of 200 consecutive third trimester fetal ultrasounds suggests an incidence of DAA of 1.5%. Ductus arteriosus aneurysm likely develops in the third trimester perhaps due to abnormal intimal cushion formation or elastin expression. Although it can be associated with syndromes and severe complications, many affected infants have a benign course. Given the potential for development of other cardiac lesions associated with connective tissue disease, follow-up is warranted.
Noma, Elliot; Olivastro, Dominic
A study comparing citations received by patents in given year to number received in subsequent years found that, even though influential patents remain influential, both highly and infrequently cited patents age at same rate. Distribution of patents by number of citations received is stable over time. (17 references) (EJS)
inventors and other correlates of patenting. 14. SUBJECT TERMS innovation, creativity , patent, patents, inventor 15. NUMBER OF PAGES 87...18 Figure 4. Three Components of Creativity . Adapted from Adams (2005). .... 21 x THIS PAGE INTENTIONALLY LEFT...TIROS Television and Infrared Observations Satellite TTCT Torrance Tests of Creative Thinking USPTO United States Patent and Trademark Office WWII
Lee, Youngok; Hong, Seong Wook
Anomalous aortic origin of the left subclavian artery (LSCA) from the left pulmonary artery (LPA) is a rare congenital cardiac malformation. We describe a case of LSCA from the LPA via ductus arteriosus in association with a double-outlet right ventricle, which never has been reported previously in Korea.
Sivakumar, Kothandam; Francis, Edwin; Krishnan, Prasad; Shahani, Jagdish
In late presenters with transposition of the great arteries, intact ventricular septum, and regressing left ventricle, left ventricular retraining by pulmonary artery banding and aortopulmonary shunt is characterized by a stormy postoperative course and high costs. Ductal stenting in the cardiac catheterization laboratory is conceptualized to retrain the left ventricle with less morbidity. Recanalization and transcatheter stenting of patent ductus arteriosus was performed in patients with transposition to induce pressure and volume overload to the regressing left ventricle. Serial echocardiographic monitoring of left ventricular shape, mass, free wall thickness, and volumes was done, and once the left ventricle was adequately prepared, an arterial switch was performed. The ductal stent was removed and the remaining surgical steps were similar to a 1-stage arterial switch operation. Postoperative course, need for inotropic agents, and left ventricular function were monitored. Ductal stenting in 2 patients aged 3 months resulted in improvement of indexed left ventricular mass from 18.9 to 108.5 g/m2, left ventricular free wall thickness from 2.5 to 4.8 mm, and indexed left ventricular volumes from 7.6 to 29.5 mL/m2 within 3 weeks. Both patients underwent arterial switch (bypass times 125 and 158 minutes) uneventfully, needed inotropic agents and ventilatory support for 3 days, and were discharged in 8 and 10 days. Ductal stenting is a less morbid method of left ventricular retraining in transposition of the great arteries with regressed left ventricle. Its major advantages lie in avoiding pulmonary artery distortion and neoaortic valve regurgitation resulting from banding and also in avoiding thoracotomy.
Schmidt, M; Theissen, P; Deutsch, H J; Erdmann, E; Schicha, H
Ductus arteriosus Botalli apertus is a congenital cardiovascular malformation usually diagnosed in childhood by echocardiography and/or cardiac catheterization. Reports about magnetic resonance imaging of ductus arteriosus Botalli apertus are rare. We report about three adult female patients and one adult male patient in whom magnetic resonance imaging was able to demonstrate the pathology. In all four patients quantitative data about right ventricular function were calculated. Pulmonary hypertension with Eisenmenger syndrome detected by cardiac catheterization had developed in three of the four patients excluding operative closure of the ductus. The patient in whom pulmonary hypertension had not developed underwent successful operative closure of the ductus. Magnetic resonance imaging is a non-invasive tool that can be used for diagnosis of ductus arteriosus Botalli apertus and it allows to quantify right ventricular function. Magnetic resonance imaging can be used repetitively in patients with Eisenmenger syndrome which may be helpful for better timing of combined heart-lung transplantation as ultimate therapeutic strategy because deterioration of right ventricular function can be monitored.
... 37 Patents, Trademarks, and Copyrights 1 2010-07-01 2010-07-01 false Identification of patent, patent application, or patent-related proceeding. 1.5 Section 1.5 Patents, Trademarks, and Copyrights UNITED STATES PATENT AND TRADEMARK OFFICE, DEPARTMENT OF COMMERCE GENERAL RULES OF PRACTICE IN PATENT...
[Postural effect in patients with patent foramen ovale: evaluation of right-to-left shunt with transcranial Doppler and transthoracic echocardiography and correlation with arterial oxygen saturation].
Lucreziotti, Stefano; Debenedetti, Chiara; Massironi, Laura; Mantero, Antonio; Di Marco, Fabiano; Chessa, Massimo; Carugo, Stefano
Transcranial Doppler echocardiography and transthoracic echocardiography may detect with high accuracy right-to-left shunt (RLS) due to patent foramen ovale (PFO). However, a standardized diagnostic protocol has never been established. It has been suggested that standing or sitting positions may improve sensitivity of transcranial Doppler due to increased LRS in such positions. We aimed to test efficacy of the sitting position in addition to the supine position in the grading of RLS in patients with PFO. We have also evaluated whether an increase in RLS is associated with a fall in oxygen saturation (SaO2). From September 2015 to February 2016, 70 consecutive patients with suspected PFO underwent transcranial Doppler echocardiography and transthoracic echocardiography with microbubble count and evaluation of SaO2. RLS due to PFO was diagnosed in 58 patients (82.9%). An increase in RLS grade in the sitting position was observed in 28 out of 58 patients (48.3%) (group 1), whereas no increase was detected in 30 patients (51.7%) (group 2). Among the clinical and echocardiographic variables considered, group 1 and group 2 differed only in the prevalence of atrial septal aneurysm (35.7 vs 3.3%, p=0.002). Postural changes were not associated with a fall in SaO2. RLS increases in about half of patients with PFO in the sitting position compared with the supine position, whereas no changes occur in SaO2.
Hattori, T; Hirata, K; Shimizu, S
Aneurysm of the diverticulum of the ductus arteriosus in adult is rare, with only 37 cases reported so far in the literatures. A 18-year-old male was admitted for abnormal tumor shadow in the scout chest X-ray film. Ductal aneurysm was preoperatively diagnosed by chest CT scan, MRI, UCG, and angiography, and was confirmed by the intraoperative findings. In this patient, narrow isthmus and ductus diverticulum were supposed to be contributing factors for aneurysm formation. The aneurysm was approached through a posterolateral thoracotomy and aneurysmal orifice was closed with a trimmed dacron graft under partial femoro-femoral cardiopulmonary bypass. Postoperative course was uneventful.
Shi, Xiaoqing; Wang, Xiaoqin; Wang, Chuan; Zhou, Kaiyu; Li, Yifei; Hua, Yimin
Pulmonary artery dissection (PAD) is a rare condition with high mortality and has not been reported in patient with infective endocarditis (IE). Here, we report the first case of such patient who experienced PDA and survived after surgical intervention.A 10-year-old female child was diagnosed as IE with a patent ductus arteriosis (PDA) and a vegetation on the left side of pulmonary artery trunk (10 × 5 mm). Following 3-week antibacterial treatment, the body temperature of patient returned to normal, and the size of vegetation reduced (7 × 3 mm). However, the patient had a sudden attack of sustained and crushing right chest pain, orthopnea with increasing respiratory rate (> 60/min), and acute high fever. Echocardiography revealed the detachment of vegetation on the first day and dissection of pulmonary artery on the next day. The patient received immediate surgical intervention. It was found that aneurysm had a size of 28 × 20 mm and its orifice (the dissecting site) located on the opposite side of the PDA opening (right side of the pulmonary artery trunk). The dissected left wall of pulmonary artery trunk was reconstructed followed by the closure of PDA with suture. The patient recovered uneventfully.From this case, we learned that the surgical intervention should be considered at an early time for IE patients who have a vegetation in pulmonary artery and PDA. After the infection is under control, the earlier surgery may prevent severe complications.
The number of patents is not so important as the market value. The market value is especially important for licensing of patents, make-or-buy decisions for technology procurement, corporate finance. Patents can be used as collateral for financing. Patents and credit approvals: without patents only 46% and with patents 54%. The value share of knowledge-based components to industrial products already reached 50% and it is still rising. OECD called these developments under the slogan "knowledge economy”. German Norm-DIN 77100 provides a working method for monetary evaluation of a patent. The value of a patent arises from its use. A patent can be used to protect or to earn licensing revenues. An evaluation expertise is required in areas, such as marketing, finance, R & D and strategic planning. As an indicator of the value of a patent is often used the number of citations. The number of a patent citation refers to its meaning and value. Other indicators would be: size of the patent family, validity of the patent, result of objections against patent application, number and quality of claims. The analysis of 9.000 patents resulted that only 7.2% worth over 10 million euro and 68% below 1 million euro. The cost method: it is considered the cost that would be incurred for the development and patenting of a similar invention. The market method: are used the prices that have been achieved in comparable with recently transactions. The Income method: the potential reward is measured, which can arise from a patent. The evaluation will be in the following areas: legal status, technology, market conditions, finance and strategy. Each question relates to a different parameter of a value.
Liu, Xiaoxuan; Calvert, Patrick A; Arif, Sayqa; Keane, Pearse A
Retinal artery occlusion in an otherwise healthy, young patient is rare. In this context it is important to consider patent foramen ovale as a differential. Early referral to a cardiology specialist for diagnosis and treatment is important for preventing further ocular and non-ocular events. PMID:28203381
Jackson, C M; Sandor, G G S; Lim, K; Duncan, W J; Potts, J E
To present four cases of ductus arteriosus aneurysm (DAA) detected by fetal echocardiography and highlight the value of the three-vessel view in the diagnosis of DAA. In addition to the standard fetal echocardiographic views, we examined the three-vessel view in four cases of DAA. The three-vessel view was achieved by sliding the transducer cranially from the four-chamber plane toward the fetal upper mediastinum to demonstrate cross-sections of the main pulmonary artery, the ascending aorta and superior vena cava arranged in a straight line from the left anterior to the right posterior aspect of the mediastinum. DAA was diagnosed when there was a tortuous ductus arteriosus with a dilation that protruded leftward of the aortic arch. In the first case, an insulin-dependent diabetic woman underwent fetal ultrasound examination at 36 weeks' gestation showing right-to-left cardiac disproportion and bidirectional flow in the aorta and main pulmonary artery (PA). The three-vessel view showed a dilated ductus arteriosus (DA) which was stenosed at its distal end. In the second case, a woman had fetal ultrasound scans at 38 and 39 weeks' gestation for suspected intrauterine growth restriction and oligohydramnios. The scans identified an abnormal aortic arch and the three-vessel view showed an elongated vascular structure at the distal end of the PA, which was the DAA. In the third case, a woman with a high-risk obstetric history had multiple scans showing an abnormal PA to aorta relationship, with an apparent 'kink' in the PA. The three-vessel view clarified that this was the DAA. In the fourth case, a woman was scanned because of a 3-kg weight gain in 1 week. The fetal ultrasound scan showed moderate polyhydramnios with normal fetal growth and normal intracardiac anatomy and flow, and the three-vessel view demonstrated a large DA. In each of these cases, the DAA appeared to have occurred in isolation with non-specific clinical findings. We advocate the use of the three
Dasraf, D.; Djer, M. M.; Advani, N.
Persistent ductus arteriosus is one of the most frequent congenital heart diseases found in infants, mainly in preterms. Echocardiography is the gold standard for the diagnosis of hemodynamically significant patent ductus arteriosus (hs-PDA) in preterm neonates. A few studies have suggested that the use of a simple blood assay to detect N-terminal pro-brain natriuretic peptide (NT-proBNP) may be useful in determining the diagnosis and management of hs-PDA. No such studies have been conducted in Indonesia, although the assay kit and characteristics of the patient (gestational age and chronological age) influence the accuracy of NT-proBNP levels in determining hs-PDA. The aim of this study was to determine the association between the NT-proBNP level and the prevalence of hs-PDA in an Indonesian patient population. A cross-sectional study was conducted at Dr. Cipto Mangunkusumo Hospital. PDA was determined using echocardiography in 49 preterm neonates (gestational age <37 weeks and birthweight <2000 g). Subsequently, these patients were divided into three groups: non-PDA, non-hsPDA, and hs-PDA. The blood NT-proBNP level was then determined in the non-hsPDA and hs-PDA groups, and between-group differences were compared. Among the 49 neonates, 33 patients had PDA, and 16 of these had hs-PDA. The results revealed a significant association between the NT-proBNP level and hs-PDA (p < 0.001).
O'Malley, Maureen A; Bostanci, Adam; Calvert, Jane
Gene patenting is now a familiar commercial practice, but there is little awareness that several patents claim ownership of the complete genome sequence of a prokaryote or virus. When these patents are analysed and compared to those for other biological entities, it becomes clear that genome patents seek to exploit the genome as an information base and are part of a broader shift towards intangible intellectual property in genomics.
The problem of patenting of human genes, which was discussed at the Workshop organized by OECD, has become very actual due to granted patents that concern testing of genetic disposition for breast cancer. Companies that had made large investments into this research clearly support patenting of their discoveries. But such patents can reduce general accessibility of genetic testing. Existing laws, and namely the Directive of the European Council unfortunately are not unambiguous and allow rather free explanation.
Schranz, Dietmar; Akintuerk, Hakan; Voelkel, Norbert F
The final therapy of ‘end-stage heart failure’ is orthotopic heart, lung or heart-lung transplantation. However, these options are not available for many patients worldwide. Therefore, novel therapeutical strategies are needed. Based on pathophysiological insights regarding (1) the long-term impact of an obstructive pulmonary outflow tract in neonates with congenitally corrected transposition of the great arteries, (2) the importance of a restrictive versus a non-restrictive atrial septum in neonates born with a borderline left ventricle and (3) the significance of both, a patent foramen ovale and/or open ductus arteriosus for survival of newborns with persistent pulmonary hypertension, the current review introduces some therapeutical strategies that may be applicable to selected patients with heart failure. These strategies include (1) reversible pulmonary artery banding in left ventricular-dilated cardiomyopathy with preserved right ventricular function, (2) the creation of restrictive interatrial communication to treat diastolic (systolic) heart failure, (3) atrioseptostomy or reverse Potts shunt in pulmonary arterial hypertension and (4) return to a fetal, parallel circulation by combining atrioseptostomy and reversed Potts shunt with or without placement of a bilateral pulmonary artery banding. While still being experimental, it is hoped that the procedures presented in the current overview will inspire future novel therapeutic strategies that may be applicable to selected patients with heart failure. PMID:28011759
Schranz, Dietmar; Akintuerk, Hakan; Voelkel, Norbert F
The final therapy of 'end-stage heart failure' is orthotopic heart, lung or heart-lung transplantation. However, these options are not available for many patients worldwide. Therefore, novel therapeutical strategies are needed. Based on pathophysiological insights regarding (1) the long-term impact of an obstructive pulmonary outflow tract in neonates with congenitally corrected transposition of the great arteries, (2) the importance of a restrictive versus a non-restrictive atrial septum in neonates born with a borderline left ventricle and (3) the significance of both, a patent foramen ovale and/or open ductus arteriosus for survival of newborns with persistent pulmonary hypertension, the current review introduces some therapeutical strategies that may be applicable to selected patients with heart failure. These strategies include (1) reversible pulmonary artery banding in left ventricular-dilated cardiomyopathy with preserved right ventricular function, (2) the creation of restrictive interatrial communication to treat diastolic (systolic) heart failure, (3) atrioseptostomy or reverse Potts shunt in pulmonary arterial hypertension and (4) return to a fetal, parallel circulation by combining atrioseptostomy and reversed Potts shunt with or without placement of a bilateral pulmonary artery banding. While still being experimental, it is hoped that the procedures presented in the current overview will inspire future novel therapeutic strategies that may be applicable to selected patients with heart failure.
Zielinsky, Paulo; Busato, Stefano
Fetal circulation has characteristic features, being morphologically and functionally different from extrauterine circulation. The ductus arteriosus plays a fundamental role in directing the blood flow to fetal inferior body parts. Basically, the ductus arteriosus directs 80–85% of the right ventricular output arising from the superior vena cava, coronary sinus, and a small part from the inferior vena cava to descending aorta. Its histological structure is made up predominantly by a thick muscular layer, differently from the aorta and the pulmonary artery, which increases with gestational age. The fibers have a circumferential orientation, especially at the external layers, facilitating and making effective ductal constriction. These factors may generate lumen alterations which may cause fetal and neonatal complications, such as heart failure, hydrops, neonatal pulmonary hypertension, and even death. Classically, maternal administration of indomethacin and/or other antiinflammatory drugs interfere in prostaglandins metabolism, causing ductal constriction. However, many cases of fetal ductal constriction, as well as of persistent neonatal pulmonary artery hypertension, remain without an established etiology, being referred as “idiopathic.” In recent years, a growing body of evidence has shown that herbs, fruits, nuts, and a wide diversity of substances commonly used in daily diets have definitive effects upon the metabolic pathway of inflammation, with consequent inhibition of prostaglandins synthesis. This antiinflammatory action, especially of polyphenols, when ingested during the third trimester of pregnancy, may influence the dynamics of fetal ductus arteriosus flow. The goal of this review is to present these new observations and findings, which may influence dietary orientation during pregnancy. Birth Defects Research (Part C) 99:256–274, 2013. © 2013 Wiley Periodicals, Inc. PMID:24339037
Rooksby, Jacob H.
American research universities frequently obtain and license patents to their faculty members' inventions. While university licensing is carefully tracked and thoroughly studied, little is known about university decisions to assertively litigate their patents through filing patent infringement lawsuits in federal court. Which universities…
Diseases and Conditions Patent foramen ovale By Mayo Clinic Staff A patent foramen ovale (PFO) is a hole in the heart that didn' ... foramen ovale doesn't close, it's called a patent foramen ovale. Although it's not uncommon to have ...
Rooksby, Jacob H.
American research universities frequently obtain and license patents to their faculty members' inventions. While university licensing is carefully tracked and thoroughly studied, little is known about university decisions to assertively litigate their patents through filing patent infringement lawsuits in federal court. Which universities…
Laborda-Vidal, P; Pedro, B; Baker, M; Gelzer, A R; Dukes-McEwan, J; Maddox, T W
Pulmonic stenosis (PS) is the most common congenital cardiac disease in dogs. Boxers and English bulldogs are among the most commonly affected breeds and also commonly associated with an aberrant coronary artery (CA). If an aberrant CA is suspected and balloon valvuloplasty indicated, an intra-operative angiography is recommended prior to the procedure. ECG-gated computed tomography (CT) can be used to screen for CA anomalies in a quick and minimally-invasive way (preventing side effects associated with selective catheter angiography) and allowing early planning of the procedure. The aim of this case series was to report CT findings associated with PS diagnosed by echocardiography. Our database was retrospectively searched for cases of dogs with PS diagnosed by echocardiography, where an ECG-gated CT was performed. A total of six cases were retrieved: all were diagnosed with severe PS. Four dogs had concurrent congenital defects: two dogs had a patent ductus arteriosus, one dog had a ventricular septal defect and an overriding aorta, one dog had an aberrant CA. Detailed CT findings of all cases were reported, including one case of a patent ductus arteriosus and an overriding aorta not identified by transthoracic echocardiography. In addition, an abnormal single left coronary ostium, with a pre-pulmonic right CA was described. In conclusion, despite echocardiography remaining the gold standard for diagnosis and assessment of PS, ECG-gated-CT angiography is a complementary diagnostic method that may provide additional relevant information, shorten surgery/anaesthesia time and reduce the amount of radiation to which the clinician is subjected. Copyright © 2016 Elsevier B.V. All rights reserved.
Fay, F. S.; Cooke, P. H.
To investigate the mechanism underlying irreversibility of ductal closure after birth, studies were undertaken to determine the exact time course for the onset of irreversible closure of the guinea pig ductus arteriosus. Parallel studies of the reactivity of ductal smooth muscle to oxygen and studies of the postpartum cellular changes within the vessel were also carried out.
Fay, F. S.; Cooke, P. H.
To investigate the mechanism underlying irreversibility of ductal closure after birth, studies were undertaken to determine the exact time course for the onset of irreversible closure of the guinea pig ductus arteriosus. Parallel studies of the reactivity of ductal smooth muscle to oxygen and studies of the postpartum cellular changes within the vessel were also carried out.
van Raden, L
Inventions related to living material are in principle patentable as well as inventions in the "classical" fields of technology as long as they are new, industrially applicable and involve an inventive step. A patent gives to its owner for a limited period of time the exclusive right to prevent others from using his patented new technical know-how. Starting point of patent protection in the field of genetic engineering is a genetic information or a genetically induced characteristic of an organism; there is no such thing as a "Patent on Life". As far as inventions relate to genetically modified organisms, patents give to their owners no additional property rights that might exclude the applicability e.g. of the laws on animal protection. Intellectual property like any other property is subject to the limits set up by law. It is neither scientifically correct nor does it help in finding a solution for the conflict within society to shift the--undoubtedly necessary--discussion about research and application in the field of genetic engineering to a discussion about patent law.
Khadir, Mohammed Abdul; Narayana, Ganesh; Nayar, Pradeep G
Isolated Unilateral hypoplasia or agenesis of a branch of pulmonary artery is very rare. It is usually seen associated with congenital heart diseases such as tetralogy of Fallot, atrial septal defect, coarctation of the aorta, right aortic arch, truncus arteriosus, patent ductus arteriosus and pulmonary atresia. It occurs as a result of lack of embryological development of either the left or right sixth aortic arch and has been found to present itself with various clinical manifestations as during childhood it presents as contralateral pulmonary hypertension and in adults as haemoptysis. Early diagnosis and early surgical indication avoids the evolution of pulmonary hypertension to unfavourble state of more severe and progressive degrees and also prevents the development of pulmonary systemic collateral circulation, which is mainly responsible for subsequent haemoptysis in the adulthood. We hereby, report the case of an infant who presented with features of lower respiratory tract infection and later diagnosed as isolated congenital hypoplasia of left pulmonary artery and hence planned for proper follow-up for early surgery thereby preventing complications in the future. PMID:28208970
Khadir, Mohammed Abdul; Narayana, Ganesh; Ramagopal, Ganavi; Nayar, Pradeep G
Isolated Unilateral hypoplasia or agenesis of a branch of pulmonary artery is very rare. It is usually seen associated with congenital heart diseases such as tetralogy of Fallot, atrial septal defect, coarctation of the aorta, right aortic arch, truncus arteriosus, patent ductus arteriosus and pulmonary atresia. It occurs as a result of lack of embryological development of either the left or right sixth aortic arch and has been found to present itself with various clinical manifestations as during childhood it presents as contralateral pulmonary hypertension and in adults as haemoptysis. Early diagnosis and early surgical indication avoids the evolution of pulmonary hypertension to unfavourble state of more severe and progressive degrees and also prevents the development of pulmonary systemic collateral circulation, which is mainly responsible for subsequent haemoptysis in the adulthood. We hereby, report the case of an infant who presented with features of lower respiratory tract infection and later diagnosed as isolated congenital hypoplasia of left pulmonary artery and hence planned for proper follow-up for early surgery thereby preventing complications in the future.
Garg, Gaurav; Tyagi, Himanshu; Agrawal, Gaurav; Anil, S R
A 6-year-old female child was admitted with complaints of progressive dyspnea on exertion since last 3 years. She was saturating 100% on room air with stable vitals. On clinical examination, left precordial bulge was seen with prominent epigastric pulsations. Chest X-ray showed rightward shift of mediastinum and huge homogenous opacity occupying almost entire left lung field. On two-dimensional echocardiography, a large aneurysmal mass was seen occupying left hemithorax which was suspected to be arising from pulmonary artery but its exact site of origin could not be determined. A small patent ductus arteriosus (PDA) was also seen. PDA could be seen directly supplying the aneurysm (Fig. 1). CT angiography was done to confirm the diagnosis. It showed a huge aneurysmal sac measuring 12 cm × 8.9 cm × 14 cm, arising from left pulmonary artery (LPA) opposite to the site of insertion of PDA. Sac was occupying most of the left lung and pushing down the left diaphragm (Fig. 2). Cause of formation of such a huge aneurysm could not be found out. Surgery was performed and mouth of the sac was closed along with ligation of duct, repair of LPA and drainage of the sac. After surgery, lung expansion was good. Patient was discharged and she is doing well. Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Yildirim, Ali; Aydin, Alperen; Demir, Tevfik; Aydin, Fatma; Ucar, Birsen; Kilic, Zubeyir
The aim of the present study was to evaluate the echocardiographic follow-up of patent foramen ovale, which is considered a potential etiological factor in various diseases, and to determine the factors affecting spontaneous closure. Between January 2000 and June 2012, records of 918 patients with patent foramen ovale were retrospectively reviewed. Patency of less than 3 mm around the fossa ovalis is called patent foramen ovale. Patients with cyanotic congenital heart diseases, severe heart valve disorders and severe hemodynamic left to right shunts were excluded from the study. The patients were divided into three groups based on age; 1 day-1 month in group 1, 1 month-12 months in group 2, and more than 12 months in group 3. Of the 918 patients, 564 (61.4%) had spontaneous closure, 328 (35.8%) had patent foramen ovale continued, 15 (1.6%) patients had patent foramen ovale enlarged to 3-5 mm, 6 patients were enlarged to 5-8 mm, and in one patient patent foramen ovale reached to more than 8 mm size. Defect was spontaneously closed in 65.9% of the patients in group 1, 66.7% of the patients in group 2, and 52.3% of the patients in group 3. There was a negative correlation between the age of diagnosis and spontaneous closure (p < 0.05). Gender, prematurity and coexisting malformations such as patent ductus arteriosus and atrial septal aneurysm did not have any effect on spontaneous closure of patent foramen ovale (p > 0.05). However, ventricular septal defect and spontaneous closure of patent foramen ovale had a positive correlation (p < 0.01). No correlation was noted between the existence of atrial septal aneurysm, prematurity, and maturity of the patients. The present study demonstrated that spontaneous closure rate of patent foramen ovale is high. Furthermore, a positive correlation was found between spontaneous closure of patent foramen ovale with early diagnosis and small defect size.
Putra, Sukman Tulus; Djer, Mulyadi M; Idris, Nikmah S; Sastroasmoro, Sudigdo
During 11 years period from January 2005 to December 2015 there were 18 adolescent and adult patients who underwent transcatheter closure of PDA using PDA Amplatzer Duct Occluder (ADO). There were 9 cases with age of 14 to 18 years and 9 cases with age of more than 18 years where the oldest case was 46 years old. Two cases were male and 16 cases were female. Prior to procedures, clinical assessment, ECG, chest x-ray and transthoracic echocardiography (TTE) were performed to confirm the diagnosis of PDA. The procedures of device implantation was performed under conscious sedation in adults and using general anesthesia in adolescents.The size of PDA ranged from 1.6 mm to 11.1 mm. Based on Kritchenko classification, the type of PDA were 15 type A1 and 3type A2. Flow ratio between pulmonary to systemic circulation was between 1.1 and 5.9. The procedure time ranged from 60-189 minutes and the fluoroscopic time 7.1-77.3 minutes. The PA pressure ranged from 22 to 63 mmHg. Immediate results after procedures as seen in angiography showed complete closure in 14 cases and smoky residual shunt or minimal residual shunts in 4 cases, which probably due to the temporary leaking through the devices. In 24 hours, complete closure was achieved in all cases (100%) and continued until 1months. At 6 month follow up, there was no residual shunts detected and also there was no significant complications, such as device embolization or recanalization. This case series suggest that transcatheter closure of PDA in adolescents and adults using Amplatzer duct occluder (ADO) is effective and has excellent resultswithout significant complication. However, long-term follow up is required to assess long term efficacy and safety.
Márquez-González, Horacio; Castro-Contreras, Uriel; Cerrud-Sánchez, Carmen Emma; López-Gallegos, Diana; Yáñez-Gutiérrez, Lucelli
Introducción: la persistencia del conducto arterioso (PCA) representa una de las enfermedades con mayor prevalencia en los hospitales que atienden cardiopatías congénitas (CC). En la actualidad en pacientes mayores de un año de edad el cierre percutáneo es la terapéutica estándar. El objetivo de este trabajo fue conocer la frecuencia, características y tratamiento de PCA en el servicio de Cardiopatías Congénitas en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI. Métodos: en el servicio de Cardiopatías Congénitas del Hospital de Cardiología del CMN SXXI se realizó un estudio descriptivo de 2010 a 2015 de los enfermos que fueron tratados con cierre percutáneo y cirugía de PCA. Se dividieron en las siguientes edades: lactantes, preescolares, escolares, adolescentes y adultos. Se registraron las frecuencias absolutas. Resultados: se seleccionaron 187 pacientes, de los cuales los preescolares y escolares representaron el 60% del total de la muestra. El cierre percutáneo por cateterismo intervencionsta se realizó en 90%; se registró un 2% de complicaciones. Conclusiones: en esta clínica de cardiopatías congénitas, la PCA es tratada por cateterismo intervencionista en la mayoría de las etapas del ser humano, lo que ha registrado mínimas complicaciones.
Juárez-Domínguez, Gabriela; Iglesias-Leboreiro, José; Rendón-Macías, Mario Enrique; Bernardez-Zapata, Isabel; Patiño-Bahena, Emilia Josefina; Agami-Micha, Sion; Ortega-García, Karla Leticia; Torres-Palomino, Gregory; Delgado-Franco, Dagoberto
Introducción: el objetivo es evaluar el posible beneficio en el tratamiento en el cierre de la persistencia del conducto arterioso cuando se realiza una pesquisa (< 72 horas de vida) por ecocardiograma, que cuando se realiza solo ante la presencia de síntomas asociados. Métodos: niños pretérmino sin malformaciones en dos estrategias diagnósticas: por pesquisa (asintomáticos) y por sintomatología asociada a la persistencia del conducto arterioso (PCA). Se analizaron las características del conducto, la presencia de hipertensión pulmonar y el tratamiento recibido. Se compararon los resultados entre: tardíos (34 a 36 semanas de gestación [SEG]), moderados (30 a 33 SEG) y extremos (< 30 SEG). Resultados: no hubo diferencias en las proporciones de diagnósticos de PCA por estrategias (pesquisa 18.6 % [101/543] contra 18.1 % [55/304], p = 0.92). Sin pesquisa, el 53 % se diagnosticó después de las 72 horas de vida. No hubo diferencias en las características del conducto entre los grupo. El tratamiento recibido no difirió entre las estrategias en los prematuros moderados y tardíos, pero sí fue más agresivo en los extremos. Conclusiones: la pesquisa de una PCA por ecocardiografía en los infantes pretérmino extremos acorta el tiempo de detección y permite un tratamiento menos agresivo. No lo recomendamos en pretérminos moderados y tardíos.
Wu, Ming-Fu; Chang, Keng-Wei; Zhou, Wei; Hao, Juan; Yuan, Chien-Chung; Chang, Ke-Chiun
This study applies two variables in the measurement of company patent deployment strategies: patent family depth and earn plan ratio. Patent family depth represents the degree to which certain fields and markets are valued by the patent owner. Earn plan ratio defined as the ratio of the number of patent forward citations to patent family size. Earn plan ratio indicates the degree to which a patent family could be cited by later innovators and competitors. This study applies a logistic regression model in the analysis LED industry data. The results demonstrate that patent value has a positive relationship with the patent family depth, and earn plan ratio. PMID:26098313
Wu, Ming-Fu; Chang, Keng-Wei; Zhou, Wei; Hao, Juan; Yuan, Chien-Chung; Chang, Ke-Chiun
This study applies two variables in the measurement of company patent deployment strategies: patent family depth and earn plan ratio. Patent family depth represents the degree to which certain fields and markets are valued by the patent owner. Earn plan ratio defined as the ratio of the number of patent forward citations to patent family size. Earn plan ratio indicates the degree to which a patent family could be cited by later innovators and competitors. This study applies a logistic regression model in the analysis LED industry data. The results demonstrate that patent value has a positive relationship with the patent family depth, and earn plan ratio.
Ector, Gerren; Galindo, Cristi L.; Hooper, Christopher W.; Brown, Naoko; Wilkerson, Irene; Pfaltzgraff, Elise R.; Paria, Bibhash C.; Cotton, Robert B.; Stoller, Jason Z.; Reese, Jeff
Failure of the ductus arteriosus (DA) to close at birth can lead to serious complications. Conversely, certain profound congenital cardiac malformations require the DA to be patent until corrective surgery can be performed. In each instance, clinicians have a very limited repertoire of therapeutic options at their disposal - indomethacin or ibuprofen to close a patent DA (PDA) and prostaglandin E1 to maintain patency of the DA. Neither treatment is specific to the DA and both may have deleterious off-target effects. Therefore, more therapeutic options specifically targeted to the DA should be considered. We hypothesized the DA possesses a unique genetic signature that would set it apart from other vessels. A microarray was used to compare the genetic profiles of the murine DA and ascending aorta (AO). Over 4,000 genes were differentially expressed between these vessels including a subset of ion channel-related genes. Specifically, the alpha and beta subunits of large-conductance calcium-activated potassium (BKCa) channels are enriched in the DA. Gain- and loss-of-function studies showed inhibition of BKCa channels caused the DA to constrict, while activation caused DA relaxation even in the presence of O2. This study identifies subsets of genes that are enriched in the DA that may be used to develop DA-specific drugs. Ion channels that regulate DA tone, including BKCa channels, are promising targets. Specifically, BKCa channel agonists like NS1619 maintain DA patency even in the presence of O2 and may be clinically useful. PMID:24790087
Polat, Tugcin Bora; Celebi, Ahmet; Hacımahmutoglu, Sevim; Akdeniz, Celal; Erdem, Abdullah; Fırat, Fatih
Reduced left lung perfusion has been described after transcatheter closure of the patent ductus arteriosus (PDA) with several prostheses. Although the Amplatzer ductal occluder (ADO) device is currently the most widely used occluder for closure of large-sized PDAs, the potential consequences of flow distribution to the lungs of this device have not been completely clarified. We evaluated lung perfusion following occlusion of PDA with the ADO device. Forty-seven patients underwent successful transcatheter PDA occlusion using the ADO device were included in this study. Lung perfusion scans were performed 6 months after the procedure. Decreased perfusion to the left lung (defined as < 40% of total lung flow) was observed in 17 patients (36%), 5 of whom were low-weight symptomatic infants. Ductal ampulla length was significantly shorter and minimal ductal diameter to ampulla diameter ratio was significantly higher in patients with decreased left lung perfusion and correlated well with left lung perfusion values (r = 0.516 and r = -0.501, respectively). A cut-off value of ≤ 5.8 mm for the ductal ampulla length and ≥ 1.9 for ampulla diameter to ampulla length ratio showed high sensitivity and specificity for reduced lung perfusion. The incidence of abnormal left lung perfusion is high 6 months after transcatheter closure of PDA with the ADO, more likely in the low weight symptomatic infants and in patients with a short duct or a relatively shallow duct having abrupt narrowing of a large ampulla.
year. Dr. Wells used the SonoSite system he had in Fairbanks to correctly diagnose a truncus arteriosus type 2 abnormality . He described his findings by...Patent ductus arteriosus ,Pulmonary artery - pulmonary hypertension Anomalous Left coronary artery !. Anomalous pulmonary venous return - partial...septal defect - patent foramem ovale,Patent ductus arteriosus ,Pulmonary artery - pulmonarTy hypertension Anomalous left coronary artery Anomalous
Big pharma's business model, which relies on a few blockbusters to generate profits, is clearly broken. Patent expiration on numerous blockbusters in recent years is already altering the drug landscape. Drug companies are also facing other challenges that necessitate development and implementation of novel R&D strategies, including those that focus on nanotechnology and miniaturization. Clearly, there is enormous excitement and expectation regarding nanomedicine's potential impact. However, securing valid and defensible patent protection will be critical. Although early forecasts for nanomedicine commercialization are encouraging, there are numerous bottlenecks as well. One of the major hurdles is an emerging thicket of patent claims, resulting primarily from patent proliferation as well as continued issuance of surprisingly broad patents by the US Patent and Trademark Office (PTO). Adding to this confusion is the fact that the US National Nanotechnology Initiative's widely cited definition of nanotechnology is inaccurate and irrelevant from a nanomedicine perspective. It is also the cause of the inadequate patent classification system that was recently unveiled by the PTO. All of this is creating a chaotic, tangled patent landscape in various sectors of nanomedicine where the competing players are unsure of the validity and enforceability of numerous issued patents. If this trend continues, it could stifle competition and limit access to some inventions. Therefore, reforms are urgently needed at the PTO to address problems ranging from poor patent quality and questionable examination practices to inadequate search capabilities, rising attrition, poor employee morale and a skyrocketing patent application backlog. Only a robust patent system will stimulate the development of commercially viable nanomedicine products that can drastically improve a patient's quality of life and reduce healthcare costs.
Vogel, Melanie; Wilkins-Haug, Louise E; McElhinney, Doff B; Marshall, Audrey C; Benson, Carol B; Silva, Virginia; Tworetzky, Wayne
Fetal cardiac intervention (FCI) has been performed at our center in selected fetuses with complex congenital heart disease since 2000. Most interventions are performed in fetuses with a ductus arteriosus (DA)-dependent circulation. Indomethacin promotes closure of the DA in newborns and in fetal life, a potentially life threatening complication in fetuses with ductus-dependent congenital heart disease. We reviewed our experience with FCI with a focus on the frequency, features, and clinical course of ductal constriction. Fetuses undergoing FCI receive comprehensive pre- and postoperative cardiac and cerebral ultrasound evaluation, approximately 24 hours before and after the procedure, including imaging of DA flow and Doppler assessment of the umbilical artery and vein, ductus venosus, and, since 2004, the middle cerebral artery. Among 113 fetuses that underwent FCI, 24 of which were older than 28 0/7 weeks gestation, 2 were found to have DA constriction due to indomethacin therapy within 24 hours of intervention. Both of these were 30-week fetuses with hypoplastic left heart syndrome and restrictive or intact atrial septum. The DA was stenotic by spectral and color Doppler, and middle cerebral and umbilical artery pulsatility indexes were depressed. After discontinuation of indomethacin, the Doppler indices improved or normalized. Close echocardiographic monitoring of fetal Doppler flow velocities is very important after fetal intervention and indomethacin treatment, as the consequences of DA constriction in a fetus with hypoplastic left heart syndrome are potentially lethal. Sonographic evaluation should include measurement of cerebral and umbilical arterial flow velocities as well as color and spectral Doppler interrogation of the DA. Copyright 2009 S. Karger AG, Basel.
... 37 Patents, Trademarks, and Copyrights 1 2013-07-01 2013-07-01 false Identification of patent, patent application, or patent-related proceeding. 1.5 Section 1.5 Patents, Trademarks, and Copyrights..., the title of the invention, the date of filing the same, and, if known, the group art unit or...
... 37 Patents, Trademarks, and Copyrights 1 2012-07-01 2012-07-01 false Identification of patent, patent application, or patent-related proceeding. 1.5 Section 1.5 Patents, Trademarks, and Copyrights..., the title of the invention, the date of filing the same, and, if known, the group art unit or...
... 37 Patents, Trademarks, and Copyrights 1 2014-07-01 2014-07-01 false Identification of patent, patent application, or patent-related proceeding. 1.5 Section 1.5 Patents, Trademarks, and Copyrights..., the title of the invention, the date of filing the same, and, if known, the group art unit or...
... 37 Patents, Trademarks, and Copyrights 1 2011-07-01 2011-07-01 false Identification of patent, patent application, or patent-related proceeding. 1.5 Section 1.5 Patents, Trademarks, and Copyrights..., the title of the invention, the date of filing the same, and, if known, the group art unit or...
Xie, Jiajun; Juan, Yu-Hsiang; Wang, Qiushi; Chen, Jimei; Zhuang, Jian; Xie, Zhaofeng; Liang, Changhong; Zhu, Yulei; Yu, Zhuliang; Li, Jinglei; Saboo, Sachin S.; Liu, Hui
We evaluated the prevalence, image appearance, associated cardiovascular anomalies, and surgical outcomes of left pulmonary artery sling (LPAS) using cardiovascular computed tomography angiography (CCTA). A retrospective search of patients from our database between October 2007 and December 2014 identified 52,200 patients with congenital heart diseases (CHD) referred for CCTA, echocardiography, or magnetic resonance imaging. Clinical information, CCTA findings, associated cardiovascular anomalies, and surgical outcomes were analyzed. We showed a hospital-based prevalence of 71 patients with LPAS (0.14%, 71/52,200) among CHD patients. Of these, 47 patients with CCTA examinations were assessed further. Most patients (40/47, 85%) had associated cardiovascular anomalies, of which ventricular septal defects (22/47, 47%), atrial septal defects (20/47, 43%), patent ductus arteriosus (16/47, 34%), persistent left superior vena cava (14/47, 30%), and abnormal branching of the right pulmonary artery (ABRPA) (14/47, 30%) were most commonly identified. In total, 28 patients underwent LPA reanastomosis and/or tracheoplasty in our center, and 5 died. LPAS had a hospital-based prevalence of 0.14% among CHD patients. ABRPA is not uncommon and must be recognized. CCTA is a feasible method for demonstrating LPAS and its associated cardiovascular anomalies for an optimal pre-operative assessment of LPAS. PMID:28053308
Sherkow, Jacob S
Clinical research faces a reproducibility crisis. Many recent clinical and preclinical studies appear to be irreproducible--their results cannot be verified by outside researchers. This is problematic for not only scientific reasons but also legal ones: patents grounded in irreproducible research appear to fail their constitutional bargain of property rights in exchange for working disclosures of inventions. The culprit is likely patent law’s doctrine of enablement. Although the doctrine requires patents to enable others to make and use their claimed inventions, current difficulties in applying the doctrine hamper or even actively dissuade reproducible data in patents. This Article assesses the difficulties in reconciling these basic goals of scientific research and patent law. More concretely, it provides several examples of irreproducibility in patents on blockbuster drugs--Prempro, Xigris, Plavix, and Avastin--and discusses some of the social costs of the misalignment between good clinical practice and patent doctrine. Ultimately, this analysis illuminates several current debates concerning innovation policy. It strongly suggests that a proper conception of enablement should take into account after-arising evidence. It also sheds light on the true purpose--and limits--of patent disclosure. And lastly, it untangles the doctrines of enablement and utility.
Moore, Jerilou; Sumrall, William J.
Exploring our patent system is a great way to engage students in creative problem solving. As a result, the authors designed a teaching unit that uses the study of patents to explore one avenue in which scientists and engineers do science. Specifically, through the development of an idea, students learn how science and technology are connected.…
When Blackboard unveiled its U.S. patent for 44 features of learning management systems and then filed a patent infringement suit against Design2Learn, the response of the educational technology community was negative and swift. Stephen Downes discusses why many educators oppose Blackboard's proprietary claims to technologies long considered in…
When Blackboard unveiled its U.S. patent for 44 features of learning management systems and then filed a patent infringement suit against Design2Learn, the response of the educational technology community was negative and swift. Stephen Downes discusses why many educators oppose Blackboard's proprietary claims to technologies long considered in…
Moore, Jerilou; Sumrall, William J.
Exploring our patent system is a great way to engage students in creative problem solving. As a result, the authors designed a teaching unit that uses the study of patents to explore one avenue in which scientists and engineers do science. Specifically, through the development of an idea, students learn how science and technology are connected.…
Lachs, Phyllis S.
An analysis of problems relating to university patents today is presented, and a policy for the institution which addresses the issues that these problems present is suggested. Patenting the results of university research would not delay the publication of research and would provide a needed source of funding. (Author/MLW)
Crouch, Dennis D.; Crouch, Henry L.
There is a need for investigators, legislators, and business leaders to understand the magnitude of innovation and discovery in the field of environmentally conscious technologies (ECTs). Knowledge of the "big picture" is important to providing a national and global account of actual environmental stewardship over the last twenty-five years. A recitation of the Environmental Protection Agency (EPA) supported Acts which have been enacted into law reveals one facet of the multifaceted dynamic of environmental consciousness. The popular discussion and debate, as well as partisan lobbying, which created the political forces leading to environmentally conscious legislation is another facet. A third facet is the corporate response to the threats and opportunities predicted by CEO"s and others through environmental scanning. This paper examines changes in environmentally conscious inventive effort by comparing data from United States Patents issued from 1976 through 2003. Patents are useful tool for measuring technological innovation because they are publicly available records of innovative activity. Although not all inventions result in patent applications, the monopoly rights granted on the invention give the inventor a strong incentive to obtain patents on any viable product or process. Among the results, we found a significant increase in patents relating to environmentally conscious products and processes during the period in question. Specifically, a dramatic increase in patent activity was seen for the decade of the 1990"s. Surprisingly, the patenting rate from 2000 to 2003 seems to have stabilized. Additionally public discussion of ECTs appears to have a positive impact on patent filings.
Yu, Hee Chul; Murakami, Gen; Rodríguez-Vázquez, José Francisco; Cho, Baik Hwan
In serial sagittal sections of a fetus on week 9 (crown-rump length, 36 mm), we incidentally found absence of the usual portal vein through the hepatoduodenal ligament. Instead, an anomalous portal vein originated behind the pancreatic body, crossed the lesser sac and merged with the upper part of the ductus venosus. During the course across the lesser sac, the vein provided a deep notch of the liver caudate lobe (Spiegel's lobe). The hepatoduodenal ligament contained the hepatic artery, the common bile duct and, at the right posterior margin of the ligament, and a branch of the anomalous portal vein which communicated with the usual right branch of the portal vein at the hepatic hilum. The umbilical portion of the portal vein took a usual morphology and received the umbilical vein and gave off the ductus venosus. Although it seemed not to be described yet, the present anomalous portal vein was likely to be a persistent left vitelline vein. The hepatoduodenal ligament was unlikely to include the left vitelline vein in contrast to the usual concept. PMID:26417483
Patent classification systems have traditionally evolved independently at each patent jurisdiction to classify patents handled by their examiners to be able to search previous patents while dealing with new patent applications. As patent databases maintained by them went online for free access to public as also for global search of prior art by examiners, the need arose for a common platform and uniform structure of patent databases. The diversity of different classification, however, posed problems of integrating and searching relevant patents across patent jurisdictions. To address this problem of comparability of data from different sources and searching patents, WIPO in the recent past developed what is known as International Patent Classification (IPC) system which most countries readily adopted to code their patents with IPC codes along with their own codes. The Cooperative Patent Classification (CPC) is the latest patent classification system based on IPC/European Classification (ECLA) system, developed by the European Patent Office (EPO) and the United States Patent and Trademark Office (USPTO) which is likely to become a global standard. This paper discusses this new classification system with reference to patents on bioremediation.
Clinical outcomes and a high prevalence of abnormalities on comprehensive arterial and venous thrombophilia screening in TIA or ischaemic stroke patients with a patent foramen ovale, an inter-atrial septal aneurysm or both.
Lim, Soon Tjin; Murphy, Stephen J X; Smith, Deirdre R; Williams, Jennifer; Navarro, Silvia Gil; McCabe, John; Moore, David P; McHugh, Johnny; McCabe, Dominick J H
Data are limited on the optimal management of cryptogenic TIA/stroke patients with a patent foramen ovale (PFO)±inter-atrial septal aneurysm (IASA), especially with an inherited thrombophilia. Prospectively-collected data on TIA/ischaemic stroke patients with PFO, IASA or both who received 'goal-directed secondary-prevention medical treatment' were analysed. All patients had trans-oesophageal echocardiography, anti-nuclear, anti-cardiolipin, anti-beta 2 glycoprotein I antibodies, rheumatoid factor, lupus anticoagulant, protein C&S, anti-thrombin, factor VIII activity, activated protein C resistance, Factor V Leiden, prothrombin gene and MTHFR-c.677C>T mutation screening. ENA and homocysteine were assessed in the latter study period. Eighty-three patients were recruited. Mean follow-up: 48.1months. Forty-seven patients (56.6%) had an isolated PFO, 32 (38.6%) a PFO and an IASA, and 4 (4.8%) an IASA alone. Eighteen (21.7%) had ≥1 abnormality on thrombophilia screening. The most important abnormalities which lead to treatment changes in 11 patients (13.3%) were primary anti-phospholipid syndrome (N=3; 3.6%), protein S deficiency (N=2; 2.4%) hyper-homocysteinaemia (N=6/72 screened, 8.3%). Four patients (4.8%) opted for PFO closure: two with protein S deficiency, and two with no identified thrombophilia. Seven (8.4%) had recurrent TIA/ischaemic stroke during follow-up (overall annualised incidence: 2.1%), of whom five had a PFO alone and two a PFO and IASA. Comprehensive arterial and venous thrombophilia screening is warranted in TIA/ischaemic stroke patients with a PFO±IASA, is conclusively abnormal in over a fifth, and informed important decision-making regarding individualised therapy in 13.3% of patients. The incidence of recurrent vascular events in this population is low on optimal, personalised secondary-prevention treatment, even with an underlying thrombophilia. Copyright © 2017 Elsevier B.V. All rights reserved.
Wohrley, Andrew A.; Mitchell, Cindy
Patent information has never been so available, at such low cost, to so many people. Describes patent databases accessible on the Web (Micropatent, Source Translation and Optimization Questel-Orbit QPAT, Internet Patents/Community of Science, and the U.S. Patent and Trademark Office), lists their strengths and weaknesses, and recommends the best…
Wohrley, Andrew A.; Mitchell, Cindy
Patent information has never been so available, at such low cost, to so many people. Describes patent databases accessible on the Web (Micropatent, Source Translation and Optimization Questel-Orbit QPAT, Internet Patents/Community of Science, and the U.S. Patent and Trademark Office), lists their strengths and weaknesses, and recommends the best…
Malaria is an important tropical infection affecting millions of world population each year. Malarial vaccine development is the hope for successful control of malaria. Knowledge on malaria vaccine has been considered patentable subject for decades. Due to the present advance biotechnology, the number of patent applications related to malarial vaccine is growing exponentially. Several malarial vaccine candidates have been recently identified and the genetic manipulation of these candidates is becoming more efficient with the advancement of new biotechnologies. This review summarizes some of the recent published patents on malarial vaccines covering antigens, candidate epitopes and recombinant processing.
This page highlights patented EPA-developed technologies that are available for licensing. FTTA staff contacts (link) can provide more information on any of these technologies, as well as information on licensing.
Patent urachal tube repair ... belly. Next, the surgeon will find the urachal tube and remove it. The bladder opening will be ... surgeon uses the tools to remove the urachal tube and close off the bladder and area where ...
... have it. A patent foramen ovale is often discovered during tests for other problems. Learning that you ... atrium. The upper right chamber (right atrium) receives oxygen-poor blood from your body and pumps it ...
Kaback, Stuart M.
This paper discusses patent information retrieval from online files in terms of types of questions, file contents, coverage, timeliness, and other file variations. CLAIMS, Derwent, WPI, APIPAT and Chemical Abstracts Service are described. (KP)
Antunes, Adelaide; Fierro, Iolanda; Guerrante, Rafaela; Mendes, Flavia; Alencar, Maria Simone de M.
Investment in nanotechnology is now a given constant by governments, research centers and companies in both more developed countries and emerging markets. Due to their characteristics, such as high stability, ability to enable antigen identification on specific cells in the human body and controlling the release of drugs and, therefore, improving therapies, nanoparticles have been the subject of research and patent applications in the pharmaceutical field. According to the Organization for Economic Co-operation and Development (OCDE), patent data can be used as a source of information in order to measure science and technology activities. Thereby, this paper presents an analysis based on patent documents related to nanotechnology in the pharmaceutical sector. As a result, the analysis of patents demonstrate primarily that nanobiotechnology attracts high levels of R&D investments, including nanoparticle-based chemotherapeutic agents/drugs, monoclonal antibody nanoparticle complexes and their role in drug delivery or contrast agents with non-toxic effects. PMID:23535336
Kaback, Stuart M.
This paper discusses patent information retrieval from online files in terms of types of questions, file contents, coverage, timeliness, and other file variations. CLAIMS, Derwent, WPI, APIPAT and Chemical Abstracts Service are described. (KP)
Mei, Dan Feng; Liu, Josephine
An exciting discovery in the laboratory may translate to a commercial product. How does the patent system fit into the picture? We first discuss the circumstances under which an invention is granted a patent. What is the purpose of a patent and what are the functions of the patent system? Who can apply for a patent? What makes an invention patentable? A patent does not automatically grant a right to make or sell a product. This is because multiple patents can cover a single pharmaceutical product. Understanding the patent landscape covering a product of interest is key to evaluating the risk of infringing another's exclusivity rights. We use a hypothetical example relating to skin cancer to guide a discussion of patent law.
Haponiuk, Ireneusz; Paczkowski, Konrad; Chojnicki, Maciej; Jaworski, Radosław
A 10-month-old girl was admitted to the Intensive Care Unit with the symptoms of critical cardiac decompensation. In the 3(rd) month of life, 3 kg bw, she underwent an interventional persistent ductus arteriosus (PDA) closure in a high-reference pediatric cardiology center. Echocardiography performed on admission showed myocardial injury, with poor contractility, mild pulmonary hypertension and severe stenosis of the isthmus of aorta. The girl was urgently referred for surgical removal with the use of extracorporeal circulation (ECC) and deep hypothermia circulatory arrest (DHCA) technique. In the 4(th) postoperative day (POD), she developed cardiovascular decompensation and died in the 7(th) POD due to circulatory arrest in the mechanism of refractory ventricular fibrillation. In autopsy there were found microscopic signs of apoptosis in parenchymal organs below iatrogenic 'coarctation', typical for chronic ischemia. In the segments proximal to iatrogenic aortic stenosis there were evident vascular changes characteristic for chronic severe arterial hypertension.
De Luca, Carmela; Trifonova, Anastassia
Therapeutic antibodies have grown to become an important product class within the biopharmaceutical market. A prerequisite to their commercialization is adequate patent protection. Disclosure requirements and the types of claims available in different jurisdictions can impact the scope of protection available for antibodies. Areas covered: A comparative review of statutory bases, patent office practices and selected decisions in Canada, the United States and the United Kingdom related to disclosure requirements is provided. Expert opinion: Differences in disclosure requirements exist in different jurisdictions which can impact the type of claims obtained and their survival when attacked in litigation. Including a wide variety of claim types is a key strategy to ensuring therapeutic antibodies are adequately protected. Method of use claims may provide advantages and broader protection in some circumstances and should also be considered.
Fok, Henry; Jiang, Benyu; Chowienczyk, Phil
Objectives Exposure to intravascular microbubbles after diving and during medical procedures alters endothelial function. The aim of this study was to investigate whether a patent foramen ovale altered forearm endothelial function by facilitating microbubbles transfer. Design Patients attended on two separate visits, at least seven days apart receiving agitated saline or no active intervention in random order. On both days, flow-mediated dilatation of the brachial artery was measured using vascular ultrasound. On the intervention visit, agitated saline was injected and the passage of microbubbles into the arterial circulation was confirmed by echocardiography. Serial flow-mediated dilatation measurements were made after agitated saline and at the same time points after no intervention. Setting St Thomas’ Hospital in London. Participants Patients with a patent foramen ovale (PFO+n = 14, 9 male, mean ± SD age 42.2 ± 10.5 years) and patients without a patent foramen ovale (PFO− n = 10, 7 male, mean ± SD age 49.4 ± 18.4 years) were recruited. Main outcome measures Change in brachial artery flow-mediated dilatation. Results In patent foramen ovale + patients, flow-mediated dilatation did not change significantly on the control day but after agitated saline reduced by 2.3 ± 0.3%, 20 minutes after bubble injection (P < 0.005 vs. corresponding change in flow-mediated dilatation during control study). There was no significant change in flow-mediated dilatation for patent foramen ovale− patients at either visit. Conclusion These results suggest that the presence of a patent foramen ovale facilitated impairment of endothelial function acutely by the transfer of microbubbles into the arterial circulation. As a patent foramen ovale is a common condition, this may be relevant to microbubbles exposure in medical procedures and in decompression illness. PMID:26668739
Fok, Henry; Jiang, Benyu; Chowienczyk, Phil; Clapp, Brian
Exposure to intravascular microbubbles after diving and during medical procedures alters endothelial function. The aim of this study was to investigate whether a patent foramen ovale altered forearm endothelial function by facilitating microbubbles transfer. Patients attended on two separate visits, at least seven days apart receiving agitated saline or no active intervention in random order. On both days, flow-mediated dilatation of the brachial artery was measured using vascular ultrasound. On the intervention visit, agitated saline was injected and the passage of microbubbles into the arterial circulation was confirmed by echocardiography. Serial flow-mediated dilatation measurements were made after agitated saline and at the same time points after no intervention. St Thomas' Hospital in London. Patients with a patent foramen ovale (PFO+n = 14, 9 male, mean ± SD age 42.2 ± 10.5 years) and patients without a patent foramen ovale (PFO- n = 10, 7 male, mean ± SD age 49.4 ± 18.4 years) were recruited. Change in brachial artery flow-mediated dilatation. In patent foramen ovale + patients, flow-mediated dilatation did not change significantly on the control day but after agitated saline reduced by 2.3 ± 0.3%, 20 minutes after bubble injection (P < 0.005 vs. corresponding change in flow-mediated dilatation during control study). There was no significant change in flow-mediated dilatation for patent foramen ovale- patients at either visit. These results suggest that the presence of a patent foramen ovale facilitated impairment of endothelial function acutely by the transfer of microbubbles into the arterial circulation. As a patent foramen ovale is a common condition, this may be relevant to microbubbles exposure in medical procedures and in decompression illness.
Chang, Hee-Yoon; Locker, Joseph; Lu, Run; Schuster, Victor L.
Background Prostaglandin E2 (PGE2) plays a major role both in maintaining patency of the fetal ductus arteriosus (DA) and in closure of the DA after birth. The rate- limiting step in PGE2 signal termination is PGE2 uptake by the transporter PGT. Methods and results To determine the role of PGT in DA closure, we used a gene-targeting strategy to produce mice in which PGT exon 1 was flanked by loxP sites. Successful targeting was obtained since neither mice hypomorphic at the PGT allele (PGT Neo/Neo) nor global PGT knockout mice (PGT −/−) exhibited PGT protein expression; moreover, embryonic fibroblasts isolated from targeted mice failed to exhibit carrier-mediated PGE2 uptake. Although born in a normal Mendelian ratio, no PGT −/− mice survived past post-natal day 1, and no PGT Neo/Neo mice survived past post-natal day 2. Necropsy revealed patent DA with normal intimal thickening but with dilated cardiac chambers. Both PGT Neo/Neo and PGT −/− mice could be rescued through the post-natal period by giving the mother indomethacin before birth. Rescued mice grew normally and had no abnormalities by gross and microscopic post-mortem analysis. In accord with PGT’s known role in metabolizing PGE2, rescued adult PGT −/− mice had lower plasma PGE2 metabolite levels, and higher urinary PGE2 excretion rates, than wild type mice. Conclusions PGT plays a critical role in closure of the DA after birth by ensuring a reduction in local and/or circulating PGE2 concentrations. PMID:20083684
Venema, Andrea; DeRuiter, Marco C.; van Munsteren, Conny; Olive, Michelle; Nabel, Elizabeth G.; Gittenberger-de Groot, Adriana C.
Closure of the ductus arteriosus (DA) at birth is essential for the transition from fetal to postnatal life. Before birth the DA bypasses the uninflated lungs by shunting blood from the pulmonary trunk into the systemic circulation. The molecular mechanism underlying DA closure and degeneration has not been fully elucidated, but is associated with apoptosis and cytolytic necrosis in the inner media and intima. We detected features of histology during DA degeneration that are comparable to Hutchinson Gilford Progeria syndrome and ageing. Immunohistochemistry on human fetal and neonatal DA, and aorta showed that lamin A/C was expressed in all layers of the vessel wall. As a novel finding we report that progerin, a splicing variant of lamin A/C was expressed almost selectively in the normal closing neonatal DA, from which we hypothesized that progerin is involved in DA closure. Progerin was detected in 16.2%±7.2 cells of the DA. Progerin-expressing cells were predominantly located in intima and inner media where cytolytic necrosis accompanied by apoptosis will develop. Concomitantly we found loss of α-smooth muscle actin as well as reduced lamin A/C expression compared to the fetal and non-closing DA. In cells of the adjacent aorta, that remains patent, progerin expression was only sporadically detected in 2.5%±1.5 of the cells. Data were substantiated by the detection of mRNA of progerin in the neonatal DA but not in the aorta, by PCR and sequencing analysis. The fetal DA and the non-closing persistent DA did not present with progerin expressing cells. Our analysis revealed that the spatiotemporal expression of lamin A/C and progerin in the neonatal DA was mutually exclusive. We suggest that activation of LMNA alternative splicing is involved in vascular remodeling in the circulatory system during normal neonatal DA closure. PMID:21915271
Waleh, Nahid; Barrette, Anne Marie; Dagle, John M.; Momany, Allison; Jin, Chengshi; Hills, Nancy K.; Shelton, Elaine L.; Reese, Jeff; Clyman, Ronald I.
Objective To identify genes affected by advancing gestation and racial/ethnic origin in human ductus arteriosus (DA). Study design We collected three sets of DA tissue (n=93, n=89, n=91; total = 273 fetuses) from second trimester pregnancies. We examined four genes, with DNA polymorphisms that distribute along racial lines, to identify "Caucasian" and "Non-Caucasian" DA. We used RT-PCR to measure RNA expression of 48 candidate genes involved in functional closure of the DA, and used multivariable regression analyses to examine the relationships between advancing gestation, "Non-Caucasian" race, and gene expression. Results Mature gestation and Non-Caucasian race are significant predictors for identifying infants who will close their patent DA when treated with indomethacin. Advancing gestation consistently altered gene expression in pathways involved with oxygen-induced constriction (e.g., calcium-channels, potassium-channels, and endothelin signaling), contractile protein maturation, tissue remodeling, and prostaglandin and nitric oxide signaling in all three tissue sets. None of the pathways involved with oxygen-induced constriction appeared to be altered in "Non-Caucasian" DA. Two genes, SLCO2A1 and NOS3, (involved with prostaglandin reuptake/metabolism and nitric oxide production, respectively) were consistently decreased in "Non-Caucasian" DA. Conclusions Prostaglandins and nitric oxide are the most important vasodilators opposing DA closure. Indomethacin inhibits prostaglandin production, but not nitric oxide production. Because decreased SLCO2A1 and NOS3 expression can lead to increased prostaglandin and decreased nitric oxide concentrations, we speculate that prostaglandin-mediated vasodilation may play a more dominant role in maintaining the "Non-Caucasian" PDA, making it more likely to close when inhibited by indomethacin. PMID:26265282
Bjornstad, David J; Santore, Rudy; McKee, Michael
Production requiring licensing groups of complementary patents implements a coordination game among patent holders, who can price patents by choosing among combinations of fixed and royalty fees. Summed across patents, these fees become the total producer cost of the package of patents. Royalties, because they function as excise taxes, add to marginal costs, resulting in higher prices and reduced quantities of the downstream product and lower payoffs to the patent holders. Using fixed fees eliminates this inefficiency but yields a more complex coordination game in which there are multiple equilibria, which are very fragile in that small mistakes can lead the downstream firm to not license the technology, resulting in inefficient outcomes. We report on a laboratory market investigation of the efficiency effects of coordinated pricing of patents in a patent pool. We find that pool-like pricing agreements can yield fewer coordination failures in the pricing of complementary patents.
Aguilera, Marijo; Ramin, Kirk; Nyholm, Jessica; Gidvani, Monisha; Jacobs, Katherine; Sivanandam, Shanthi
The etiology of polyhydramnios may be attributed to either increased production of amniotic fluid (fetal polyuria or high-output cardiac failure) or decreased fetal swallowing (obstruction or neurological impairment). Although idiopathic polyhydramnios occurs in nearly half of all cases, it is often associated with fetal abnormalities. Fetal ductus arteriosus flow is normally from right to left. We report a case of antenatally detected bidirectional fetal ductus arteriosus flow diagnosed concomitantly with polyhydramnios. Amnioreduction was performed due to severe maternal symptoms, which resulted in correction of the fetal ductus arteriosus flow. Postnatal diagnosis of a Morgagni diaphragmatic hernia indicates that our sonographic findings collectively may have been a diagnostic clue.
Gokhale, M; Gupta, D; Gupta, U; Faraz, R; Sandhu, S S
Endophytic fungi are taxonomically and ecologically heterogeneous group of organisms, mainly belonging to the Ascomycotina and Deuteromycotina. Endophytes usually produce the enzymes necessary for the colonization of plant tissues. Endophytes are able to utilize components of plant cells without disturbing host metabolism, which is confirmed by isozyme analysis and studies on substrate utilization. The patents related to enzymes and metabolites produced by endophytic fungi are associated with their ecological significance. Application of metabolites and growth promoting factors produced from endophytic fungi, in the pharmaceutical and agricultural industries, is now well established. The patents on secretion of extracellular enzymes in vitro by endophytic fungi needed for cell wall degradation, support the hypothesis that fungal endophytes represent a group of organisms specialized to live within plant tissue. This review presents the patents granted on different aspects of endophytic fungi for the last 11 years. This expresses the scenario and impact of these patents regarding significance in human society. In the last few years, research and inventions regarding the different aspects of endophytic fungi beneficial for host plant as well as for human beings have been carried out, which is supported by the increasing number of patents granted on endophytic fungi. Copyright© Bentham Science Publishers; For any queries, please email at firstname.lastname@example.org.
Rolfe, Damian; Parker, Jayson; Morgan, Max
This paper explores whether, and under what circumstances, a biosimilar approved in the United States under the Biologics Price Competition and Innovation Act (hereafter 'BPCIA') can be patented. The possibility that a biosimilar product could have meaningful patent protection arises from specific requirements for biosimilarity under the BPCIA, which account for the fact that manufacturing processes of biologics are inherently imprecise. The requirements for biosimilar approval may provide sufficient leeway to a biosimilar applicant to patent structural or formulation differences that provide non-clinical but business-relevant advantages over the reference molecule, such as improved shelf-life or ease of manufacture, without compromising clinical biosimilarity. Examination of the BPCIA and related Acts, Food and Drug Administration (FDA) guidance papers, case law, patent database searching, and relevant scholarly articles. Legislative and regulatory requirements for the approval of a biosimilar under the BPCIA are focused on clinical results and allow a degree of leeway for differences to exist between a biosimilar's structure and non-clinical components and those of the biosimilar's reference molecule. This leeway can be exploited to provide the biosimilar with potentially patentable business-relevant advantages over its reference product while maintaining clinical biosimilarity to the reference product.
Zhao, Feng; Bosserhoff, Anja-Katrin; Buettner, Reinhard; Moser, Markus
Background Patent ductus arteriosus (PDA) is one of the most common forms of congenital heart disease. Mutations in transcription factor TFAP2B cause Char syndrome, a human disorder characterized by PDA, facial dysmorphysm and hand anomalies. Animal research data are needed to understand the mechanisms. The aim of our study was to elucidate the pathogenesis of Char syndrome at the molecular level. Methodology/Principal Findings Gene expression of Tf