Muhammad Shabbir ( Department of Cardiology, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi )
Waqar Ahmed ( Department of Cardiology, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi )
Omarah Qureshi ( KRL General Hospital, Islamabad. )
Jahanzeb Ali ( Department of Cardiology, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi )
We report a case of Patent ductus arteriosus (PDA), which was closed successfully by transcatheter technique in a pregnant patient. This procedure was safe, effective and uncomplicated, obviating the need for surgery in this high risk patient.
Patent ductus arteriosus (PDA) is a common cardiac anomaly (1 in 3000 births), nearly 15% of all adults with congenital heart disease have PDA.1 If PDA is an isolated lesion, it is almost uniformly undesirable. Surgical management of the PDA has been the "gold standard" since 1939.2
Porstmann et al. first demonstrated the feasibility of nonsurgical closure of the PDA in 1967 without thoracotomy.3
Since then Transcatheter occlusion of PDA has evolved into an important form of therapy with excellent results and it obviates the need for surgical intervention for these defects.4
We report a case of PDA which was closed successfully by Transcatheter technique during pregnancy. To our knowledge, this is the first reported case from Pakistan, when PDA was closed successfully by Transcatheter Technique during pregnancy.
A 27 years old pregnant woman in her second trimester in 20th week of gestation presented with history of worsening shortness of breath at rest and on exertion, for the last 02 months. On examination, she had good volume regular pulse at 105/min. Her JVP was raised and she had pedal oedema. Examination of precordium showed left parasternal heave. On auscultation she had continuous "machinery" murmur. Transthoracic Echocardiogram (TTE) revealed dilated left atrium (LA) and left ventricle (LV). PDA of 4.8 mm in diameter was seen. Her predicted pulmonary artery systolic pressure (PASP) was 50 mm of Hg. Transcatheter occlusion of PDA was planned. Before starting the procedure, a lead sheet was placed on the table and her abdomen was covered completely with another lead apron as well for added radioprotection. Cardiac catheterization revealed mean PASP of 54 mm Hg and Type 'A' PDA of 5.00 mm in diameter, which was occluded successfully with 10/8 mm Amplatzer PDA occluder device under local anaesthesia. PASP reduced to 25 mm of Hg immediately after the procedure. Total radiation time was only 45 seconds. Follow up TTE at 24 hours did not show any residual shunt. She was reviewed two weeks after the procedure. Her symptoms had significantly improved and later, she delivered a healthy baby at 38 weeks of gestation. Follow up TTE at six months revealed a normal sized LA and LV. Pulmonary artery systolic pressure was 20 mm Hg. She had no residual leak.
The normal closure process of PDA begins within few hours after birth and unique pathological and histological findings have been noted in the ducti that are not destined to close.5
Smaller lesions are not associated with haemodynamic abnormalities or left heart volume overload but these defects are at significant risk for endarteritis. Correction of these defects is therefore recommended.6,7
PDA, if left uncorrected can result in a number of long term complications. Flow across the PDA is determined by the size of the defect and the compliance of the lung vasculature.8
Moderate to large sized defects are associated with left sided cardiac volume overload. However, patients who are asymptomatic before pregnancy may become symptomatic and their clinical condition may deteriorate due to significant increase in volume overload during pregnancy. Transcatheter closure of PDA may be the treatment of choice during pregnancy as it avoids the complications of surgery, shortens the hospital stay and resultantly may improve morbidity and mortality in these high risk patients.
Transcatheter treatment to occlude PDA is a safe and effective procedure during pregnancy.
1. Krasuski RA. Patent Ductus Arterious closure. J Interven Cardiol 2006;19:560-66.
2. Gross RE, Hubbard JP. Landmark article Feb 25, 1939: Surgical ligation of a patient ductus arteriosus. Report of first succssful case. By Robert E Gross and John P. Hubbard. JAMA 1984; 251: 1201-2.
3. Portmann W, Wierny L, Warneke H. Closure of the persistent ductus arteriosus without thoracotomy. Ger Med Mon 1967;12:259-61.
4. Pass RH, Hijazi Z, Hsu DT, Lewis V, Hellenbrand WE. Multicenter USA Amplatzer Patent Ductus Arteriosus Occlusion Device Trial. Initial and one year results. J Am Coll Cardiol 2004;44:513-9.
5. Gitten berger-de Groot AC, Strengers JL. Histopathology of the arterial duct (ductus arteriosus) with and without treatment with prostaglandin EI. Int J Cardiol 1998; 19:153-66.
6. Lankipalli RS, Lax K, Keane MG, Toca M, Bavaria JE, Milas BL et al. Images in cardiovascular medicine. Infected patent ductus arteriosus. Circulation 2005; 112 : e364-5.
7. Sadiq M, Akram Z, Rathore AW, Latif F, Rehman A. Risk of Infective Endarteritis in Patent Ductus Arteriosus. Is closure in all PDA's justified? Pak Paed J 2003; 27:101-7.
8. Brili SV, Toutouzas P. Patent arterial duct and aortopulmonary window. In: Gatzoulis MA, Webb GD, Daubeney PEF, eds. Diagnosis and management of Adult Congenital heart disease. New York: Churchill Livingstone, 2003; 247-52.