CATH MEETDr.NAGULA PRAVEEN

Case• 2 year old male child.• h/o recurrent LRTIs at presentation.• Patient had h/o breathing difficulty, feeding difficulty and poor

weight gain at the age of 3 months. Symptoms decreased with medications,was diagnosed to have a heart disease at this admission.• No H/o cyanotic spells, pedal edema .• No F/o consanguinity, no other member in the family having a

Heart disease.

On examination:Physical Examination: • weight-8kg, height-81 cm, • No anemia,no cyanosis,no jaundice,no clubbing,no

lymphadenopathy,no pedal edema.Vitals : • Pulse - 106/min,regular,high volume & no special character

no Radio radial or radiofemoral delay.• B.P-110/50mmhg,• RR-25/min,• Afebrile.

CardioVascular System

• JVP : normal mean column height with normal wave pattern.Inspection & Palpation : • Apex is in 6th ICS,LV type at Anterior Axillary line, hyperdynamic.• Grade 2/3 parasternal pulsations felt, • Palpable P2, • Systolic thrill in 1st & 2nd Lt ICS.Auscultation:• S1-Normal • S2- Narrow split ; P2 >A2 in Pulmonary Area • no additional sounds• A 4/6 long systolic murmur most prominent in 1st & 2ndLt ICS, high

pitched,increases with inspiration, • no other murmur.

ECG

ECHO

• Situs solitus,levocardia, 2atria,2ventricles, AV –VA concordance , NRGA , normal systemic and pulmonary venous drainage.• PDA of size 8mm - shunt is Left to right shunt with Pressure

Gradient of 25 mm hg in systole and 10mm in diastole.• PA Systolic pressure of 80 mm hg.• LA, LV are dilated .• Mild MR,no PR,TR.• Normal biventricular function• No associated VSD,COA, ASD.• Left sided aortic arch.

2 year old,Height - 81 cm, weight - 8.5 kg, BMI- 12.95 Kg/m²,Hb-10.1gm/dl, O2 con-175 ml/min/mt², BSA- 0.48 m²Catheter course:

RT FV---IVC---RA--- RV--- PA---PCW RT FA---Ao---LV PDA ---DES.AORTA.

CATHETERISATION

PRESSURE DATA in mm HgFA--- 110/50 (67)RA--- 4RV--- 80/0-6PA--- 80/40(54)PCWP--- 5LV--- 106/0-8

SATURATION DATA in %SVC--- 64.6IVC--- 68.6MVO2--- 65.07RA--- 63.4RV--- 67.5PA--- 83.4FA--- 94.9PV - 98.0

• Qp = 175/13.6 × 10.1×(0.98 -0.83) = 8.73 L/min.

• Qs = 175/13.6 × 10.1 ×(0.95 -0.67) = 4.77 L/min.

• Qp/Qs = 8.73/4.77 = 1.83

• PVR = 54-5 / 8.73 = 5.612 wood units

• SVR = 67-4 / 4.77 = 13.2 wood units

• PVRI/SVRI = 5.612/13.2 = 0.425

CATHETERISATION

CATHETERISATIONPOST O2

Pressure Data in mm HgFA--- 120/74 (90)RA--- 3RV--- 70/0-4PA--- 70/40(50) PCWP--- 15LV--- 115/0-6

Saturation data in %SVC--- 82.1IVC--- 87.5MVO2--- 83.45PA--- 98.7 (pO2=161mmhg)FA--- 99.9 (pO2 =417mmhg)

• Qp = 175/(13.6×10.1×0.99+13.34) – (13.6×10.1×0.987 + 5.15) = 17.78L/min.

• Qs = 175/(13.6 ×10.1×0.99+13.34)-(13.6×10.1×0.834+1.8) = 6.04L/min.

• Qp/Qs= 17.78/6.04 = 2.94• PVR= 50-15/17.78 = 1.96 wood unit• SVR= 90-3= 14.40 wood unit• PVRI/SVRI =1.96/14.40 = 0.136

CATHETERISATIONPOST O2

Case 2• 3 yr old F• Wt 13.6 kgs• Child had been very active,without evident dyspnea or cyanosis.• A murmur was first reported at 1 ½ yrs.• Her development was normal for her age.• Mild pallor• JVP normal,BP – 104/38mmHg• Systolic at left 2nd and 3rd Left ICS.• P2 masked by murmurs.• Very loud,continuous,machinery type systolic and diastolic

murmurs,left 2nd 3rd ICS.• ECG- normal ,normal axis,LVH

Cath dataPressure data (mm Hg)• RA – 5 • RV – 31/4 (13)• PA – 30/13(19)• LA – 8 • LV – 90/40 (65)Saturation data • IVC – 65• SVC – 62• MV02 – 62.75• RA – 61• RV - 65• MPA – 65 • LPA – 80• AORTA – 95

PDA without pulmonary hypertensionQs – 2.38 l/minQp – 4.98 l minQp/Qs – 2.09:1

Case3 • 8yrs old F• Weight 18.4 kg• 2 episodes of pneumonia and frequent bronchitis.• Less active than other children.easy fatiguability and dyspnea on climbing more than one

flight of stairs.• No h/o suggestive of rheumatic fever.• Fragile,under developed child.• No cyanosis.• Examination: slight precordial bulge to left of sternum.• JVP normal• Systolic thrill at left 2nd ICS.• S1 loud,P2 accentuated.• Long loud coarse systolic• Coarse early to mid diastolic left 2nd ICS.• High pitch Systolic murmur LLSB.• MDM at apex • ECG- notching of P wave,biventricular hypertrophy

Cath data

• Saturation data:• SVC – 60• IVC – 65• MVO2 – 61.25• RA – 60• RV – 72• PA – 88• PV - 98 • Aorta -98

Pressure data:RA – 5RV - 64/6(25)PA – 64/23(39)LV – 104/10Aorta – 107/46(73)LA – 8

Qp = 9.50 lit/minQs = 3.10 lit/minL-R shunt ventricular – 0.90 lit/minAorta to pulmonary – 5.5 lit/min

PDA with VSD with pulmonary hypertension

PATENT DUCTUS ARTERIOSUS

Indications for catheterization

• Usually does not require.• Color doppler is as sensitive as cardiac catheterization for

detecting even a small PDA.

• 1.Clinical findings – symptomatology discreprancy.• 2.Severity of pulmonary hypertension.• 3.Reactivity to pulmonary vasodilators.• 4.If closure is indicated in a particular case scenario.• 5.Detection of assosciated lesions.

• Right heart catheterization – suffices to confirm diagnosis.• Venous catheter from MPA – PDA – descending aorta.• Retrograde – if interatrial spetum is intact, LV cannot be

entered prograde.• Catheters used.• Multipurpose catheter• Pigtail

Angiographic views

• Defining the anatomy of the PDA.• Left Lateral projection. – for sizing of device• LAO 60 - profile of PDA • RAO caudal• RAO 30 – ampulla at pulmonary end

Isolated PDA type A

Ductus in Tricuspid atresia

Ductus arising more proximally

Ductus arising more proximally,elongated

Ductus arising very proximally underside of arch typically seen in TOF -PA

Ductus arising from subclavian artery in TOF PA with right sided aortic arch

Significant shunt at great arteries

• An increase of pulmonary arterial blood oxygen content of >0.5mL/dL or a saturation increase of >4% to 5% from that in right ventricular blood indicates a significant left to right shunt at the pulmonary arterial level.

Imp pointsFeature Implication

Increase in O2 saturation just below the pulmonary valve

Pulmonary Regurgiation

A sample from either one of the pulmonary artery branches does not reflect mixed pulmonary arterial blood oxygen saturation

preferential streaming of oxygenated blood from the PDA into one or another pulmonary branch.

Accurate pulmonary blood flow from blood oxygen data

difficult

Accurate calculation of true magnitude of left to right shunting

impossible

Reduced PVO2 LV failure with pulmonary edema

Increased O2 saturation in RA blood PFO with L-R shunt

Presence of large ASD Masks the significant shunt at great artery level

O2 saturation of blood in the descending aorta less than that obtained in the ascending aorta

Significant Pulmonary hypertension,R-L shunting

• Increase in oxygen saturation in pulmonary arterial blood is not diagnostic of a PDA,But may be present in lesions such as • Aortopulmonary window,• Supracristal VSD, streaming may direct the highly saturated blood into the pulmonary

artery.• Calculation of pulmonary blood flow is inaccurate,the calculation

of pulmonary vascular resistance is also inaccurate.

Shunt depends upon3 major factors• Diameter and the length of the ductus arteriosus• Pressures between the aorta and the pulmonary artery• Systemic and pulmonary vascular resistances

Pulmonary arterial blood pressure

Systemic arterial pressures

Pulse pressure

SBP/DBP/MP SBP/DBP/MP

Small PDA normal Low diastolic pressure widened

Moderate sized PDA Slightly elevated,less than Systemic Pressures

Low DBP Mean pressure elevated

widened

Large PDA with pulmonary hypertension

Equal to Systemicpressures

Increased LVEDPDiastolic gradient between LA and LVLA mean pressure may be increased Prominent V waveSmall systolic difference between LV and aorta

decreased

Classifications • Krichenko’s classification• Sri Chitra Tirunal classification• Size of the ductus

• Staging of PDA

Krichenko classification Type A : CONICAL ductusWell defined aortic ampullaConstriction near pulmonary artery end

Type B : WINDOW ductusVery short length

Type C : TUBULAR ductusNo constrictions

Type D: COMPLEX ductusmultiple constrictions

Type E: ELONGATED ductusConstriction remote from the anterior edge of trachea

Krichenko et al .Am J Cardiol.1989;63:877-79

Sri Chitra Tirunal Classification of PDA,Prof Jagan Mohan A.Tharakan et al.(2003)• Angiographic appearance of PDA• Retrograde analysis of the appearance of PDA on angiography

selected for device closure.Magnification factor = catheter size measured on the screen / Actual catheter size.• Measurement of anatomical components of ductusEx:Ampulla size = ampulla measured on screen / magnification factor.Lateral view167 pts

Pate

nt d

uctu

s arte

riosu

s Saucer shaped Length of the ductus < 6 mm

Narrowing at PA end by > 50% of the width of the ampulla

Cylindrical (tubular ductus)

Length of ductus > 6mmNarrowing at PA end by < 50 % the

width of ampulla

Conical (cup shaped)

Length of ductus > 6mmNarrowing at PA end >50% of the width of ampulla

Length of this narrow portion (stem of the ductus ) < 1/3 of the total length of the ductus

Funnel shaped Similar to conical

Longer stem >1/3 of the total length of ductus

Hour glass shaped Ampulla at both PA end and the aortic end

Patent Ductus Arteriosus

Length of ductus

< 6mm

PA end narrowing

> 50% of width of ampulla

Saucer shaped

> 6mm

PA end narrowing

> 50% width of ampulla

Length of narrow portion< 1/3

of length of ductus

Conical (cup shaped)

Longer stem

Funnel shaped

< 50 % of width of ampulla

Cylindrical

Ampulla

Usually at aortic end

At both ends

Hourglass type

Saucer shaped ductusShallow depth of ductusHardly any narrowing at the pulmonary end

Based on size of ductus

Staging of PDA• Clinical • C1 – Asymptomatic • C2 – Mild • C3 – Moderate• C4 – severe

• Echocardiography• E1 – no evidence of flow on 2D or doppler interrogation• E2 - small non significant ductus • E3 – moderate HSDA• E4 - Large HSDA

Staging of PDA

Treatment of preterm infantsMedical :Oral /IV indomethacin• Effects are apparent when administered < 10 days of age, less mature infants.• Infants <1000g before manifestation (<72 hrs of age).

• C/I : Renal dysfunction, necrotizing enterocolitis,overt bleeding, shock, ECG evidence of myocardial ischemia.

• Serum creatinine >1.6mg/dl, BUN >20 mg/dl.• Dose – 0.2mg/kg NG or IV.

• A total of three doses,12-24 hrs apart, based on urinary output.• If urine flow decreases – increase the time period or less doses.

• Second course if clinical signs reappear.• True prophylactic therapy on the first day after birth - no advantage.• Refractory patients – L NMMA and indomethacin.Ibuprofen (less side effects,increased pulmonary hypertension).

Oral paracetamol

< 48 hrs Subsequent two doses are 0.10mg/kg IV2-7 days 0.20mg/kg>7 days 0.25mg/kg

Surgical • Unsuccessful /not possible medical treatment.• <10 days of age - duration of ventilatory support,hospital

stay,lowers morbidity.• Ligation rather than division of ductus arteriosus.• Thoracoscopic surgery• Both are safe,0% mortality,100% complete closure.• Less morbidity with thoracoscopic surgery.

Complications

• Bleeding• Pneumothorax• Infection• Injury to recurrent laryngeal nerve• Ligation of the left pulmonary artery or aorta

Percutaneous in pre term infants• 4F catheters,outer diameter <1.3mm.• Reports of closure in infants <1.5kg.• Antegrade apporach –femoral vein.• Late femoral vein thrombosis.• Device embolization.

Prophylactic closure• Not advised in preterm infants,even extremely low birth weight ones.

Term infants,children,adults• 9 months of age – asymptomatic infants.• Catheter coil/device closure• Surgery• Indomethacin – ineffective

Catheter coil/device closure• Outpatient procedure.• Sheaths 4-8 Fr.(1.3 to 2.5 mm outer diameter)• Single coil loop on the pulmonary artery side and the remaining three

to four loops – aortic ductal ampulla.• Size of the device atleast 2 mm more than the narrow diameter of the

duct.• >97% success procedural rate.• >98% closure rate at 6 months.

< 2.5 mm Occluding coilsPlatinum, stainless steel

Few mm to < 12 mm ADO,PFM duct occlud coil

> 12 mm AGA septal occluder, AGA VSD device,

NMT cardio SEAL device.Covered stents

Complications • Embolization • Usually can be retreived

• Disturbance in the proximal left pulmonary artery or descending aorta from a protruding device

• Hemolysis from high velocity residual shunting.• Femoral artery or vein thrombosis• Infection.

Surgery • Surgical ligation --- left 4th ICS lateral thoracotomy• Surgical division• Midline thoracotomy with cardiopulmonary bypass – complex

cases• Post device embolization• Calcified PDA

• VATS • Transaxillary muscle sparing thoracotomy

Surgery • Indications : PDA too large for catheter closure.• Minimal mortlaity and morbidity.• Return to activity in <3 weeks.• Video Assisted Thoracoscopic Surgical (VATS) closure.• Advantages over conventional• Tearing and hemorrhage with large PDAs in adults (calcified)• Higher rate of laryngeal nerve injury

PDA with Pulmonary hypertension Response to test occlusion with a balloon catheter,O2,NO. Good response – closure advised.

Device closure > surgical. Equivocal response –

Home oxygen Sildenafil Bosentan Inhaled iloprost Repeat catheterization 4-9 months later

Post procedure – pulmonary vasodilators. Only C/I to closure – severe pulmonary hypertension with

irreversible pulmonary vascular disease and baseline right to left ductal shunting despite maximal medical pulmonary vasodilation.

Take home message• PDA is congenital malformation with a left to right shunt at

great artery level.• Clinical implications vary depending on the age,anatomy of the

ductus and the underlying cardiovascular status of the patient.• Echocardiographic diagnosis is enough in most of the

case,reserving the catheterization in complex cases,Pulmonary hypertension for feasibility.• Surgery was definitive treatment for PDA previously.• Transcatheter replacing the surgery over the past 3 decades in

most of the patients.• Complications can be avoided by appropriate diagnosis and

management.

Questions asked• 1.what are the lesions to be suspected along with PDA?• 2.what are ductal dependent lesions ?• 3.what will be the gradients between the aorta and pulmonary

artery in restrictive,moderately restrictive,unrestricted PDA?• 4.what is the importance of the ampulla?• 5.how you will assess the size of device for PDA?• 6.describe the procedure of PDA device closure?• 7.how do you suspect based on the catheter course whether PDA or

AP window?• 8.significant step up at the great artery level ?• 9.what is the criteria for adequate response of reversibility?• 10.what is the use of covered stent in PDA?• 11.in what cases PDA will be kept patent?