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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 186-190

Role of Echocardiography in Percutaneous Closure of Patent Ductus Arteriosus


1 Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Pediatric Cardiology, Kasturba Medical College, Manipal, Karnataka, India

Date of Submission21-May-2022
Date of Decision08-Jul-2022
Date of Acceptance10-Jul-2022
Date of Web Publication12-Nov-2022

Correspondence Address:
Dr. Navaneetha Sasikumar
Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_29_22

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  Abstract 

Patent ductus arteriosus is a common congenital heart disease. The disease has varied presentations, ranging from severe respiratory distress and ventilatory requirements in preterm babies to asymptomatic ducts in older children. Echocardiography is the primary tool for diagnosis and assessment of its hemodynamic significance. The decision on the need for and timing of duct closure is made after integrating clinical and echocardiographic findings. Echocardiography is also utilized for planning percutaneous closure where the size and shape of the duct is key. During transcatheter closure, echocardiography helps assess device placement and impingement of nearby structures. This approach makes arterial access dispensable in experienced hands and is particularly helpful in preterm babies and young infants.

Keywords: Device closure, echocardiography, patent ductus arteriosus


How to cite this article:
Alawani SS, Teli AS, Sasikumar N. Role of Echocardiography in Percutaneous Closure of Patent Ductus Arteriosus. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:186-90

How to cite this URL:
Alawani SS, Teli AS, Sasikumar N. Role of Echocardiography in Percutaneous Closure of Patent Ductus Arteriosus. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2023 Feb 4];6:186-90. Available from: https://jiaecho.org/text.asp?2022/6/3/186/361061


  Introduction Top


A patent ductus arteriosus (PDA) is an integral part of fetal circulation. In the normal course of events, PDA closes spontaneously soon after birth as the circulation transitions from fetal to postnatal. The incidence of PDA in children who are born at term gestation is 1 in 2000.[1] However, the incidence of PDA increases with prematurity and is inversely proportional to the gestational age.[2] The incidence in premature babies born under 28 weeks of age or those with a birth weight of <1000 g is around 66%.[2],[3] The presence of a persistent PDA in these newborns is associated with increased mortality and morbidities, including intraventricular hemorrhage, pulmonary hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia.[4],[5],[6] Infants and children with moderate-to-large PDA develop congestive heart failure of various degrees due to volume overload and may eventually develop irreversible pulmonary vascular disease (Eisenmenger syndrome).[7],[8] Other complications include infective endarteritis (0.4% per year) and aneurysm formation (incidence of 8%).[9],[10],[11],[12]

The degree of left-to-right shunt in PDA is determined by the size and length of the PDA as well as the systemic and pulmonary vascular resistance. Accordingly, a small PDA has a shunt ratio of <1.5:1. Infants and children with small PDA are asymptomatic. There might be a continuous or a systolic murmur. A moderate-sized PDA has a shunt between 1.5 and 2.2:1. Large PDAs have a shunt >2.2:1. The latter two groups are generally symptomatic with varying degrees of heart failure and/or evidence of left ventricular (LV) volume load. The murmur in moderate PDA is continuous and becomes systolic or disappears in large shunts. Silent PDAs are the ones that can be detected only via echocardiography, not by clinical examination.

PDA also exhibits significant shape variation. The angiographic classification of PDA was originally described by Krichenko et al.[1],[13] In this classification, type A is the conical type ductus, type B window type ductus, type C tubular ductus, type D complex ducts with multiple constrictions, and type E, an elongated ductus with a constriction at the pulmonary end. Moderate and large PDAs should be closed at a time when percutaneous closure can be safely performed. Relentless symptoms before that can be tackled by surgical ligation. Small PDAs with a continuous murmur are also recommended to be closed, the murmur being a surrogate for turbulence of flow, predisposing to infective endarteritis. Silent PDA and small PDA without a continuous murmur do not merit closure. Transcatheter closure of PDA is currently the therapy of choice.

Echocardiography is the gold standard for the diagnosis of PDA. It helps in estimating the volume of shunt and hemodynamic significance. Segmental analytic methods rule out other structural heart diseases. The decision on the need for closure and the timing of closure depends on integrating the clinical assessment and echocardiographic evaluation. It has to be remembered that surgical ligation is a closed-heart procedure with minimal morbidity and mortality, making it all the more imperative that percutaneous closure be done as safely as possible. A thorough preprocedural echocardiographic assessment of anatomy and physiology is the basis of a successful PDA device closure procedure.


  Echocardiographic Assessment of Patent Ductus Arteriosus Top


Ductal dimension

The echocardiographic windows that are most useful for the assessment of PDA are the parasternal short-axis view, the high parasternal ductal view, and the modified suprasternal long-axis view. PDA minimal diameter (usually present at the pulmonary end of PDA), ampulla size, and length of PDA are three important measurements [Figure 1]. Duct size is assessed in multiple views and multiple frames to establish the average for each value. Measurements are acquired from two dimensional (2D) images as the color mode has been shown to overestimate the vessel size.[14]
Figure 1: Two-dimensional image of Krichenko type A, conical patent ductus arteriosus from high parasternal or ductal view. The pulmonary end is measured. The ampulla is good sized

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Ductal structure

Krichenko et al.'s classification was originally described in angiograms. In the majority of patients, echocardiography can provide information regarding the shape of the duct.[1],[13] Type A (”conical”) ductus with a well-defined, larger aortic ampulla and smaller pulmonary artery end is the most common type of PDA [Figure 2]. Large type C or tubular PDA is frequently seen in infants with heart failure [Figure 3].
Figure 2: Angiographic image of a type A, conical patent ductus arteriosus from the right anterior oblique view

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Figure 3: Two-dimensional image of Krichenko type C, tubular patent ductus arteriosus from high parasternal view. As opposed to the type A conical patent ductus arteriosus, there is no tapering of diameter toward the pulmonary end. The diameters of the ampulla, the pulmonary end, and the length can be measured from this view. Blue arrow – pulmonary artery and red arrow – descending aorta

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Shunt direction

It is assessed using color Doppler. The direction of blood flow in PDA is usually left to right [Figure 4] but can be right to left [Figure 5] or bidirectional [Figure 6] when there is high pulmonary vascular resistance and in certain conditions with duct-dependent systemic circulation (such as interrupted aortic arch and severe coarctation of the aorta). Shunt direction can also be assessed using pulsed-wave or continuous-wave Doppler.
Figure 4: Continuous-wave Doppler interrogation of a patent ductus arteriosus with left-to-right shunt. The low systolic and lower diastolic velocities indicate a large shunt as described in the text

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Figure 5: Continuous-wave interrogation of patent ductus arteriosus with continuous right-to-left shunt, indicating suprasystemic pulmonary artery pressure. This patient had transposition of great arteries with intact ventricular septum

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Figure 6: Pulsed-wave Doppler assessment of patent ductus arteriosus with bidirectional shunt. This patient had transposition of great arteries with suprasystemic pulmonary artery pressures and continuous right-to-left flow across the patent ductus arteriosus at presentation. The shunt became bidirectional after treatment with pulmonary vasodilators as shown in the figure

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Patent ductus arteriosus shunt velocity and its significance

Pulsed-wave and continuous-wave Doppler are useful in determining shunt velocity across the PDA during the cardiac cycle. The peak velocity during systole and diastole can be measured. Large, nonrestrictive shunts have a low peak systolic velocity and a steep systolic to end-diastolic velocity gradient. Small, restrictive shunts have a high peak systolic velocity and a low systolic-to-diastolic velocity gradient. When the ratio between peak systolic and end-diastolic velocities is >2, it is considered a pulsatile flow pattern. A ratio of < 2 is described as a restrictive shunt. In the setting of a preterm PDA, it is suggestive of a closing PDA.[15-17]

Shunt from left to right

Increased pulmonary blood flow due to left-to-right shunt in PDA leads to increased pulmonary venous return. This leads to left atrial (LA) enlargement and eventually LV enlargement. The LA-to-aortic annulus ratio in the parasternal long-axis view can be used to assess LA enlargement. A ratio of >1.4 is considered significant.[18],[19] LV internal dimension can be measured at the level of the tip of mitral valve leaflets in parasternal long-axis view using M-mode. Z scores for age, weight and height are available, which are helpful in ojectively assessing LV enlargement.

The presence of diastolic antegrade flow in branch pulmonary arteries has been shown to be a marker of significant left-to-right shunt in PDA in preterm babies. The mean and end-diastolic velocity in left pulmonary artery (LPA) can be measured using pulsed-wave Doppler and cutoff velocity of 0.42 and 0.20 m/s, respectively, is indicative of a hemodynamically significant PDA (hsPDA).[18]

Hemodynamic significance of PDA in preterm babies can also be assessed from the diastolic filling pattern of the LV. Normally preterm babies have an E/A ratio (early diastolic phase ventricular filling velocity to atrial contraction phase velocity) of less than one as the LV is relatively non-compliant. In the presence of a hsPDA, E velocity increases because of high pulmonary venous return and the E/A ratio becomes >1.[20]

Pressure in the pulmonary arteries

Pulmonary artery pressure is estimated using the simplified Bernoulli equation. Pulmonary artery systolic and diastolic pressures can be obtained from systemic pressures by subtracting four times the square of systolic and diastolic velocities across the duct when the shunt is left to right. When the shunt is right to left, the same principle applies; four times the square of systolic and diastolic velocities across the duct should be added to systemic pressures.[21] When ductal flow velocity cannot be obtained, pulmonary artery pressure can be obtained directly from tricuspid or pulmonary regurgitation jets. Indirect assessment can also be done based on the interventricular septal position in the parasternal short-axis view or subcostal short-axis view.


  The Role of Echocardiography in the Diagnosis of Hemodynamically Significant Patent Ductus Arteriosus in Premature Infants Top


The hemodynamic significance of PDA in preterm babies is assessed from multiple echocardiographic findings as mentioned below.

  • Dilated left side of the heart on visual “eyeballing”[18]
  • LV end-diastolic dimension (correlates with z-scores)
  • Size of PDA (≥1.4 mm/kg)[18]
  • Doppler flow assessment of maximum velocity (Vmax) in systole and end-diastole[15],[16],[17]
  • LPA diastolic velocity, a mean velocity of >0.42 m/s and an end-diastolic velocity of >0.2 m/s[18]
  • Mitral E/A ratio >1 (pseudonormalization)[20]
  • Diastolic retrograde or absent blood flow in the descending aorta or celiac trunk or superior mesenteric artery or anterior or middle cerebral artery[20]
  • LV output-to-superior vena cava flow ratio of more or equal to 4[18]
  • Reduced isovolumetric relaxation time (40 ms) using Tissue Doppler imaging.[20]


The decision to close a PDA in a preterm baby by pharmacological, interventional, or surgical means is a clinical decision supported by echocardiographic assessment.


  Echocardiography's Role in Transcatheter Patent Ductus Arteriosus Device Closure Top


Preprocedural echocardiography has been found to correlate well with angiographically obtained measurements of PDA minimal diameter, ampulla size, and ductal shape in various studies.[22-24] The Amplatzer duct occluder 1 is the prototype device that is used for PDA device closure. A device size 2 mm larger than the smallest diameter of the PDA is classically chosen. Certain anatomical as well as physiologic changes alter the device choice, and it is important to identify them on echocardiography. Examples include large tubular ducts (Krichenko type C) and the window type ductus (Krichenko type B), both of which are present generally in early infancy. Furthermore, elongated (type E) and complex (type D) ducts would necessitate alternate device selection and deployment strategies. When echocardiographic images are satisfactory, they can be used to guide device size selection without an aortogram. This strategy helps avoid arterial puncture (and its complications), shorten procedure time, and reduce fluoroscopy exposure and contrast use, especially in younger infants and preterm babies. Angiogram remains the gold standard for assessment of PDA. Echocardiography based device selection is best done by trained and experienced operators. When arterial puncture and aortgram are avoided, angiograms are done from the side arm of the delivery sheath while it is across the PDA. The threshold for obtaining a proper aortogram should be low whenever the anatomy is unclear on echocardiography. For larger ducts in older children, and in hypertensive ducts where closure is indicated, additional imaging using aortogram is routinely done. Angiography is preferably done before crossing the PDA as crossing or attempts at crossing can alter the size and shape of the PDA by the mechanism of smooth muscle contraction. Before releasing the device, assessment of device position, presence of residual PDA flows, and LPA and descending aorta flows can be done by echocardiographic assessment. Obstruction or possibility of obstruction after release in the left pulmonary artery and/or aorta needs to be carefully assessed, particularly in younger infants with large PDAs [Figure 7]. Once satisfactory, the device can be released and the echocardiogram rechecked.

Echocardiography is particularly important for PDA device closure in preterm babies. The Amplatzer Piccolo device is frequently the preferred choice. The device selection is based on echocardiographic measurements of the PDA. Intraprocedural monitoring is also done using echocardiography as mentioned above.
Figure 7: Continuous-wave Doppler interrogation of descending aorta after device deployment in a young infant with a large patent ductus arteriosus. The signal shows significant obstruction with diastolic tailing. The device was removed and patent ductus arteriosus was closed surgically

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Echocardiography is integral to patient selection for PDA closure using coils, where the presence of a good-sized ampulla is key.[25],[26]

Zero X-ray PDA device closure has also been reported where transthoracic echocardiography-guided PDA device closure is done. The advantage is that the procedure would be radiation and contrast free. Initial studies from select centers have shown promising results.[27],[28],[29]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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