|Year : 2022 | Volume
| Issue : 3 | Page : 191-196
Role of Echocardiography in Ductal Stenting
Bharti Sharma, Shreepal Jain
Department of Cardiology, B.J Wadia Hospital for Children, Mumbai, Maharashtra, India
|Date of Submission||23-Jan-2022|
|Date of Decision||01-Mar-2022|
|Date of Acceptance||03-Apr-2022|
|Date of Web Publication||29-Jul-2022|
Dr. Bharti Sharma
Tender Hearts Clinic, Shop 16, Avighna IX, Dr. B.A.Road, Lalbaug, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Patent ductus arteriosus stenting has been acknowledged as a reliable alternative to palliative shunt surgeries in neonates with duct-dependent circulation. This procedure is technically challenging and can have serious complications; hence, a thorough evaluation of the case and preprocedural planning is required. Transthoracic echocardiography (TTE) remains the first diagnostic modality for all congenital heart defects. This article focuses on the role of TTE in diagnosis and transcatheter management of duct-dependent lesions.
Keywords: Ductal stenting, patent ductus arteriosus, transthoracic echocardiogram
|How to cite this article:|
Sharma B, Jain S. Role of Echocardiography in Ductal Stenting. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:191-6
|How to cite this URL:|
Sharma B, Jain S. Role of Echocardiography in Ductal Stenting. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2023 Feb 4];6:191-6. Available from: https://jiaecho.org/text.asp?2022/6/3/191/352991
| Introduction|| |
Neonates with duct-dependent circulation present either with cyanosis or circulatory shock. Initiation of prostaglandin E1 (PGE1) infusion for ductal patency in these neonates is the first temporary measure in management until a definitive palliative or corrective surgery is performed. Duct-dependent critical congenital defects include three groups:
- Duct-dependent pulmonary circulation: Such as pulmonary atresia with intact interventricular septum (PA-IVS), tetralogy of Fallot with pulmonary atresia (TOF-PA), tricuspid atresia with pulmonary atresia, severe Ebstein's anomaly, or any single ventricle lesion with pulmonary atresia
- Duct-dependent systemic circulation: Such as hypoplastic left heart syndrome (HLHS), interrupted aortic arch, severe aortic stenosis (AS), and severe coarctation of the aorta
- Inadequate mixing of pulmonary and systemic blood: Such as transposition of the great arteries (TGA).
In the current era, prenatal detection of these defects helps initiate an appropriate therapeutic strategy. Transthoracic echocardiography (TTE) plays a crucial role in the diagnosis of these defects. Over the decades, there have been advances in surgical techniques with improved survival of pediatric patients with cyanotic heart disease. With more primary corrective surgeries at early age, the need for palliative surgeries has shifted to hearts with single-ventricle physiology and TOF-PA. Modified Blalock–Taussig (BT) shunt remains the most common palliative procedure for such defects.
The success of ductal stenting as a palliative procedure was first reported in 1992, for neonates with pulmonary atresia. Since then, there have been various studies comparing BT shunt and patent ductus arteriosus (PDA) stenting.,, The primary goal of PDA stenting is to provide sufficient blood supply to the lungs, ensuring equal distribution, for the desired interval of time, till a definitive or another palliative surgery can be performed. Usefulness of PDA stenting has been documented for the following lesions:-
- Pulmonary atresia: PA-IVS, TOF-PA
- Hybrid procedure in HLHS as a first-stage palliation
- Retraining left ventricle in TGA
- Drug-refractory idiopathic pulmonary hypertension: Creation of reverse Potts shunt.
Ductal stenting has a relatively high failure rate of 16%–20%.,, This makes it a challenging procedure and necessitates the need for thorough preprocedural assessment. TTE is the most accessible tool which provides the following necessary details for planning:
- Complete cardiac morphology
- Ductal anatomy: Ductus origin, ductus morphology (straight or tortuous [≥2 turns]), and ductal length
- Connection to pulmonary artery and associated pulmonary coarctation.
Although TTE is the most feasible and operator-friendly tool, sometimes, it may not provide complete information about ductal morphology, especially if there are multiple turns. In such cases, further assessment by cardiac computed tomography angiography with 3-dimensional planning becomes imperative.
The utility of TTE is not only vital for preprocedure planning but also during the procedure to check stent position and postprocedure to assess stent flow into branch pulmonary arteries.
| Imaging Views for Patent Ductus Arteriosus|| |
Parasternal short axis
PDA is visualized in this view by sweeping the probe in the anterior direction, toward pulmonary artery. Color Doppler helps in identifying a small PDA which can be missed on 2-dimensional imaging.
For this view, the operator needs to place the probe in the suprasternal groove in the midline, oriented sagittally, so that the pulmonary artery can be visualized on the left and descending aorta toward the right. PDA is visualized in between the two great arteries.
Ductal view (high left parasternal view)
The probe is placed in the sagittal view above the level of parasternal short-axis (PSAX) view. Then, it is tilted leftward and anterior from the main pulmonary artery (MPA), a little above the origin of branch pulmonary artery, and the duct is visualized to the left. This view is the most accurate for getting the ductal size. The use of color Doppler is not recommended while measuring the duct as it overestimates the size of the duct.
Parasternal long axis
Moving the probe from the classic parasternal long-axis position to anteriorly toward the pulmonary artery can help visualize the PDA.
Doppler of the abdominal aorta may show flow reversal in diastole, which may be an indirect assessment of runoff through the PDA into the pulmonary artery.
| Cardiac Morphology|| |
TTE provides information about overall cardiac anatomy. Whether the management will be along the single ventricle pathway or biventricular pathway, TTE plays a vital role in decision-making and discussing about the treatment options with guardians.
The management of duct-dependent pulmonary blood flow has shifted toward selective PDA stenting, for example, in PA-IVS and expected two ventricle patients with antegrade pulmonary blood flow as they have favorable PDA anatomy., However, Ratnayaka, et al. suggest PDA stenting universally for all ductal-dependent cyanotic newborns.
Similarly, few studies consider the existence of aortic atresia, serious noncardiac anomalies, low body weight (<2.5 kg), an intact or restrictive atrial septum, prematurity, and poor ventricular function in HLHS and its variants as an indication for hybrid procedure for stage-I palliation which includes PDA stenting. However, many centers consider all neonates with HLHS and its variants for hybrid procedures.,
| Ductal Anatomy|| |
Unlike isolated PDA, ductus in cyanotic congenital heart disease (CHD) varies in origin, shape, and insertion onto branch pulmonary artery. TTE helps in delineating all these details which eventually help in deciding vascular access for PDA stenting procedure.
PDA in duct-dependent cyanotic CHD can arise from the ascending aorta, the undersurface of the aortic arch, arch vessels (subclavian artery and the innominate artery), and descending aorta. Ideally, the closest and the straightest site should be used to gain vascular access for PDA stenting.
Ductus arising from proximal descending aorta has a normal course such as conventional PDA and is seen with tricuspid atresia or PA-IVS. These ducts are more suitable for stenting through transfemoral access.,
Ductus arising from the undersurface of the arch also referred to as “vertical PDA” has a more complex anatomy and is seen with TOF-PA, and other forms of pulmonary atresia including TGA with ventricular septal defect (VSD) and single-ventricle physiology. These ducts are approached from transaxillary route or carotid artery surgical cut-down.,
Axillary arterial technique on the ipsilateral side just opposite to the duct insertion is achievable for stenting a vertical PDA in neonates. Carotid artery access prevents the complications of femoral artery thrombosis in higher-risk infants, such as small neonates weighing <2.5 kg, or after the failure of the femoral arterial approach in a vertical PDA. Studies have shown that percutaneous carotid artery access is also safe even in small preterms.
For ductus arising from innominate artery, subclavian artery, or ascending aorta, access from the groin (femoral artery or vein [in the presence of a VSD]) or umbilical artery will be favorable.
On TTE, duct can be straight or tortuous. PDA anatomy is classified by angiography as straight (type 1), mildly tortuous (type 2, one turn in ductus), or severely tortuous (type 3, multiple complex turns in ductus).
Straight duct with short course and wide ampulla resembling conventional duct that tapers down to a constricted pulmonary end inserting onto the dome of MPA as seen with PA-IVS are favorable for stenting [Figure 1].
|Figure 1: Parasternal short axis view showing the constricted pulmonary end of the patent ductus arteriosus (arrow). Right pulmonary artery can be visualized in the view (*)|
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Most ducts arising from the undersurface of the aortic arch taper down, frequently forming kink near the insertion point on the pulmonary artery (left pulmonary artery in the left-sided arch) with a tight constriction. In few cases, duct can have less vertical take-off and can be elongated or tubular with a more tortuous course close to the pulmonary end. This anatomy is challenging for ductal stenting because of difficulty to cross, variation in ductal configuration poststretching with guidewire, and inaccurate measurement of the ductal length.
In <5% cases, ductus can originate from the subclavian artery (left subclavian in left arch or right subclavian in right arch), coursing down roughly perpendicularly to join the pulmonary artery, in a manner similar to a BT shunt. The site of insertion is typically severely constricted.
Although many studies have shown that PDAs that have >2 curves are not amenable for ductal stenting,, Ratnayaka, et al. consider this a relative contraindication, particularly for units with poor experience in stenting the highly tortuous duct.
Various ductal morphologies (including both favorable and unfavorable for ductal stenting) are depicted in [Figure 2].
|Figure 2: (a-c) The ductal morphologies favorable for stenting. (d) This has associated pulmonary coarctation and is not the ideal case for stenting|
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Ductal length is important for choosing the right size stent. Although stent size selection is based on duct length acquired during angiograms when performing the procedure, measurements on TTE provide a rough estimate of the same.
Ideally, the stent should cover 1–2 mm distal to the pulmonary artery end of the duct and extend only 1–2 mm proximal to ductal ampulla. Selection is easier when PDA is straight but in case of tortuous ducts, ductal length is reconfirmed when duct gets stretched after it has been crossed using a guidewire.
| Connection to Pulmonary Artery and Associated Pulmonary Coarctation|| |
As discussed earlier, straight ductus arteriosus inserts onto the dome of MPA which is suitable for stenting [Figure 3]. On the other hand, duct morphology in TOF-PA or in other forms of pulmonary atresia with complex univentricular defects is tortuous and inserts onto the proximal branch pulmonary artery (left pulmonary artery in the left-sided arch), with significant constriction (“pulmonary coarctation”), resulting in distortion of the proximal pulmonary artery [Figure 4].,,
|Figure 3: Parasternal short axis view showing confluent branch pulmonary arteries without any evidence of pulmonary coarctation. Patent ductus arteriosus (arrow) can be seen inserting into the roof of the main pulmonary artery|
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|Figure 4: Suprasternal view showing patent ductus arteriosus (*) from the undersurface of the aortic arch (Ao) and inserting into the proximal left pulmonary artery (LPA) with coarctation of the distal end of LPA (arrow)|
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As per the American Heart Association 2011 guidelines for catheterization in pediatric cardiac diseases, ductal stenting should not be performed in an infant with cyanotic CHD who has obvious proximal pulmonary artery stenosis in the vicinity of the ductal insertion (class III, level of evidence C). Alwi and Mood consider branch pulmonary artery stenosis as an absolute contraindication for ductal stenting. They reported worsening of branch pulmonary artery stenosis with PDA stenting. However, few studies have shown that stenting in these subsets is possible and has no subsequent progression of the stenosis.,
Visualizing the pulmonary end of PDA is important to note because if there is a stenosis at the pulmonary artery end then, stent has to be deployed to cover the entire segment of pulmonary coarctation and the duct. Assessment by TTE helps to layout these details which can be confirmed on angiography.
| When to Stop PGE1?|| |
Reevaluation of the duct by TTE 4–6 h before the procedure is important to look for ductal constriction, in neonates who are on PGE1 infusion. Aim oxygen saturations around 75%–80% and ductal waist of 2.5–3 mm. PGE1 should be reduced or discontinued if the ductal waist is more than 3 mm. PDA must constrict before procedure otherwise there are higher risk of stent migration.
| Patent Ductus Arteriosus Stenting as Part of Hybrid Procedure in Hypoplastic Left Heart Syndrome|| |
Gibbs et al. first described a hybrid approach, i.e., combined surgical and interventional approach, in neonates with HLHS in 1993. This included bilateral pulmonary artery banding, surgical or interventional atrial septectomy, and ductal stenting as stage-I palliation. Although initial results were not encouraging, subsequent series with slight modification in the technique improved outcomes of the hybrid procedure.,
TTE not only assists in PDA stenting but also aid the interventionist for balloon atrial septostomy (BAS) in HLHS patients. BAS may also be required for single-ventricle lesions with a restrictive patent foramen ovale precluding adequate mixing of systemic and pulmonary venous blood [Figure 5]. Umbilical or femoral vein can be used for this procedure. Septostomy catheter will directly enter the inferior vena cava and then into the right atrium, which can be visualized on TTE in subcostal sagittal view [Figure 6]. The catheter should go almost straight into the left atrium (LA) if angled correctly [Figure 7]. The balloon is then gently inflated using saline and it's position is reconfirmed on TTE [Figure 8]. The operator should be vigilant about balloon position and avoid injury to the mitral valve or the pulmonary vein. Finally, the balloon is placed abutting the atrial septum and then “jerked” across the septum to tear open the restricted opening. The defect size and the shunt across it are then assessed on TTE [Figure 9]. In case of undesirable outcome or if the shunt seems restricted, the procedure can be performed again.
|Figure 5: Subcostal bicaval view showing the restrictive opening of the patent foramen ovale (arrow) with right-to-left shunt in a child with pulmonary atresia with intact interventricular septum. LA: Left atrium, RA: Right atrium|
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|Figure 6: Subcostal bicaval view showing the septostomy catheter (arrow) being passed through the inferior vena cava (*) and into the right atrium. LA: Left atrium, RA: Right atrium|
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|Figure 7: Subcostal bicaval view showing the septostomy catheter (arrow) being passed through the inferior vena cava and across the patent formaen ovale into the left atrium. IVC: Inferior vena cava, LA: Left atrium, RA: Right atrium|
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|Figure 8: Subcostal bicaval view showing the inflated balloon (*) of the septostomy catheter positioned in the left atrium. IVC: Inferior vena cava, LA: Left atrium, RA: Right atrium|
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|Figure 9: Subcostal bicaval view showing a wide open atrial septal communication with laminar right to left shunt across it (*). LA: Left atrium, RA: Right atrium|
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| Intraprocedure (Patent Ductus Arteriosus Stenting) Assessment|| |
TTE can also help to confirm the position of stent just before deployment to ensure that the stent has covered the entire length of the duct including the aortic and pulmonary ends [Figure 10], [Figure 11], [Figure 12]. If the ductal tissue is not covered properly this can lead to constriction and eventually pulmonary hypoperfusion. In case of persistent desaturation after deploying the stent, one should assess for complications such as discrete ductal constriction, stent occlusion, or jailing of the pulmonary artery, using TTE.
|Figure 10: Parasternal short axis view showing the patent ductus arteriosus being crossed with a wire (arrow)|
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|Figure 11: Parasternal short axis view showing the stent (arrow) being positioned across the patent ductus arteriosus and well beyond the pulmonary end into the main pulmonary artery|
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|Figure 12: Parasternal short axis view showing the aortic end of the stent (arrow) being positioned well into the aorta with flow from aorta into the stent. Ao: Aorta|
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| Postprocedural Assessment|| |
Systemic arterial saturation after ductal stenting will improve and should be around 85%. The evaluation of the stent position, branch pulmonary artery, and the ventricular function is essential after the procedure. Tortuous ducts are prone for stent migration and in ducts with associated pulmonary coarctation, jailing of the pulmonary artery can complicate outcomes. An echocardiogram postprocedure will provide all these details which can be used for comparison on follow-up.
| Conclusion|| |
TTE is an excellent tool to provide essential fundamental information regarding the duct-dependent lesions. It not only provides distinct details about the duct morphology but also aids the interventionist to formulate a road map for ductal stenting as well as provides imaging assistance during the procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]