Utility of Follow-Up Echocardiograms in Uncomplicated PDA Device Closures Performed During Infancy.
Van Pelt E, Reo R, Lovelace C, Eshelman A, Beckman B, Chisolm J, Boe B, Backes C, Cua CL.Cardiol Ther. 2022 Dec;11(4):523-530. doi: 10.1007/s40119-022-00278-2. Epub 2022 Sep 8.PMID: 36074260 Free PMC article.
Take Home Points:
- Device closure of PDAs has replaced surgical ligation as the preferred method including in extremely low birthweight infants
- Complications/echocardiographic concerns were not seen in long term follow up if they were not seen on the first follow up echo at least 3 months after device closure
- This should be further evaluated as it has the potential to decrease the number of what appears to be unnecessary echocardiograms
Commentary from Dr. Ryan Romans (Kansas City, MO), section editor of Congenital Heart Disease Interventions Journal Watch:
Transcatheter device closure has replaced surgical ligation as the preferred method of closing hemodynamically significant patent ductus arteriosus (PDA). This now includes extremely low birthweight infants with the Amplatzer Piccolo Occluder receiving FDA approval for device closure in patients 700 grams and larger. Complications from this procedure include vascular injury, tricuspid valve injury, device embolization, left pulmonary artery (LPA) stenosis, and descending aorta (DAO) stenosis. There complications are typically discovered shortly after device placement. It is unknown if infants who undergo device closure are at risk of development of LPA or aortic stenosis in the longer term. The consensus guidelines on appropriate use criteria of imaging in the follow up of congenital heart disease recommend screening echocardiograms every 5 years after the first 2 years in patients who undergo device closure of PDAs (ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease). This study sought to determine the utility of this follow up imaging.
A retrospective review was performed of all infants (1 year of age or younger) who underwent PDA device closure from 1/2002-6/2020 and did not have any concerns on follow up echocardiogram at least 3 months from device closure. Patients were excluded from analysis if they had other significant congenital heart disease, had at least moderate tricuspid regurgitation on the initial post device echocardiogram, had evidence of LPA and/or DAO stenosis (defined as echo velocity of 2 m/s or greater) on the echo 3 months post device, or did not have a follow up echo at least 3 months post device. 245 patients were reviewed with 147 meeting inclusion criteria. The average gestational age was 29.3 +/- 5.3 weeks, age at time of procedure 141 +/- 217 days, and weight at time of procedure 4.2 +/- 2.8 kg. There were no procedure related mortalities. 80 patients had an echocardiogram performed at least 3 months following the procedure and another at least 12 months after the procedure. There was a statistically significant decrease in LPA velocity, trend towards improvement in LV systolic function, and decrease in LV internal diastolic dimension with a mean follow up of >5 years. There was no change in the DAO velocity. No interventions for LPA stenosis or DAO stenosis were required.
This single center study shows that infants who undergo device closure of their PDA do not have any evidence of the development of LPA or DAO stenosis. This, along with results from a similar analysis in an older cohort (Narayan SA, Elmahdi E, Rosenthal E, Qureshi SA, Krasemann T. Long-term follow-up is not indicated after routine interventional closure of persistent arterial ducts. Catheter Cardiovasc Interv. 2015 Jul;86(1):100-4. doi: 10.1002/ccd.25912. Epub 2015 Apr 2. PMID: 25753890), suggest that the current recommendations for follow up echocardiograms in patients who undergo device closure of their PDA and have no/minimal sequela and are asymptomatic may not be necessary. This could decrease the use of resources and decrease overall costs in this patient population. However, additional longitudinal studies with longer follow up may be necessary to definitively prove this.
