Percutaneous closure of a gigantic patent ductus arteriosus (PDA) with pulmonary hypertension with an atrial septal defect occluder in a 35-year-old woman

Abstract

Patent ductus arteriosus (PDA) is a common form of congenital heart defects (CHD); it counts for about 5–10 % of all CHD with an incidence of one in 2,500–5,000 live births [1]. In general, volume overload of the left atrium and left ventricle caused by the shunt and pulmonary vascular disease is clear indication for closure of the defect, whereas the risk of endocarditis and aneurysm formation of the PDA is under discussion. If untreated, a large PDA will regularly lead to pulmonary hypertension, heart failure and Eisenmenger syndrome [2]. PDA was the first example of congenital heart disease to be treated by transcatheter closure, and has now become an established form of treatment for the majority of patients with very few side effects. After the initial description in 1967 by Porstmann a large variety of different devices have been described (i.e., Rashkind device, Sideris buttoned device, various PDA coils, as well as specific PDA occluder devices such as the Amplatzer PDA-occluders [3]). Nowadays, percutaneous PDA closure has proved to be safe and effective with shortand long-term results comparable to surgical closure including those cases with mild and moderate pulmonary hypertension [2]. A common problem of all commercially available devices is the inability to close PDAs larger than 14 mm diameter based on manufacturer’s recommendations. Therefore, the majority of large PDAs are often closed surgically, although there are occasional case reports of very large PDAs closed with Amplatzer VSD or ASD Occluders [4, 5]. In the following report, we describe a case of successful transcatheter closure of an extremely large PDA measuring minimal 24 mm with an off-label use of a 24 mm Occlutech Figulla Flex ASD Occluder. A 35-year-old African woman (weight 77 kg, height 167 cm, BMI 27.6) was referred to our institution with an unknown heart disease for further evaluation. Clinically, she was in apparent heart failure (New York Heart Association III), transcutaneous oxygen saturation was 96 % and auscultation revealed a pronounced second heart sound and diastolic murmur. Her exercise performance measured by a 6-min walk test was 215 m only. The ECG revealed signs of right heart pressure load, and by echocardiography the estimated right ventricle pressure was 100 mmHg. This was caused by a very large PDA. It was noteworthy that the patient was human immunodeficiency virus positive. For further hemodynamic evaluation, the patient underwent a diagnostic catheterization. The PDA had a minimal diameter of 22 mm and an ampulla of 40 mm (see Fig. 1). The systemic arterial blood pressure was 115/66 mmHg (mean 85 mmHg) and the pulmonary arterial blood pressure 107/67 mmHg (mean 85 mmHg). The calculated pulmonary vascular resistance index (PVRI) was 12.6 Wood Units and the cardiac index (CI) 5.1 l/min/m. For further testing of the pulmonary vasoreagibility, the PDA was balloon occluded with a 30-mm sizing balloon. When the balloon was stabilized in the PDA, the minimal waist measured 24 mms. Thereafter, vasoreagibility of the M. Froehle (&) N. A. Haas C. Happel K. T. Laser Department for Congenital Heart Defects, Heart and Diabetes Center, North-Rhine Westphalia, Georgstrasse 11, 32545 Bad Oeynhausen, Germany e-mail: mfroehle@hdz-nrw.de