Patent ductus arteriosus(PDA): Treatments
Basically, a therapeutic approach to the opening of the patent ductus begins with determining whether the progress is to be followed by ongoing observation or by active intervention. 2) severe hypertension in the left heart due to overload of the left heart, 3) reversible pulmonary hypertension in the left atrium, 4) reversible hypertension in the past, If endocarditis is present, intervention or surgical closure is recommended. After closure, symptoms are alleviated and irreversible pulmonary hypertension can be prevented from progressing.
The incidence of irreversible severe pulmonary arterial hypertension is a contraindication to closure, which increases the risk of the procedure, does not improve survival after the procedure, and is associated with pulmonary arterial hypertension, Because it is necessary for.
It is not easy to decide whether to open a small-sized patent ductus arteriosus. Experts advise that it is beneficial to perform procedures regardless of size in the case of a patent ductus arteriosus that can stenose a continuous murmur. This is because the potential long-term benefits outweigh the risks of the procedure. There is a possibility of various complications including infective endocarditis over time, but the complication is not common in small ductal anatomy, but the possibility is not ruled out. In addition, recent technological developments have made it possible to minimize the risk of minimally invasive procedures. In adults, as well, if there is a small aneurysm present, percutaneous catheterization is recommended, even if the left cardiac load is not increased. If not, continuous follow-up at 3 to 5 year intervals is necessary. There is still controversy about the treatment of small ducts without audible murmur of the stethoscope.
In the case of follow-up without treatment, it is necessary to continuously evaluate whether the cardiac load increases or changes in the pulmonary artery pressure, and preventive antibiotics need not be used. When performing PDA closure, the age and physique of the patient or patient and the size and shape of the ductus arteriosus should all be considered.
(1) Patients should be treated with NSAIDs such as indomethacin and ibuprofen before the procedure.
(2) It is not recommended at term due to the effect of these NSAID drugs. Newborns weighing less than 5kg may have difficulty performing the procedure immediately, so if there are symptoms of heart failure (poor eating, no weight gain, difficulty in breathing), medical treatment should be performed. Medical treatment for heart failure is Digoxin, Furosemide.
(3) In patients with 5 kg or more, the procedure should be performed to directly close the patent ductus. The instrument closure through percutaneous catheterization is the most noninvasive, effective, cost effective and useful.
When performing instrument closure through cardiac catheterization, the type of instrument should be selected appropriately.
(1) It is advantageous in terms of safety and efficiency to use a coil in a small ductal tube of 3 mm or less. There may be some shorts left, but it can disappear in a few months.
(2) On the other hand, multiple coils must be inserted at the same time in the large ductal artery. In this procedure, the procedure is complicated and thromboembolism is increased. Amplatzer ductal occluder is the most commonly used, but in this case, weighing less than 6kg, and children under 6 weeks of age are restricted. ADO I and ADO II were approved for more than 6 months, over 6 kg, and PFM Nit-Occlud device was approved in children> 5 kg.
(3) If an excessively large device is used compared with the vascular structure of the infant, caution may be necessary because it may cause aortic coarctation.
Intervention may be constrained by small infants, and surgical closure may be a safe alternative. Using video assisted thorascopic surgery (VATS), surgery can be performed in these small children with minimal invasiveness. The procedure is summarized as follows: In infancy, through the 3rd intercostal space, in the elderly, through the 4th intercostal space, the incision is made and the patent duct is removed through the thoracoscopic view.
There are no established criteria for follow-up after treatment, but pediatric pediatricians generally follow-up from 6 months to 1 year without pulmonary stenosis or aortic occlusion. Observation without treatment requires careful monitoring of cardiac load and pulmonary vascular pressure as noted above, and treatment should be performed if changes occur. After the procedure, prophylactic antibiotics should be administered for 6 months until the device is completely covered with endothelial cells. Unlike cyanotic congenital heart disease, antibiotics need not be administered prophylactically to prevent infective endocarditis before dental procedures.
It should be noted that when using a stainless steel metal coil closure, there is a limitation in subsequent MRI imaging. ADO I, II, and PFM Nit-Occluders may be relatively safe to use MRI, but require a constraint. Limit magnetic field strength to less than 3T, magnetic field slope to less than 720G / cm, and specific average specific absorption rate to less than 2W / kg.
The incidence of irreversible severe pulmonary arterial hypertension is a contraindication to closure, which increases the risk of the procedure, does not improve survival after the procedure, and is associated with pulmonary arterial hypertension, Because it is necessary for.
It is not easy to decide whether to open a small-sized patent ductus arteriosus. Experts advise that it is beneficial to perform procedures regardless of size in the case of a patent ductus arteriosus that can stenose a continuous murmur. This is because the potential long-term benefits outweigh the risks of the procedure. There is a possibility of various complications including infective endocarditis over time, but the complication is not common in small ductal anatomy, but the possibility is not ruled out. In addition, recent technological developments have made it possible to minimize the risk of minimally invasive procedures. In adults, as well, if there is a small aneurysm present, percutaneous catheterization is recommended, even if the left cardiac load is not increased. If not, continuous follow-up at 3 to 5 year intervals is necessary. There is still controversy about the treatment of small ducts without audible murmur of the stethoscope.
In the case of follow-up without treatment, it is necessary to continuously evaluate whether the cardiac load increases or changes in the pulmonary artery pressure, and preventive antibiotics need not be used. When performing PDA closure, the age and physique of the patient or patient and the size and shape of the ductus arteriosus should all be considered.
(1) Patients should be treated with NSAIDs such as indomethacin and ibuprofen before the procedure.
(2) It is not recommended at term due to the effect of these NSAID drugs. Newborns weighing less than 5kg may have difficulty performing the procedure immediately, so if there are symptoms of heart failure (poor eating, no weight gain, difficulty in breathing), medical treatment should be performed. Medical treatment for heart failure is Digoxin, Furosemide.
(3) In patients with 5 kg or more, the procedure should be performed to directly close the patent ductus. The instrument closure through percutaneous catheterization is the most noninvasive, effective, cost effective and useful.
When performing instrument closure through cardiac catheterization, the type of instrument should be selected appropriately.
(1) It is advantageous in terms of safety and efficiency to use a coil in a small ductal tube of 3 mm or less. There may be some shorts left, but it can disappear in a few months.
(2) On the other hand, multiple coils must be inserted at the same time in the large ductal artery. In this procedure, the procedure is complicated and thromboembolism is increased. Amplatzer ductal occluder is the most commonly used, but in this case, weighing less than 6kg, and children under 6 weeks of age are restricted. ADO I and ADO II were approved for more than 6 months, over 6 kg, and PFM Nit-Occlud device was approved in children> 5 kg.
(3) If an excessively large device is used compared with the vascular structure of the infant, caution may be necessary because it may cause aortic coarctation.
Intervention may be constrained by small infants, and surgical closure may be a safe alternative. Using video assisted thorascopic surgery (VATS), surgery can be performed in these small children with minimal invasiveness. The procedure is summarized as follows: In infancy, through the 3rd intercostal space, in the elderly, through the 4th intercostal space, the incision is made and the patent duct is removed through the thoracoscopic view.
There are no established criteria for follow-up after treatment, but pediatric pediatricians generally follow-up from 6 months to 1 year without pulmonary stenosis or aortic occlusion. Observation without treatment requires careful monitoring of cardiac load and pulmonary vascular pressure as noted above, and treatment should be performed if changes occur. After the procedure, prophylactic antibiotics should be administered for 6 months until the device is completely covered with endothelial cells. Unlike cyanotic congenital heart disease, antibiotics need not be administered prophylactically to prevent infective endocarditis before dental procedures.
It should be noted that when using a stainless steel metal coil closure, there is a limitation in subsequent MRI imaging. ADO I, II, and PFM Nit-Occluders may be relatively safe to use MRI, but require a constraint. Limit magnetic field strength to less than 3T, magnetic field slope to less than 720G / cm, and specific average specific absorption rate to less than 2W / kg.
