NON INVASIVE PREDICTORS OF COIL VERSUS DEVICE CLOSURE IN PATIENTS UNDERGOING PERCUTANEOUS PATENT DUCTUS ARTERIOSUS CLOSURE

Abstract

Two-dimensional and Doppler echocardiography has long been used as the modality of choice for diagnosis of PDA and to assess suitability for tans-catheter closure before angiography [7]. A study to determine the noninvasive predictors of the mode of trans-catheter closure (i.e. device versus coil closure) has never been carried out based on the current literature. This study enrolled 66 patients who were referred for elective trans-catheter closure of their PDA in the Cardiology department – Ain Shams university hospitals where all patients were subjected to adequate history taking, proper physical examination, 2D and Doppler echocardiography, and catheterization to assess the following before closure: The pulmonary arterial end diameter, color flow width and extent in the main the pulmonary artery, the peak and diastolic Doppler gradients of flow across the duct, diastolic flow reversal across the descending thoracic aorta, the magnitude of shunting (Qp/Qs), left atrial (LA) dimensions and volume, the global left ventricular (LV) sphericity index, left ventricular dimensions, volumes and systolic function, and cardiac catheterization for assessment of the pulmonary arterial and aortic peak, mean and trough pressures and the angiographic measurement of the pulmonary end of the duct. Closure was achieved in all cases with either detachable coils or ADO devices. Patients were then divided into two groups according to the mode of closure; the device closure group (29 patients (43.9%)), and the coil closure group (37 patients (56.1%)). The clinical and echocardiographic characteristics of patients in both groups were compared and there were no statistically significant differences in all clinical parameters except for the presence or absence of murmur of PDA which showed a P-value of 0.02. As regards the echocardiographic and catheterization variables, there were no statistically significant differences between the 2 groups in all parameters except: End diastolic volume index (EDVI); t = 4.491, p = 0.0001, and end systolic volume index measured by M-mode (ESVI); t = 3.573, p = 0.0011. End diastolic volume index (EDV Mod. Index); t = 4.219, p = 0.0001, and end systolic volume index (ESV Mod. Index) measured by modified biplane simpson method; t = 3.073, p = 0.0036. Left atrial volume (LAV); t = 2.527, p = 0.0163, Left atrial volume index (LAVI); t = 3.677, p = 0.0009, and Qp/Qs; t = 3.929, p = 0.0004. Pulmonary end diameter measured from the SSN view; t = 9.614, p < 0.0001, pulmonary end diameter measured from the PSAX view; t = 9.820, p < 0.0001, color flow width; t = 9.218, p < 0.0001, color flow extent; t = 6.503, p < 0.0001 and diastolic flow reversal (DFR) %; t = 5.323, p < 0.0001. Pulmonary artery systolic pressure (PASP); t = 2.923, p = 0.0056, mean pulmonary artery pressure (MPAP); t = 2.676, p = 0.0098, peak pressure gradient across the duct (PDA PG); t = 2.385, p = 0.0205 and pulmonary end diameter measured by angiography; t = 10.69, p < 0.0001. The pulmonary end diameter measured from the suprasternal notch view and that measured from the parasternal short axis view showed a strong positive correlation with that measured by angiography as the gold standard (r = 0.9658 & 0.9627 respectively), p <0.0001 for both measurements. Of all the variables that showed statistically significant differences, the pulmonary end measured from the parasternal short axis view was the most independent predictor of determining the mode of trans-catheter closure by multiple regression analysis (P value <0.001) with a value greater than 2.61 mm in favor of device closure (rather than coil closure). Other independent predictors were: • The pulmonary end diameter of PDA measured from suprasternal view with a value greater than 2.5 mm in favor of device closure (rather than coil closure). • The color flow width of PDA jet with a value greater than 2.3 in favor of device closure. • The diastolic flow reversal time with a value greater than 96.6% of the total diastolic period in favor of device closure. • The color flow extent of PDA jet in the main pulmonary artery with a value greater than 70% of pulmonary artery length in favor of device closure. • The pulmonary to systemic flow ratio (Qp/Qs) with a value greater than 1.5 in favor of device closure. The study concluded that the selection between coil or device closure methods can be done on the basis of non-invasive anatomic and hemodynamic data obtained by 2D and Doppler echocardiography.