|Year : 2021 | Volume
| Issue : 2 | Page : 148-150
Left ventricular systolic dysfunction following percutaneous closure of patent ductus arteriosus: A case series
Balasubramaniyan Amirtha Ganesh, Arumugam Aashish, Selvaraj Karthikeyan, Srinivasan Giridharan, Palamalai Arun Prasath
Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
|Date of Submission||05-Feb-2021|
|Date of Decision||26-Apr-2021|
|Date of Acceptance||26-Apr-2021|
|Date of Web Publication||25-Aug-2021|
Dr. Srinivasan Giridharan
Department of Cardiology, 1st Floor, E Block, Mahatma Gandhi Medical College and Research Institute, Puducherry
Source of Support: None, Conflict of Interest: None
Transcatheter closure has become the standard treatment for patent ductus arteriosus (PDA) with excellent short- and long-term results. Left ventricular systolic dysfunction after closure is a known phenomenon rather than a complication with varied incidence documented in literature. Here, we report our experience of six cases who developed left ventricle (LV) dysfunction following percutaneous closure of PDA. Age, PDA size indexed to body surface area and pulmonary hypertension were the parameters noted to be associated with poorer LV function after closure. The LV dysfunction was transient and asymptomatic in most with delayed recovery noted with increasing age.
Keywords: Indexed patent ductus arteriosus size, patent ductus arteriosus, postclosure left ventricle systolic dysfunction
|How to cite this article:|
Ganesh BA, Aashish A, Karthikeyan S, Giridharan S, Prasath PA. Left ventricular systolic dysfunction following percutaneous closure of patent ductus arteriosus: A case series. Heart India 2021;9:148-50
|How to cite this URL:|
Ganesh BA, Aashish A, Karthikeyan S, Giridharan S, Prasath PA. Left ventricular systolic dysfunction following percutaneous closure of patent ductus arteriosus: A case series. Heart India [serial online] 2021 [cited 2021 Dec 4];9:148-50. Available from: https://www.heartindia.net/text.asp?2021/9/2/148/324609
| Introduction|| |
The treatment of choice for patent ductus arteriosus (PDA) is either transcatheter closure using detachable coils/duct occluders or surgical ligation based on size and ductus anatomy. Percutaneous closure has been shown to be safe and effective in terms of both short- and long-term outcomes compared to surgery., However, there are studies which have reported an immediate deterioration in systolic and diastolic functions of the left ventricle (LV) following closure., It is usually transient but may persist for few months in some. Here, we discuss our experience of LV systolic dysfunction following percutaneous PDA closure.
| Case Reports|| |
Six cases who developed LV systolic dysfunction underwent right heart catheterization to assess pulmonary artery pressures and subsequently, PDA device closure was done.
A 17-year-old female with a moderate-sized PDA measuring 5.5 mm was closed using Amplatzer Ductal Occluder (ADO) [Figure 1]. Her postprocedure LV ejection fraction (EF) dropped to 48% which recovered completely without any intervention by 2 weeks after discharge.
|Figure 1: Successful closure of patent ductus arteriosus with amplatzer ductal occluder device|
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A 1-year-old male infant with failure to thrive was diagnosed to have a large PDA (4.8 mm) with PH. He also had associated congenital complete heart block with ventricular rate of 70/min with the narrow QRS complex. It was percutaneously closed with ADO device. He developed transient mild LV dysfunction (EF = 42%) which settled by 48 h.
A 2-year-old female kid with a large PDA (4.5 mm) and moderate pulmonary hypertension underwent successful transcatheter PDA closure. Her postoperative LVEF reduced by 15%–54% without any symptoms and it normalized before discharge.
A 6-month-old female infant with a large PDA underwent closure. Post deployment EF dropped to 35%. Since she had features to suggest pulmonary venous congestion, she was treated with low dose dobutamine and intravenous diuretic for 24 h. By 48 h her EF recovered to preprocedure values.
The details about other two cases are provided in [Table 1].
|Table 1: Clinical, echocardiographic and catheterization details of patients with left ventricle systolic dysfunction|
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| Discussion|| |
This case series attempts to briefly highlight about the pattern of LV systolic dysfunction in patients undergoing transcatheter closure of PDA. A moderate to large-sized PDA increases preload to the LV which in turn increases its contractility, thereby a higher fractional shortening (FS) of LV is noted (Frank-Starling law). Closure of a hemodynamically significant PDA causes an abrupt decrease in preload and hence both LV contractility and FS drops. Before closure, the LV ejects blood both into the high-pressure systemic circulation and low-pressure pulmonary circulation through the PDA. Post closure LV empties into the high-pressure systemic circulation alone and hence its afterload increases which contributes to the reduced FS. This simultaneous reduction in preload and increase in afterload leads to systolic dysfunction of LV (preload-afterload mismatch).
[Table 2] provides information about the incidence and determinants of deterioration in systolic LV function post closure/ligation of PDA. Galal et al. did a seminal study on patients undergoing both percutaneous and surgical ligation of PDA in the relatively older population (mean age 3.8) and concluded that patients with a large PDA (taken as >3.1 mm in that study) had frequent drop in EF (60%) while those with small PDA (<3.1 mm) did not. LV function normalized in all except for one by 3–6 months. The fact pointed out by Galal et al. was that the incidence of LV dysfunction increases as age advances. This is in accordance with worsening of systolic performance noted after surgical correction in other long-standing volume overloaded conditions like aortic and mitral regurgitation., In our series only 2 out of 6 patients were aged ≤1 year.
|Table 2: Incidence and variables predicting postprocedural left ventricle systolic dysfunction|
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Kim et al. identified two preclosure variables namely a larger left to right (L-R) shunt and higher pulmonary artery pressure in predicting an increased likelihood of FS <29% postclosure in a group of children between 6 and 97 months. Pulmonary to systemic blood flow ratio (QP/QS) >1.60 and pulmonary to systemic pressure ratio (PP/PS) >0.32 had a sensitivity of 86% and a specificity of 84% for predicting FS to below 29% at postclosure. The results in our case series were similar to Kim et al. findings. Five out of six of our cases who had a postclosure drop in EF had pulmonary hypertension by RHC and a PP/PS >0.32 before intervention.
The size of the PDA attains significance only when it is corrected for age or more scientifically to one's body surface area. The indexed PDA size is an excellent parameter in predicting the occurrence of LV dysfunction. In a recent retrospective study by Kiran et al., the incidence of LV dysfunction increased from 2.8% in those with an indexed PDA size of <3 mm/m2 to 91.4% in whom the index was >9 mm/m2 irrespective of their age. Two third of our patients who showed a transient decline in LVEF (4 out of six) had an indexed PDA size ≥6 mm/m2.
The observations made from our case series can be used to predict the possible occurrence of post closure LV dysfunction so that appropriate counseling and allocation of resources can be done. Though LV function recovers completely, the duration it takes to normalize was more in the adults as compared to the younger subgroup. Another interesting fact noted was the asymptomatic nature of the LV dysfunction. Only one in our series had symptoms of pulmonary venous congestion necessitating administration of intravenous diuretics and low dose dobutamine.
| Conclusion|| |
LV dysfunction following trans catheter closure of PDA is a well-documented entity and it is mostly reversible. The key predictors are age, large defect (indexed size >6mm/m2) and a higher pulmonary artery pressure. The incidence of LV dysfunction increases as age advances and is mostly asymptomatic. Based on our observation LV dysfunction occurred even in those with moderate-sized defect (indexed PDA size <6 mm/m2) in adult patients. The drop in LV EF is transient and the recovery although complete may get prolonged as the age advances.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Balasubramaniyan AmirthaGanesh developed the concept, performed device closure and supervised the manuscript preparation. Arumugam Aashish was involved in patient care, literature search, data acquisition and analysis, manuscript preparation and editing. Selvaraj Karthikeyan was involved in data and literature search. Srinivasan Giridharan was involved in definition of intellectual content, literature search, data analysis, statistical analysis and manuscript editing. Palamalai ArunPrasath was involved in patient care and manuscript editing.
Kasi Rajabupathy – Cardiac Technician, Menagapriya – Staff Nurse.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]