Acute stent thrombosis may complicate neonatal arterial duct stenting for reduced pulmonary blood flow. Thrombolytic agents recanalise the clot but may cause bleeding around the vascular sheaths and other sites. Since early thrombus is platelet mediated, intravenous platelet glycoprotein inhibitor like eptifibatide is likely to be effective, but rarely utilised in neonates. Ductal stent thrombosis treated with eptifibatide is reported.

Abernethy malformation connecting to a supradiaphragmatic vein may be missed due to their rarity or lack of awareness. Embryological reasons explain the involvement of the left superior caval vein in these connections.

A child undergoing routine transcatheter patent arterial duct closure developed severe transient ischemic changes in the electrocardiogram (Pardee waves) while the aortic retention skirt of the Amplatzer™ Duct Occluder was pulled against the duct orifice. The occluder was then released, and the delivery system was pulled back to inferior caval vein which led to electrocardiogram normalisation. Aortic root angiography showed a single coronary artery originating from the right sinus of Valsalva with the left coronary stem wedged behind the posterior aspect of the right ventricular outflow tract. We believe that the left coronary artery was compressed while applying tension on the occluder delivery system.

A neonatal ductal stent deployed in a straight short conical duct on second postnatal day migrated owing to inadequate ductal constriction. It was successfully retrieved using a larger balloon and redeployed in the duct again. Intravenous indomethacin prevented further stent migration. This is the first report of successful transcatheter retrieval and repositioning of a migrated expanded neonatal ductal stent.

Isolation of the subclavian artery is associated with “steal” of blood from the carotid circulation to the arm, through the circle of Willis and the vertebral artery. When associated with a patent arterial duct, there is an additional “steal” of blood from the arm to the lungs, through the arterial duct because of the lower pulmonary vascular resistance. When this combination manifests clinically with arm ischaemia on the side of the isolated subclavian artery, closure of the arterial duct will prevent the “steal” of blood from the subclavian artery to the pulmonary artery and may improve the blood flow to the arm. We report three patients with this unusual combination of the “steal” phenomenon that improved after interventional closure of the arterial duct. This report discusses the embryological basis of the defect, clinical and echocardiographic clues to diagnose this unusual anomaly, angiographic findings, and transcatheter management options.

We report a development of severe haemolysis after complete transcatheter closure of patent arterial duct. Aortography and echocardiography revealed no signs of residual shunt. Haemolysis occurred a day after the implantation. Aortography was performed and the extrusion of coil in aorta was evident. The extruded part of the coil was surgically removed. No signs of haemolysis remained.

Intermittent functional closure of a patent duct has been reported both clinically and echocardio-graphically. We describe the case of a 6-year-old with intermittent complete closure of a patent duct occurring during attempted transcatheter closure. Recurrence of clinical and echocardiographic signs prompted restudy. A patent duct of moderate size was demonstrated and successfully occluded by coil embolization. The interventional aspects of this unusual condition are discussed.

We have now achieved transcatheter occlusion of the patent arterial duct as a day-case procedure in 26 patients. In all but two, who were judged not to be appropriate for the device, implantation was successful. Most of the patients arrived in the hospital at 8:00 a.m. and had to wait for a mean time of 154 minutes until they were taken for cardiac catheterization. The procedure, performed under sedation in 25 patients and under general anesthesia in two, took a mean of 91 minutes. The children were then monitored for two hours in the recovery room. The interval From the time of arrival in the Unit until waking was a mean of 196 minutes. Then, from the time of waking, a mean of 123 minutes elapsed prior to discharge. Admission of the patient was necessary in three instances (11.1%). Two patients vomited and remained too drowsy for safe discharge. A third patient had either occlusion or thrombosis of the femoral artery and received an infusion of heparin which necessitated admission overnight. All three patients were discharged the following morning. Patients from outside Riyadh stayed overnight in Riyadh before they went home. One patient complained of non-cardiac chest pains a few hours after discharge and was subsequently sent home. Total occlusion, as judged by mean follow-up of 13 months (5–26 months) using color flow Doppler was achieved in 19 of the 24 patients (79!) in whom devices were inserted. All patients are well and there are no complaints concerning the procedure done on a day-case basis. We conclude that the day-case protocol for transcatheter occlusion of the patent arterial duct is a safe and cost-effective option for selected patients.

In recent years, the percutaneous closure of small and medium-sized patent arterial ducts has been achieved using occluding spring coils. We describe our experience in 33 patients with this technique using a snare to facilitate the procedure. All patients had a clinically apparent patent arterial duct and underwent an attempt at transcatheter closure at a mean age of 5.6 years. In one patient, the duct was a residual lesion following surgical ligation, and in three was residual following attempted closure with a Rashkind double-umbrella. The mean narrowest diameter of the ducts was 1.9 mm. The coil embolized in two of the first four patients, and subsequent to that experience we used a snare to improve delivery. Of the 33 patients, implantation was successful in 32 (97%) using one [29 patients] or two [two patients] coils and in one by a combination of a double-umbrella device and an occluding spring coil. The mean fluoroscopic screening time for the whole group was 26.5 minutes, this time decreasing to 18.5 minutes in the last 26 patients [p <0.05]. Color-Doppler echocardiogram performed the morning after placement of the coils has shown residual leaks in nine of 32 patients [28%]. At a mean follow-up of 7.6 months, repeated imaging has shown residual leaks in four of these patients [12.5%]. No patient had a residual continuous murmur immediately following occlusion. Based on our results, we conclude that occlusion of small to medium-sized ducts using coils appears to be effective. The use of a snare to hold and manipulate the coil as it is delivered improves both control of the coil and the accuracy of its placement.

Severe mechanical haemolysis occurred in an 11-month-old boy after implantation of the new Amplatzer duct occluder. Temporary balloon occlusion of the aortic ampulla was performed 4 days after the initial procedure leading to prompt abolition of the haemolysis.

We describe a newborn who had echocardiogaphic features of severe hypertrophic cardiomyopathy and duct-dependent systemic blood flow. Blood flow to the upper body could be maintained only by prostaglandin El, as in the case of hypoplastic left heart syndrome. Forward flow was gradually established from the left ventricle, and the patient weaned from prostaglandin El. Although the patient's mother had poorly controlled diabetes, the patient at 24 months of age shows residual but lessened ventricular hypertrophy and increased cavity size.

We present a 14-year-old female with a massive aneurysm of the pulmonary trunk occurring secondary to bacterial endocarditis of the patent arterial duct. Echo Doppler imaging, magnetic resonance and angiography confirmed the diagnosis. On intermediate follow-up after surgical correction, the echo studies and cardiac catheterization disclosed no residual lesions. The patient is now asymptomatic.

We describe a neonate with tricuspid atresia, absent pulmonary valve, right ventricular hypoplasia, small venrricular septal defect, left ventricular ourflow tract obstruction and a patent arterial duct. These finding were diagnosed by echocardiography and confirmed by cardiac catherterization and postmortem examination. This is a unique report of a functionally single ventricle variant of absent pulmonary valve syndrome and biventricular outlet obstuction.

Background: Arterial access is traditionally considered mandatory during coil occlusion of the patent arterial duct. Arterial access necessitates heparinization and carries the risk of femoral artery occlusion in small children. Methods and Results: Between July 1999 and May 2001, we attempted coil occlusion of patent arterial ducts in 104 patients without arterial access. The patients were aged from 3 months to 14 years. The median age was 2 years. They weighed 3–35 kg. The median weight was 9.8 kg. The duct diameter at pulmonary artery insertion was 1.8–3.5 mm. The patients were selected on basis of echocardiographic evaluation of duct diameter at pulmonary artery insertion and morphology of the ampulla. Doppler color flow imaging was used in the catheterization laboratory to confirm duct closure. Arterial access was required in 21 patients. The reasons included accidental puncture in 5 patients, failure to obtain venous access in 1 patient, aortic embolization in 3 patients, poor echo images in 2 patients, requirement for additional coils in 8 patients and, failure to cross the duct from pulmonary artery in 2 patients. The fluoroscopic time ranged from 2.2 to 20 min with a mean of 5.3 ± 3.8 min. Immediate closure was achieved in 98 patients and this included 79 of the 83 patients in whom arterial access was avoided. Color Doppler 3–24 h later showed residual flow in 2 patients. Four patients had new-onset left pulmonary artery turbulence with peak gradients below 5 mm of mercury. Coil embolization occurred in 6 patients and all coils were retrieved. Three-month follow up information was available for 78 patients. Small residual ductal leaks were seen in 4 patients, 2 of whom had leaks at 24 h. Two patients had recanalized their ducts. Conclusion: It is feasible to occlude small patent arterial ducts with coils using venous access alone in carefully selected patients with excellent immediate and short-term results.

Abnormalities of chromosomes 11 and 22 are associated with congenital cardiac disease and/or various syndromes. We present a patient with partial trisomy for the long arms of chromosomes 11 and 22, the result of a maternal balanced reciprocal translocation between these two chromosomes. Our patient was dysmorphic and had coarctation of the aorta, an atrioventricular septal defect with common atrioventricular junction and exclusively atrial shunting, patency of the arterial duct, supracardiac totally anomalous pulmonary venous connection, a single kidney, and tracheobronchomalacia. This patient is unusual in having extensive left-sided cardiac involvement, a feature not usually found in this condition.

Surgical treatment of cardiac defects in infants born with extremely low weight is sometimes required during the neonatal period. Optimal timing of these operations has yet to be clarified. With this in mind, we reviewed our experience of surgical treatment for 29 infants born with extremely low weight between 1994 and 2001. The main surgical procedures were ligation of a patent arterial duct in 26, a Brock procedure in 2, and ligation of an aorto-pulmonary window in 1 infant. The age at operation ranged from 5 to 57 days, with a median of 30 days, and weighed from 506 to 902 g, with a median of 710 g. There were no deaths. For the 2 infants undergoing the Brock procedure, the reduced systemic blood flow also necessitated closure of the arterial duct. For almost all the 26 infants with a patent arterial duct, indomethacin was given as the initial therapy, but the duct had not closed completely. Increased symptomatology just before the operation due to reduced systemic blood flow, such as decreased cerebral blood flow, decreased urine output, and intestinal ischemia, mandated the earlier surgical ligation (r = −0.576, p = 0.004). The youngest infant needed an infusion of catecholamines perioperatively to maintain stable hemodynamic conditions (r = 0.554, p = 0.003). In 4 infants, including the youngest 2, steroids were administered intravenously just after the ligation. Our results suggest that reduced systemic blood flow is the main indication of surgical repair in infants born with extremely low weight. Even for one in whom the supply of pulmonary blood is dependent on the arterial duct, early reconstruction of the pulmonary arterial pathways, using the Brock procedure, followed by ligation of the duct, is required. Acute adrenal insufficiency should not be overlooked just after the surgery, particularly in the youngest patients.

We report a 12-year-old girl who had multiple congenital cardiac lesions, specifically an arterial duct, left pulmonary arterial stenosis, an atrial septal defect in the oval fossa, and mild Ebstein's malformation of the tricuspid valve. Therapeutic transcatheter intervention was performed to stent the left pulmonary artery, occlude the arterial duct with a coil, and place a device to close the atrial septal defect. Subsequent to the catheterization, she complained of hoarseness, which was shown to be due to entrapment of the left recurrent laryngeal nerve between the coil used to close the arterial duct and the stent placed in the left pulmonary artery. Laryngoscopy confirmed paralysis of the recurrent laryngeal nerve.

Background: We have used the Amplatzer ductal occluder for transcatheter closure of large persistently patent arterial ducts, and used our experience to assess the safety and efficacy of the device in young children and infants. Methods and patients: We used the Amplatzer ductal occluder prospectively in 43 patients with large patent arterial ducts, reviewing our experience to identify any problems or complications. Results: The procedure proved successful in 42 of the patients. We achieved complete occlusion of the duct in 33 (78.5 per cent) of the patients on the day of insertion. In 6 additional patients, complete occlusion occurred 1 week to 6 months after the procedure. Trivial leaks persisted in 2 patients, while one had a significant residual leak. Problems were encountered in 7 patients. The procedure failed in one, a device was wasted in 2, pulled through in 3, while we experienced kinking of the long Mullins sheath, being unable to retrieve the device, in one patient. Minor complications occurred in 6 patients, finding flow at a peak velocity of 2.2 metres per second in the descending aorta in 2 patients, and at 2.5 metres per second in 2 further patients, and flow at 2.5 metres per second in the pulmonary arteries of two patients. One patient experienced a major complication due to excessive bleeding. Out of the 14 patients suffering adverse events, 13 weighed less than 10 kilograms. This rate of problems and complication in these patients weighing less than 10 kilograms was significantly higher than in the patients weighing more than 10 kilograms. Conclusion: Transcatheter occlusion of moderate to large patent arterial ducts with the Amplatzer ductal occluder device is safe and effective, with a high rate of complete occlusion. Problems and minor complications may be encountered in children weighing less than 10 kilograms. If the device is to be deployed completely in the ductal ampulla, and to avoid descending aortic obstruction, the size of the retention flanges of the occluder should not exceed the largest diameter of the patent arterial duct.