Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 55 years old non diabetic, non-hypertensive female presented with progressively worsening dyspnoea (NYHA-Class-III) for one year. Swelling of legs for 6 months. Infancy and childhood periods were uneventful. No h/o suggestive of rheumatic fever.No cyanosis, clubbing or differential cyanosis. Cardiomegaly with grade-III parasternal heave. Palpable P2. Grade III/VI harsh ejection systolic murmur peaking in intensity around S2 in left infraclavicular region. Grade II/VI pansystolic murmur at apex.
Relevant test results prior to catheterization
Routine Laboratory parameters: Hb-9.6gm%. Serum Creatinine- 1.2mg%. Serum bilirubin -1.9mg%. SGPT-96IU/L.
ECG- Sinus Rhythm. LBBB. LVH.
Echocardiography- Eccentric LVH with global ‘LV’ wall hypokinesia and ‘LVEF’ 35%. Thickened mitral and aortic valve leaflets with grade-3 mitral regurgitation and grade-2 aortic regurgitation. 6mm patent ductus arteriosus with L-->R shunt. PASP-50mmHg.
Relevant catheterization findings
Coronary Angiography: Normal coronary arteries.
Aortic Arch Angiography: Patent Ductus Arteriosus measuring 6 mm at aortic end.
Right femoral venous and left femoral arterial access. Arch angiogram taken with 5F Pigtail catheter and ‘PDA’ identified (6 mm at aortic end). Both straight and J-tipped Terumo wires were tried to negotiate through ‘PDA’ via pulmonary arterial route with different catheter back up (viz. MP & JR). But all attempts were failed probably due to distorted and tortuous anatomy. A 5F SIM catheter was introduced through left femoral arterial route and engage into the ‘PDA’ through aorta. A Terumo wire introduced through it and crossed into the pulmonary artery side. Wire snared and pulled back through right femoral vein. A ‘ADO’ device delivery sheath was placed across the ‘PDA’ into the aorta. An ‘ADO-II’ DEVICE (10/18) deployed successfully. Final aortic arch angiogram taken and no flow through ‘PDA’ could be seen but a non-flow limiting dissection in descending thoracic aorta was noted. All peripheral pulses were normal.
Combinations of congenital and rheumatic heart diseases are not uncommon in our developing countries. Late clinical detection and associated ventricular systolic dysfunction is also common. Tortuous anatomy of ‘PDA’ is a difficult subset for device closure. Local vascular injury due to difficult catheter manipulation can occur and needs proper treatment and follow up.