Les cardiopathies congénitales de formes diverses représentent un peu moins de 1% des naissances chaque année dont le diagnostique anténatale est fait entre le 10 et le 20 Semaine de grossesse. Il peut s’agir de communications entre les ventricules et / ou les oreillettes, des sténoses au niveau des valves, erreurs de branchement, occlusion au niveau des vaisseaux… ces différentes anomalies peuvent être parfois associes,on parle alors de cardiopathie complexe.

 

                                                              

 

La cause de ces malformations cardiaque est parfois soit génétique, soit infectieux (rubéole,  toxoplasmose, alcool chez la mère.) soit médicamenteux, pollution ….

 

                        

 

Après la naissance, le diagnostic est habituellement fait durant les premières années de vie suite a un souffle cardiaque entendu par le pédiatre lors de  l’auscultation thoracique soit à un problème d’insuffisance cardiaque, ou a une cyanose (un déficit d’oxygénation qui entraine une coloration grise bleute de la peau.)

 

Chez certains Bébé dont la cardiopathie est complexe le traitement est dans la  plupart des cas  chirurgicale .l’autre option consiste a intervenir par   

 

Cathétérisme  Interventionnel intracardiaque : le médecin introduit un petit cathéter (tuyau) dans l’artère ou la veine fémoral du BB par lequel il va faire cheminer des valves et autres stents afin d’aller dilater ou obstruer des vales ou des  

 

 vaisseaux, fermer des communications etc.

 

Ces deux techniques  complémentaires peuvent être associées.                                         

 

Il arrive que l’on réalise plusieurs interventions par cathétérisme interventionnel ou par  Chirurgie.

 

Avec ces techniques on arrive sauver, guerir et améliorer la qualité de vie des patient qui naissent avec une cardiopathie.

 

              

 

                                                                    Dr Dany YOUSSEF

 

 

 ----------------------------------------------------------------------------------------------------------------------------------------

 

Successful Percutaneous Closure of an Aneurismal PDA
 by Aortic Grafting and ASD Closure Device Implantation

D.Youssef1, P.Nassar2, Z.Neghawi3, R.Hamdan2, B.Choumar3, H.Mansour2, M.Saab4

1Pediatric Cardiology Department, 2Cardiology Department, 3Radiology Department, 4Cardiac Surgery Department

Beirut Cardiac Institute, Al Rassoul Hospital, Beirut, Lebanon

 

Background

Patent ductus arteriosus (PDA) represents 5 to 10% of all congenital heart disease. It is usually diagnosed and treated in childhood or early adulthood. When left untreated it may lead to heart failure, severe pulmonary hypertension and Eisenmenger syndrome. In older patients, a PDA could be aneurismal, which render its surgical closure hazardous due to the vulnerability of its wall and the associated aortic calcifications, yielding a high risk of rupture. We report a case of lady with such PDA that was percutaneously treated with success.

Clinical Case

A 63 year old woman was referred to our institution for the closure of her aneurismal PDA.Aneurismal PDA She is known to have hypertension, coronary artery disease on medical treatment, chronic renal failure on hemodialysis and COPD requiring home oxygen therapy.

She presented with acute pulmonary edema complicated by cardio-respiratory arrest during her dialysis session. After successful resuscitation and stabilization, her cardiology work-up revealed on echocardiography, a mildly dilated left ventricle with normal systolic function, a mild aortic stenosis, with no other significant valvulopathy and mild pulmonary hypertension. Her coronarography showed a single significant stenosis of the right coronary artery, that was later stented.

A chest angio-CT was performed, revealing pulmonary atelectasis, bilateral pleural effusion and a large aneurismal PDA (figure 1) measuring 35x31mm with a peri-ductal hematoma that suggests acute fissuration. The aortic wall had scattered calcifications, parietal infiltration without aneurism. The left sub-clavian artery was stenotic, and the left vertebral artery was patent.

Intervention and Evolution

We first implanted an aortic stent graft via trans-femoral arterial access. A 16mm Amplatzer ASD (Atrial Septal Defect) occluder device was than implanted via the femoral vein, in order to close the pulmonary artery orifice of the PDA. The control angiography showed only mild residual shunting and the control Angio-CT (figure 2) confirmed the good positioning of the devices.

An occlusion of the left sub-clavian artery was detected, and required to be managed surgically by a salvage carotido-sub-clavian bypass under general anesthesia with a good clinical evolution. A second control CT-Scan (figure 3), done 6 months later, confirmed the stability of the prostheses position and the complete involution of the PDA

Discussion

The endovascular approach has been proved successful in the treatment of PDA. In our case, a classical PDA occluder or the use of coil embolotherapy is not adequate, due to the large diameter of the duct, since these techniques are indicated in smaller PDAs (less than 12mm in diameter). Besides, the use of these devices is considered highly risky in our case, because the wall of the aneurismal duct is thin and prone to dissection and perforation. Thus, we used an Amplatzer ASD closure device to close the pulmonary orifice combined with a covered aortic graft stent to completely isolate the PDA. The positioning of the later is often complicated by the covering of the orifice of the left sub-clavian artery. This was the case in our patient, and it was followed by surgical implantation of a carotido-sub-clavian graft. The evolution was otherwise smooth and free of complications

Conclusion

We reported a case of an aneurismal PDA closure, using an aortic stent graft and an ASD Amplatzer closing device to cover both orifices of the duct. This technique is safe , reliable and simple when used  in an elderly patient.

To our knowledge this is the first  time such an approach is described to treat these kind of patients.