Percutaneous Pulmonary Artery Banding and Duct Occlusion in a Low-Birth-Weight Preterm Infant

Abstract

Background

Percutaneous pulmonary artery banding and patent ductus arteriosus closure in infants are minimally invasive, catheter-based alternatives to open-heart surgery for managing congenital heart disease with excessive pulmonary blood flow.

Case Summary

We present a preterm infant with intrauterine growth restriction (birth weight 1.4 kg), prolonged mechanical ventilation dependency, a large ventricular septal defect, and a widely open patent ductus arteriosus who underwent a complete transcatheter first-stage approach on the 35th day of life, comprising percutaneous pulmonary artery banding with modified microvascular plugs and patent ductus arteriosus closure with an Amplatzer Piccolo occluder, resulting in rapid clinical improvement and successful weaning from mechanical ventilation.

Discussion

The primary objective is to eliminate excess shunting and reduce pulmonary blood flow to manage heart failure and prevent irreversible pulmonary vascular disease.

Take-Home Message

This minimally invasive strategy offers a promising alternative to traditional surgical interventions, particularly for critically ill premature neonates, in whom the risks of open-heart surgery are magnified.

Visual Summary

Visual Summary.

Staged Percutaneous Bridge to Surgery

Clinical Challenge

A 1.4-kg preterm infant with a “double” left-to-right shunt from a 12-mm inlet VSD and a 4-mm PDA, leading to ventilator dependency. Percutaneous intervention (day 35): PDA occlusion (intraductal placement of an Amplatzer Piccolo occluder) and endoluminal banding with manually modified MVPs in the bilateral pulmonary branches to restrict flow. Outcome: Successful weaning from the ventilator within 5 days and definitive surgical VSD repair 100 days later. Take-home message: This minimally invasive approach serves as an effective bridge to surgery for fragile neonates by avoiding the risks of early open-heart procedures. APO = Amplatzer Piccolo occluder; DA = ductus arteriosus; DOL = day of life; GW = gestational week; MVP = microvascular plug; PA = pulmonary artery; PAB = pulmonary artery banding; PDA = patent ductus arteriosus; VSD = ventricular septal defect.

Clinical Presentation and History

A preterm newborn with intrauterine growth restriction exhibited signs of respiratory distress at delivery. Prenatally, polyhydramnios was observed, and the mother tested positive for Group B Streptococcus and Parvovirus B19. Delivery occurred at 33 weeks’ gestation by cesarean (birth weight 1.4 kg). Due to impending respiratory insufficiency, the patient was intubated and placed on mechanical ventilation. Surfactant was administered. In response to significant hypotension, inotropic support was initiated with a gradual dose increase. The patient was weaned from dobutamine after 6 days and from dopamine after 9 days. The DART (Dexamethasone: A Randomized Trial) protocol was initiated to prevent bronchopulmonary dysplasia. One convulsive episode was observed. Intraventricular hemorrhage was observed on echosonography.

Take-Home Messages

• •This case demonstrates that a complete transcatheter first-stage approach, using combined percutaneous PDA closure and bilateral pulmonary artery banding with modified MVPs, is a feasible and effective strategy for stabilizing critically ill preterm infants as small as 1.4 kg.
• •By providing immediate relief from pulmonary overcirculation without the risks of open-heart surgery, this minimally invasive technique serves as a successful bridge to definitive surgical repair while preserving the integrity of the pulmonary arteries.

Investigations and Imaging

On the 16th day of life, a heart murmur was noted, and echocardiography revealed a large inlet ventricular septal defect (VSD) and a widely open ductus arteriosus (PDA) with low-velocity left-to-right shunts. After 2 attempts at conservative medical PDA closure, the patient was transferred to our hospital for further treatment.

At admission, echocardiography confirmed the existence of an inlet VSD 12 mm in diameter and a PDA 4 mm in diameter with a left-to-right shunt (Figure 1). At our joint cardiology-cardiac surgery meeting, we decided to proceed with a complete percutaneous first stage.

Figure 1.

Preprocedural Echocardiographic Evaluation

Transthoracic echocardiography on admission demonstrating significant congenital defects. (A) Four-chamber view showing a large inlet ventricular septal defect measuring 12 mm in diameter, (B) High parasternal view showing a widely open patent ductus arteriosus (PDA), (C) Color Doppler confirmation of a continuous left-to-right shunt through the 4-mm PDA.

Management and Follow-Up

The intervention was performed on the 35th day of life (body weight [BW] 1.45 kg) under general anesthesia via the right femoral vein. A 4-F sheath was placed using the Seldinger technique after echocardiography-guided venipuncture. A right Judkins catheter was introduced into the descending aorta via the right ventricle and pulmonary artery, and through the PDA, using a Terumo hydrophilic 0.032-inch wire. Angiography (biplane RAO30 LL) in the PDA, the PDA Kirchenko E, length 13 mm, diameter about 3.8 mm, without localized constrictions, was visualized. The aortic end of the PDA was identified by contrast filling with nasogastric tube. The Amplatzer Piccolo occluder (APO-05-04) (Abbott Structural Heart) was placed intraductally via the TorqVue 4F system under transthoracic echocardiographic guidance. After detachment, the device assumed the “10 o'clock” position (Figure 2). Echocardiographically, no obstruction of the left pulmonary artery (LPA) or descending aorta was detected. After appropriate measurements of the pulmonary branches (right pulmonary artery diameter 5 mm, LPA 3.5 mm), we selected microvascular plug (MVP)-7Q for the right pulmonary artery and MVP-5Q for the LPA. The distal base of the triangle was sliced with a scalpel to fenestrate half a diamond (ie, 1 triangle). Two triangles were cut off on the MVP-5Q on opposite sides, and 1 on the MVP-7Q (Figure 3). The modified devices were placed in the pulmonary branches under transthoracic echocardiographic guidance. Adequate positioning of both devices, with restrictive anterograde flow, was confirmed by echocardiography and control angiography (Figure 2, Video 1). The intervention was without complications. Aspirin (5 mg/kg) and clopidogrel (1 mg/kg) were initiated after the procedure.

Figure 2.

Intraprocedural Angiography and Device Deployment

Sequential fluoroscopic stages of the transcatheter intervention. (A) Initial angiography identifying a Kirchenko Type E ductus arteriosus with a length of 13 mm and a diameter of 3.8 mm. (B) Successful intraductal placement of the Amplatzer Piccolo Occluder (APO-05-04). (C) Final result showing modified microvascular plugs deployed in both the left and right pulmonary artery branches to function as internal bands.

Figure 3.

Manual Modification of the Microvascular Plug

Ex vivo preparation of the microvascular plus 7Q for use as a pulmonary flow restrictor. The distal base of the device is manually fenestrated with a scalpel to form a half-diamond (1 triangle), thereby restricting anterograde pulmonary blood flow while preventing overcirculation.

The patient was extubated the following day but was reintubated 2 days later because of respiratory failure. The definitive weaning from mechanical ventilation was achieved 5 days after the intervention. The patient was discharged on the 53rd day of life and underwent successful surgical treatment 100 days after the index procedure. The VSD was entirely closed without the need for pulmonary branch angioplasty.

Discussion

An increase in pulmonary blood flow due to a “double” left-to-right shunt, combined with low plasma oncotic pressure and heightened capillary permeability in preterm infants, may lead to hemorrhagic pulmonary edema, decreased lung compliance, and deterioration in respiratory status, along with left ventricular overload and congestive heart failure. In addition, left-to-right shunting through a PDA and the steal phenomenon can reduce blood flow to the brain, kidneys, and intestines.1, 2, 3, 4, 5 Riko et al² found that in preterm infants, the presence of a VSD ≥2 mm increases the risk of PDA and is likely to cause severe premature complications, including pulmonary hemorrhage, intraventricular hemorrhage, and necrotizing enterocolitis. Large VSD and PDA induce “double” left-to-right shunt and lead to early pulmonary hypertension, so early interventions are necessary.^1,2 Our patient experienced signs of pulmonary overflow, with mechanical ventilation dependency, hypotension, and oliguria.

Treatment of large VSD and PDA in premature infants focuses on stabilizing hemodynamics, often initiated with diuretics and fluid management, or with PDA-specific ibuprofen/indomethacin to close the ductus.⁶ Traditional surgical approach, pulmonary artery banding (PAB) and PDA ligation, is the most acceptable in centers all over the world for managing severe congestive heart failure and high pulmonary blood flow, protecting the pulmonary vasculature before definitive repair. Surgical PAB in low-birth-weight (LBW) infants with a large VSD is a high-risk palliative procedure that is often essential to prevent irreversible pulmonary hypertension. Although advancements have been made, LBW infants (<2.5 kg) still experience significantly higher mortality (1.5-3.0 times) and morbidity compared with larger infants. Common complications include stenosis, band migration, infection, and residual VSD.⁷ Alternatively, the percutaneous method offers reduced invasiveness, shorter recovery times, quicker weaning from mechanical ventilation, and a lower risk of infection.⁸ Considering the patient's LBW (BW 1.45 kg), lengthy dependence on mechanical ventilation, and 2 failed conservative PDA closure attempts, the decision was made during our joint cardiology-cardiac surgery meeting to proceed with a complete percutaneous first stage. Although Kizilski et al⁹ reported successful percutaneous PAB in an infant with hypoplastic left heart syndrome weighing 1.4 kg, to the best of our knowledge, this is the first case of percutaneous PAB and PDA closure in the low-weight preterm infant (BW 1.45 kg) with a large VSD and significant PDA, who later underwent full surgical biventricular repair.

The primary objective is to eliminate excess shunting (PDA closure) and reduce pulmonary blood flow (PAB) to manage heart failure and prevent irreversible pulmonary vascular disease. Therefore, we initially performed PDA closure with an APO, followed by PAB using modified MVPs. Clinical studies have shown that the APO is now Food and Drug Administration–approved for PDA closure in patients weighing 700 g or more.¹⁰ In addition, the number of cases undergoing uneventful percutaneous PAB using modified MVPs is increasing.3, 4, 5 Manual modification of MVPs into pulmonary flow restrictors involves using a scalpel to fenestrate half a diamond (ie, 1 triangle) on the distal base. Regarding the triangle area, we fenestrated 2 triangles in 2 opposing diamonds on the MVP-5Q and 1 triangle on the MVP-7Q.⁵ There is no consensus on modifying the MVP. Kizilski et al⁹ proposed creating smaller holes, measuring 1 to 2 mm, to reduce the risk of overcirculation, using a scalpel and circular cautery. They also found that device oversizing, with appropriate fenestration sizing, might address migration issues while maintaining a suitable balance between pressure gradient and Qp:Qs (ratio of pulmonary [lung] blood flow to systemic [body] blood flow).⁹ Consequently, we use the MVP-5Q for an LPA of 3.5 mm and the MVP-7Q for an LPA of 5 mm. The Achilles' heel of this procedure remains device migration and collapse of the device's proximal portion, with subsequent pulmonary overcirculation. Subsequently, the procedure was guided by transthoracic echocardiography to enable adequate device positioning and flow monitoring, and to minimize radiation exposure.

This case report demonstrates the successful application of a complete percutaneous staged approach to manage a large VSD and PDA in a preterm infant. This minimally invasive strategy, involving percutaneous PAB followed by PDA closure, offers a promising alternative to traditional surgical interventions, particularly for critically ill premature neonates in whom the risks of open-heart surgery are magnified. The rapid clinical improvement and successful weaning from mechanical ventilation highlight the potential of this technique to achieve hemodynamically favorable outcomes while minimizing procedural morbidity in this fragile population. Further investigation and larger studies are warranted to establish percutaneous PAB and PDA closure as a safe and effective standard of care for similar high-risk preterm infants, potentially improving outcomes and reducing the need for complex surgical procedures.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Percutaneous Ductus Arterious Occlusion and Pulmonary Artery Banding Using Modified Microvascular Plugs in a Low-Birth-Weight Preterm Infant With Combined VSD and PDA