Transcatheter Patent Ductus Arteriosus Closure In Patients With Healed Vegetation- MTE ASMIHA.pptx

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1. TRANSCATHETER PATENT DUCTUS ARTERIOSUS CLOSURE IN PATIENTS WITH HEALED VEGETATION : A CASE SERIES DEPARTMENT OF CARDIOLOGY & VASCULAR DISEASES FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA Fairuz Syarifuddin , Ali N. Nasution, Tengku W. Ardini, Cut A. Andra, Anggia C. Lubis

2. INTRODUCTION However, until now there are no recommendations on whether or not transcatheter closure is applicable to patients with infective endocarditis and congenital heart defects. Infective endocarditis (IE) was a fatal complication of PDA and the most common cause of death (42-45%) before the antibiotic era . In one study, transcatheter closure was performed after the vegetations became invisible under ultrasonography (i.e., < 2 mm) . In most previously recorded patients with PDA and IE, the vegetation did not resolve with antibiotics and required surgical excision of the vegetation with concomitant PDA closure . Reference : Kouris NT, Sifaki MD, Kontogianni DD, Zaharos I, Kalkandi EM, Grassos HE, et al. Patent ductus arteriosus endarteritis in a 40-year old woman, diagnosed with transesophageal echocardiography. A case report and a brief review of the literature. Cardiovascular Ultrasound. 2003;1(1). Choi K-N, Yang T-H, Park B-S, Jun H-J, Lim S-J, Seol S-H, et al. A case with patent ductus arteriosus complicated by pulmonary artery endarteritis. Journal of Cardiovascular Ultrasound. 2008;16(3):90. Taha FA, Elshedoudy S. Transcatheter closure of a patent ductus arteriosus with healed vegetation: A case report. The Egyptian Journal of Hospital Medicine. 2022;89(1):4357–61 Ran B. Transcatheter closure combined with antibiotic therapies for patients with infective endocarditis and congenital heart disease. Clinical Medical Reviews and Case Reports. 2016;3(11).

3. C hief complaint of shortness of breath at rest and a history of fever since 1 week ago. Cough was found with serous sputum. History of easily fatigued since the age of 6 y.o . Has b een diagnosed with CHD since the age of 8 months old . HISTORY TAKING BP: 11 8 /60 mmHg, HR: 85 bpm , RR: 22 tpm Temp 36 o C SpO 2 99 % on all extremities C ontin u ous “ machinery-like ” murmur Crackles on the mid and lower right lung Cyanosis and clubbing finger were not found PHYSICAL EXAMINATION A 17 y.o . female admitted to the Emergency Department of Adam Malik Hospital CASE-01

4. WBC : 12,220 / mm 3 LAB FINDINGS PDA with a L-R shunt , ø 8-10 mm (PG 102 mmHg ) V egetation in the pulmonary artery , at the orifice of PDA , with ø 8x7mm . LA-LV Dilatation ( LVEDD 63 mm) LVEF 67% ( Teich ) TAPSE 22 mm ECHOCARDIOGRAPHY (9/2/2023) CASE-01

5. CASE-01 WBC : 12,220 / mm 3 LAB FINDINGS PDA with a L-R shunt , ø 8-10 mm (PG 102 mmHg ) V egetation in the pulmonary artery , at the orifice of PDA , with ø 8x7mm . LA-LV Dilatation (LVEDD 63 mm) LVEF 67% ( Teich ) TAPSE 22 mm ECHOCARDIOGRAPHY (9/2/2023)

6. Empirical antibiotics : A mpicilin IV and G entam ici n IV (2 weeks) Inpatient Therapy Possible IE (1 mayor + 2 minor) PDA, L-R shunt, ø 8-10 mm DIAGNOSIS Negative Blood Culture Clindamycin oral Cotrimoxazole oral (10 weeks) Outpatient Therapy CASE-01

7. A healed vegetation , ø 2x1 mm TEE EVALUATION (12/5/2023) CASE-01 AFTER 10 WEEKS OF ORAL ANTIBIOTICS

8. FR : 10.16 PAR : 0.46 WU PARi : 0.35 WU/ m2 RR Ratio : 0.012 SVR : 31.7 dynesec cm-5 PDA occluder size 14/16 mm T ype A PDA I sthmus ø 7.2 mm A mpula length of 28.6 mm CASE-01 AORTOGRA M & HEART CATHETERIZATION (23/5/2023)

9. FR : 10.16 PAR : 0.46 WU PARi : 0.35 WU/ m2 RR Ratio : 0.012 SVR : 31,77 dynesec cm-5 CASE-01 PDA occluder size 14/16 mm T ype A PDA I sthmus ø 7.2 mm A mpula length of 28.6 mm AORTOGRA M & HEART CATHETERIZATION (23/5/2023)

10. TTE EVALUATION(3/7/2024) Efusi pericard (-) Residual PDA (-), device insitu Normal LA-LV ( LVEDD 42 mm) No visible vegetation CASE-01 1 MONTH AFTER TRANSCATHETER PDA CLOSURE

11. H istory of frequent fevers since the last 2 months, with a tempreature reaching up to 40 o C . However, no fever was found within the last 10 days. H istory of cavities and recurrent toothaches. E as ily fatigue since the past year. HISTORY TAKING BP: 110/50 mmHg, HR: 83 bpm , RR: 18 tpm Temp 36.5 o C SpO 2 97 % on all extremities C ontin u ous “ machinery-like ” murmur Cyanosis and clubbing finger were not found PHYSICAL EXAMINATION A n 1 8 y.o . female admitted to the O utpatient Departement of Adam Malik Hospital CASE-02

12. 7.1 mm 5.4 mm PDA with a L-R shunt , ø 8- 9 mm (PG 77 mmHg ) V egetation in the pulmonary artery , at the orifice of PDA , with ø 7 x 5 mm . Multiple vegetation on the PA wall lining with ø 3 mm LA-LV Dilatation ( LVEDD 58 mm) Dilated MPA LVEF 72% ( Teich ) TAPSE 18 mm ECHOCARDIOGRAPHY (17/5/2023) CASE-02

13. Possible IE (1 mayor + 2 minor) PDA, L-R shunt, ø 8- 9 mm DIAGNOSIS Clindamycin oral Cotrimoxazole oral (10 weeks) Outpatient Therapy CASE-02

14. Vegetation still visible ø 6x4 mm TTE EVALUATION (25/7/2024) CASE-02 Planned for Surgery AFTER 10 WEEKS OF ANTIBIOTICS

15. No visible vegetation TTE EVALUATION (25/6/2024) BEFORE SURGERY CASE-02

16. FR : 5.69 PAR : 2.72 WU PARi : 2 WU/ m2 RR Ratio : 0.13 SVR : 20.6 dynesec cm-5 PDA occluder size 1 2 / 14 mm T ype A PDA I sthmus ø 6.1 mm A mpula length of 2 .6 mm CASE-02 AORTOGRA M & HEART CATHETERIZATION (1/7/2024)

17. CASE-02 PDA occluder size 1 2 / 14 mm T ype A PDA I sthmus ø 6.1 mm A mpula length of 2 .6 mm AORTOGRA M & HEART CATHETERIZATION (1/7/2024)

18. POST TRANSCATHETER CLOSURE TTE EVALUATION (2/7/24) Efusi pericard (-) Minimal residual PDA, device insitu Normal LA-LV ( LVEDD 48 mm) No visible vegetation CASE-02

19. DISCUSSION

20. PATENT DUCTUS ARTERIOSUS Reference : 1. Lilly LS. Congenital Heart Disease. In: Pathophysiology of heart disease: A collaborative project of medical students and faculty. Philadelphia, USA: Wolters Kluwer; 2020. p. 375–85. 2. Backes CH, Hill KD , Shelton EL, Slaughter JL , Lewis TR, Weisz DE, et al. Patent ductus arteriosus: A contemporary perspective for the pediatric and Adult Cardiac Care Provider. Journal of the American Heart Association. 2022;11(17). 3. Schneider DJ, Moore JW . Patent ductus arteriosus. Circulation. 2006;114(17):1873–82 PDA is the f ailure of the ductus arteriosus to close result ing in a persistent shunt between the descending aorta and the left pulmonary artery . Data among term infants suggest that PDAs are observed in ≈ 1 in 2000 , 5% to 10% of all CHDs . The clinical history varies from those who are completely asymptomatic to those with severe congestive heart failure or Eisenmenger’s syndrome .

21. PDA MANAGEMENT Reference : Park MK, Salamat M. Left-to-right shunt lesions. In: Park’s pediatric cardiology for Practitioners. Philadelphia, PA: Elsevier; 2021. p. 131–4. Schneider DJ, Moore JW . Patent ductus arteriosus. Circulation. 2006;114(17):1873–82. Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller G-P, et al. 2020 ESC guidelines for the management of adult congenital heart disease. European Heart Journal. 2020;42(6):563–645. Device closure is recommended as the method of choice when technically suitable. TRANSCATHETER Surgical ligation or division of the PDA is the treatment of choice for the rare very large ductus or with unsuitable anatomy . SURGICAL

22. PDA COMPLICATION Reference : Moore P, Brook MM. Patent ductus arteriosus and aortopulmonary window. In: Moss and adams ’ heart disease in infants, children, and adolescents: Including the fetus and Young Adult. 8th ed. Philadelphia, USA: Wolters Kluwer health - Lippincott Williams & Wilkins; 2013. p. 722–41. . Pulmonary Arterial Hypertension & Eisenmenger Syndrome Congestive Heart Failure Infective Endocarditis Aneurysm / Calcification Formation

23. Reference: Holland TL, Baddour LM , Bayer AS, Hoen B, Miro JM, Fowler VG . Infective endocarditis . Nature Reviews Disease Primers . 2016;2(1). Sa Ferreira P, Rodrigues P, Vale P, Casimoro A, Cunha F.Infective endarteritis complicating clinically silent patent ductus arteriosus . Acta Med Port 2011; 24( S3 ): 605-610 . Infective endocarditis ( IE ) is a multisystem disease that results from infection , usually bacterial , of the endocardial surface of the heart . When it involves the great vessels it is called infective endarteritis . INFECTIVE ENDOCARDITIS

24. Reference : Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC guidelines for the management of endocarditis. European Heart Journal. 2023 Aug 25;44(39):3948–4042. Mahajan OA, Agrawal G, Acharya S, Kumar S. Infective endocarditis in patient with uncorrected patent ductus arteriosus: A case report from Rural India. Cureus . 2022. Knirsch W, Nadal D. Infective endocarditis in congenital heart disease. European Journal of Pediatrics. 2011;170(9):1111–27. IE accounted for 66,300 deaths worldwide . Globally, i t is estimated that IE affects 13.8 cases per 100,000 p erson per year . The risk of childhood IE in CHD   is 4.1 cases /10,000 person- years . EPIDEMIOLOGY OF INFECTIVE ENDOCARDITIS IN CHD

25. PATHOGENESIS OF INFECTIVE ENDOCARDITIS IN CHD Reference : Knirsch W, Nadal D. Infective endocarditis in congenital heart disease. European Journal of Pediatrics. 2011;170(9):1111–27. E xposes underlying matrix proteins to thromboplastin and tissue factors . D evelopment of nonbacterial thrombotic endocarditis ( NBTE ) following platelet and fibrin deposition . Microbial adherence to thrombi . M icrobial colonization , invasion , and replication within lesions of thrombotic endocarditis , and embolization of areas affected by microbial thrombotic endocarditis . D amage of valvular or mural endocardium .

26. DUKES CRITERIA Reference : Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC guidelines for the management of endocarditis. European Heart Journal. 2023 Aug 25;44(39):3948–4042.

27. SURGICAL INTERVENTION IN ENDOCARDITIS Reference : Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC guidelines for the management of endocarditis. European Heart Journal. 2023 Aug 25;44(39):3948–4042. Shmueli , H., Thomas, F., Flint, N., Setia, G., Janjic , A., & Siegel, R. J. (2020). Right‐sided infective endocarditis 2020: Challenges and updates in diagnosis and treatment. Journal of the American Heart Association , 9 (15).