Transcatheter patent ductus arteriosus closure in a neonate,a safer,feasible alternative to surgical ligation in low-resource settings: A case report

Introduction

Patent ductus arteriosus (PDA), a persistent vascular connection between the pulmonary artery and aorta, can lead to congestive heart failure, pulmonary hypertension, feeding difficulties, and growth restrictions in neonates. In low-income countries, surgical ligation has long been the standard owing to limited access to interventional cardiology services. However, it carries inherent risks such as vocal cord palsy, thoracotomy-related complications, and post-ligation cardiac syndrome. In contrast, transcatheter closure offers a minimally invasive, less traumatic, and more efficient solution. ¹ This has become an effective alternative to surgical ligation, even in neonates. Though surgical intervention remains common, especially in resource-limited settings, the availability of low-cost occluders and increasing expertise makes catheter-based closure more viable.

Case report

A 26-day term female neonate (birth weight: 3.5 kg) presented with poor feeding, failure to thrive, respiratory distress, and feeding intolerance. Clinical examination revealed tachypnoea (70 breaths/min), tachycardia (180 bpm), SpO₂ 90%–92% in room air, bounding peripheral pulses, a hyperdynamic precordium, a loud systolic-dominant continuous murmur best heard at the left upper sternal border, and hepatomegaly, all suggestive of congestive cardiac failure.

Transthoracic echocardiography demonstrated a large PDA with a continuous left-to-right shunt. Continuous-wave Doppler revealed a peak instantaneous gradient of 74 mmHg across the ductus, indicating a significant haemodynamic burden. The duct measured 3.2 mm at its narrowest point with a tubular (Krichenko type C) morphology. The left atrium and ventricle were dilated, with a left atrium: aorta ratio of 1.8 and an increased left ventricle internal dimension. The estimated right ventricular systolic pressure was ∼66 mmHg, consistent with moderate-to-severe pulmonary hypertension. Moderate mitral regurgitation with an eccentric jet, probably secondary to left heart volume overload, and moderate tricuspid regurgitation due to elevated right ventricular pressures were also noted.

The PDA closure procedure was performed under general anaesthesia. Femoral venous access was used for device deployment, and femoral arterial access for angiographic assessment. A 6/8 mm Cocoon Duct Occluder was selected and successfully deployed under fluoroscopic and echocardiographic guidance. Post-deployment angiography confirmed complete occlusion with stable device positioning. Pre- and post-procedure echocardiography is shown in Figure 1.

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Figure 1.

(A) Pre-procedural continuous-wave Doppler demonstrating high-velocity (4.31 m/s) left-to-right shunting across a large patent ductus arteriosus (PDA) with a peak pressure gradient of 74 mmHg, consistent with a hemodynamically significant duct. (B) Post-procedural Doppler showing markedly reduced flow velocity (2.13 m/s) and pressure gradient (18 mmHg), indicating effective PDA occlusion and improved pulmonary-to-systemic flow balance.

The neonate demonstrated clinical improvement with normalised oxygen saturation, improved feeding, and regression of hepatomegaly. Follow-up echocardiography at 48 h and 2 weeks confirmed complete closure, improved pulmonary pressures, and reduced mitral regurgitation. She was discharged in stable condition on the third postoperative day.

Discussion

Our case reiterates the safety and feasibility of transcatheter PDA closure in neonates, including in low-resource settings. With the increasing availability of appropriately sized occluders, this approach is emerging as a viable and preferable alternative to surgical ligation, even in extremely premature infants. ¹

Cocoon occluders (Fig. 2) are cost-effective, made of platinum-coated nitinol, and can deliver instrumentation through smaller sheaths, reducing vascular trauma in small neonates. ² In our case, it proved effective and safe, with no post-procedural complications. Newer devices, such as the Amplatzer Piccolo Occluder, offer additional technical advantages. Their ultra-low profile and pre-loaded delivery system allow for easier and more precise deployment, especially in premature neonates. ³ However, their high cost and limited availability in low-resource settings are barriers. Cocoon devices, while slightly more challenging to use, offer a balance between affordability and performance.

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Figure 2.

Cocoon Duct Occluder.

Pre-term neonates with haemodynamically significant PDAs are at increased risk of bronchopulmonary dysplasia, intraventricular haemorrhage, and prolonged ventilator dependence. Transcatheter closure, by facilitating early ductal elimination without thoracotomy or prolonged anaesthesia, reduces morbidity. Unlike surgical ligation, it avoids complications such as post-ligation cardiac syndrome, vocal cord paralysis, and hypotension. ⁴

Potential complications include minor dysrhythmias such as atrial or ventricular ectopics and atrial tachycardia, which typically resolve with minimal intervention. Minor vascular access problems such as haematomas are usually managed conservatively. More serious, rare events include vascular damage, device embolisation, and haemolysis, requiring close monitoring and prompt management. ²