Afrikh Kawtar1, Nihat Kalay1,

1Erciyes university hospital, Kayseri, Turkey

Because of its relatively silent nature, The PDA may be asymptomatic, and sometimes diagnosed incidentally in adulthood when a murmur is auscultated. Contrariwise, in some cases, symptoms related to PAH or congestive heart failure are found. For this reason, many patients do not undergo PDA closure until they develop severe PAH.

The PDA closure is the main treatment and can be surgical or percutaneous. However, the presence of pulmonary hypertension brings a lot of limits to this procedure, with a risk of pulmonary hypertensive crisis, or even acute right heart failure.

In this report, we would discuss how to confirm the reversibility of pulmonary vascular disease using a trial balloon and therefore predict the feasibility of permanent closure of the PDA, and set example with a 29 years old man, admitted for transcatheter closure of a large PDA with severe pulmonary hypertension.

The 29 years old man has been admitted to our clinic with complaints of shortness of breath. Physical examination revealed a continuous murmur in the upper left sternal border with no cyanosis or clubbing. The transthoracic echocardiogram demonstrated a large PDA with continuous flow and left to-right shunt with enlarged left heart cavities.The patient was diagnosed then as a PDA case with severe pulmonary hypertension and was planned for cardiac catheterization with possibly percutaneous closure.

After a complete hemodynamic evaluation (Aortic pressure was 120/70 (70) mm Hg and pulmonary artery pressure (PAP) was 60/35 (45) mm Hg) and descending aortogram, trial occlusion with ballon was performed for 30 minutes to record the change in hemodynamic and clinical data. We have noticed that the pulmonary arterial pressure fell to 25 mmHg with no modifications in the aortic pressure, and without worsening of the signs and symptoms. A PDA occluder was then advanced to the site of the PDA.
Post deployment,  a second check aortogram with Pigtail catheter was performed and there was no trace of residual shunt of the ductus and no aortic obstruction or embolism. The PDA has been closed successfully.

The transcatheter PDA closure remains the procedure of choice in most cases. Different techniques using different devices are available. however, in patients complicated with pulmonary hypertension, a serious risk assessment is necessary, and the use of trial balloon occlusion allows to better assess the hemodynamic state of the patient and therefore predict the mid and long term evolution.