HJAR Jan/Feb 2020

HEALTHCARE JOURNAL OF ARKANSAS  I  JAN / FEB 2020 41 the presence of a PDA continues to be as- sociated with worse outcomes, the avail- able therapies have proven of little benefit in improving those outcomes. A New Device Device closure of the patent ductus ar- teriosus in the cath lab has long been the standard of care for older patients with a PDA. Through the use of catheters, the ab- normal connection is closed by navigating through a small entry point into the blood vessels, rather than through a surgical in- cision. A number of tools are available for use in the cath lab, including vascular coils for smaller PDAs, and a variety of special- ly designed occluders for larger defects. While traditionally reserved for patients over a year of age, many centers have ex- plored whether the available technology could be used in smaller infants. A recent review of national experience in using these devices in infants showed an excel- lent success rate of more than 94 percent. However, major adverse events occurred in one out of every eight cases, most com- monly due to damage to the arteries, or blockage of other major blood vessels near the PDA. Due to these known limitations, a new device was approved by the FDA, and has been available to trained interventional pediatric cardiologists since last April. The Amplatzer Piccolo™ Occluder is the only Michael Angtuaco , MD Associate Professor of Pediatrics Arkansas Children’s Hospital and University of Arkansas for Medical Sciences Dr. Michael J. Angtuaco is a tenured associate professor of pediatrics in the section of pediatric cardiology at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital. A native of Little Rock, Dr. Angtuaco received an undergraduate degree in pre-professional studies and philosophy from the University of Notre Dame in 2001. He returned to Arkansas for medical school and received a medical degree from the University of Arkansas for Medical Sciences in 2005. He then studied pediatrics at Emory University in Atlanta, Georgia, completing his residency in 2008. He again returned home to Little Rock for a fellowship in pediatric cardiology at Arkansas Children’s Hospital, which he finished in 2011. He has also completed an advanced fellowship in interventional pediatric cardiology at the University of Colorado Denver and Children’s Hospital Colorado. Dr. Angtuaco has been a member of the faculty at the University of Arkansas for Medical Sciences since 2012. He serves as medical director of the Pediatric Catheterization Laboratory at Arkansas Children’s Hospital, and is also co-director of the Pediatric Pulmonary Hypertension Clinic. He is a fellow of the Society for Cardiovascular Angiography and Interventions (FSCAI) and the American Academy of Pediatrics (FAAP). His primary research interest is the evaluation of outcomes following both surgical and transcatheter interventions for congenital heart disease. device designed specifically for premature infants, and has now been successfully used to treat hundreds of infants around the world, even those weighing as little as two pounds. Building on previous tech- nologies using a nickel-titanium “memory wire,” this device was developed to avoid potential complications through a smaller delivery system to avoid vessel injury, and shorter device to avoid obstruction of oth- er vascular structures. In addition to design improvements for the device and delivery system, special precautions are taken at the time of pro- cedure to maintain normal body tempera- ture. Trauma to the blood vessels is also limited as much as possible, avoiding arte- rial access entirely, and using the smallest possible needle to enter the vein through which the device is delivered. Intravascu- lar contrast is typically used for cath pro- cedures in older patients, but is limited in these premature infants to avoid kidney injury, with ultrasound guidance used in its stead. At present, this procedure is saf- est when performed in a pediatric cardiac cath lab with a team of an interventional pediatric cardiologist and a pediatric car- diovascular anesthesiologist, though it could become available for bedside care in the future. While early results are very encourag- ing, with near universal closure of the PDA and low procedural complication rates, not much is known outside of the safety and efficacy. It remains to be seen whether this device will improve outcomes in pre- mature infants with a PDA over conserva- tive management. More formal random- ized control research trials are planned in the near future to compare the approaches and determine whether catheter therapy is finally ready to change the game for pre- mature infants. n “The Amplatzer Piccolo™ Occluder is the only device designed specifically for premature infants, and has now been successfully used to treat hundreds of infants around the world, even those weighing as little as two pounds.”