PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1046-1047

Possible Steroid-Induced Recurrent Patent Ductus Arteriosus After Device Closure

To the Editor.

We wish to alert those who treat infants and children with steroids of the possible adverse effects that may occur in patients who have had vascular occlusion devices placed.

We treated and closed by catheter device (Gianturco-Grifka vascular occlusion device [GGVOD], Cook Laboratories) a moderately large patent ductus arteriosus (PDA) in a 4-month-old girl. Angiography, subsequently reviewed by Dr R. G. Grifka, showed the device in proper position with the ductus closed. PDA is a common congenital vascular defect that now can often be closed by catheterization techniques with different devices.^1-3 The closure of the PDA with virtually all present devices consists both of mechanical closure/obstruction and obstruction to flow by thrombus formation. In animal studies, the different devices have cellular covering of the aortic and pulmonary aspects of the ductus by approximately 6 weeks.^4,5 The in-growth and complete transformation of the thrombus in the ductus proper varies depending on implanted material but occurs within 4 months in dogs with the GGVOD,³ and within 6 months or less in implants with stainless steel, nickel/titanium coil, and polyvinylalcohol foam plug in lambs.⁵ There are no reports of PDA recurrence in humans or animals after GGVOD placement and ductal closure in the absence of the device moving (R. G. Grifka, personal communication, August 5, 2000).

Within 4 weeks the infant started steroid therapy for newly diagnosed infantile spasms, and the ductus was subsequently reopened clinically in three weeks. By echocardiographic Doppler studies, there were at least 2 and probably 4 different areas around the device that were leaking, but the device remained in proper position. MRI studies were not performed because of concern that the device was not fixed in place cellularly. After 1 month off steroids, the ductal leakage was diminished, and 1 year later the infant has a trivial residual leak around the device.

Patients who undergo device closure of a ductus should probably avoid treatment with relatively high-dose steroids for 6 months when possible. The complete healing and tissue organization at the ductal site takes at least 4 weeks and may take up to 6 months after device placement. The use of prednisolone and adrenocorticotropic hormone in this infant within a month of device closure with subsequent reopening of the PDA is suggestive that steroid treatment may interfere with the cellular responses at the ductus site and the device(s) closing the ductus.

William C. Kirby, MD
Russell D'Sa, DCRI
Aurelio Reyes II, MD
Child Cardiology Associates
Fairfax, VA 22031-5218

REFERENCES

1. Radtke WAK Current therapy of the patent ductus arteriosus. Curr Opin Cardiol. 1998; 13:59-65 [Medline]
2. Moore JW, Cambier PA Transcatheter occlusion of patent ductus arteriosus. J Interventional Cardiol. 1995; 8:517-531 [Medline]
3. Grifka RG, Mullins CE, Gianturco C, New Gianturco-Grifka vascular occlusion device: initial studies in a canine model. Circulation. 1995; 91:1840-1846 [Abstract/Free Full Text]
4. Grabitz RG, Freudenthal F, Sigler M, Le T, Double-Helix Coil for Occlusion of Large Patent Ductus Arteriosus: Evaluation in a Chronic Lamb Model. JACC. 1998; 31:677-683 [Abstract/Free Full Text]
5. Sigler M, Handt S, Seghaye M-C, von Bernuth G, Grabitz RG Heart. 2000; 83:570-573 [Abstract/Free Full Text]