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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patent ductus arteriosus &#40;PDA&#41; is one of the most frequent congenital heart defects and may occur as an isolated lesion or in association with others&#46; Its incidence varies from 5&#37; to 10&#37; of all congenital heart disease in term infants&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> increasing to 20&#37; to 60&#37; in preterm neonates&#46; This is attributable to the lack of normal closure mechanisms due to immaturity in the premature neonate&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Most patients have a small to moderate PDA causing restrictive flow with small left-to-right shunt&#44; presenting as symptom-free or with few symptoms&#46; The natural history of these lesions would probably be uneventful&#44; except for the risk of infective endocarditis&#46; Moderate to large PDA will cause an unrestrictive flow&#44; with potential for congestive heart failure &#40;HF&#41; and pulmonary vascular disease&#46; The rational for PDA closure is to prevent late complications such as canaliculitis&#44; HF or Eisenmenger syndrome in late age&#46; Exceptions are neonate or preterm infants with large PDA and the presence of severe pulmonary hypertension&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the first successful reports of surgical treatment of a PDA&#44; by Gross and Hubbard in 1939&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> surgical technique&#8212;either ligation of division&#8212;has been widely used for large and symptomatic PDA&#46; Although it has been shown that surgery is safe and effective with only occasional complications and some cases of recanalization&#44; pediatric cardiologists have always tried to develop a transcatheter method to close PDA and other anomalies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first report on non-surgical closure was by Portsmann et al&#46; in 1967&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> This investigator along with Rashkind et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> pioneered the development of several PDA closure devices&#46; Due to their efforts&#44; PDA percutaneous occlusion became an effective and safe procedure&#44; and is nowadays the standard method for PDA closure&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After these initial devices&#44; various types of occlusion systems have been developed&#46; Gianturco&#44; Jackson coils &#40;both free and detachable&#41; and similar devices have become an established method for PDA transcatheter closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;9</span></a> Since 1992&#44; coils have evolved into the most commonly used devices for small-sized PDA occlusion&#46; The introduction of the Amplatzer&#174; duct occluder family &#40;ADO&#44; Abbott&#44; USA&#41; in 2001&#44; changed the perspective on this procedure&#44; because of increased safety characteristics&#44; like retrievability&#44; repositioning and also the possibility to close defects up to 16 mm in diameter&#46; They are among the most frequently used occluders for large and moderate PDA occlusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#8211;12</span></a> Another recent device is the Nit-Occlud&#174; &#40;NOc&#44; pfm&#44; Germany&#41; coil&#44; which was designed specifically for PDA closure&#46; This coil has undergone several modifications since it was first developed&#44; with the latest version in use since 2001&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;14</span></a> Procedures using these techniques were reported to be safe and effective&#44; and although complications occur&#44; critical complications are rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;14</span></a> Device embolization&#44; the most feared complication&#44; was relatively common in early experience with coils but became rare with the new generation of devices&#46; Reported occlusion rates vary according to operator experience&#44; and post procedure period&#44; from 41&#37; immediately after the procedure to 95 to 100&#37; at three months of follow up&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15&#8211;18</span></a> Nevertheless&#44; several studies have demonstrated that intermediate and long-term outcomes of percutaneous PDA occlusion with current devices are excellent&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the present study&#44; Sarmento et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> present the results with percutaneous PDA occlusion from a single center for twelve years using at least three different devices&#46; The authors claim to report one of the largest series using the PDA NOc devices&#44; which adds value to the study&#46; In their series&#44; the immediate procedural occlusion rate&#44; assessed by angiography&#44; was high &#40;98&#46;6&#37;&#41;&#44; with a low complication rate &#40;1&#46;8&#37;&#41;&#44; and a single case of embolization&#44; in line with other reported data&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;21</span></a> The success rate was associated with vascular accessibility&#44; morphology of the ductus&#44; imaging modality&#44; and adequate selection of the device&#46; The study adds no novelty to the technique&#44; but reports on an important case experience at national level&#46; However&#44; the authors fail to explain the set for &#8220;adequate selection of device&#8221; and the criteria for performing coil&#47;device closure&#46; Also&#44; regarding the results&#44; the reported occlusion rate refers to the immediate result&#44; assessed by aortography&#46; The study would be more robust if the authors had described the immediate or 24-hour occlusion rate assessed by echocardiography&#44; which would enable a more accurate assessment and long-term outcomes&#44; as we would expect from a twelve-year retrospective study&#46; Despite these limitations&#44; the study is of value and it gives us the opportunity to discuss issues germane to transcatheter PDA closure&#44; such as indications&#44; selection of devices&#44; expected results and future perspectives&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Percutaneous PDA occlusion is indicated for lesions presenting with suggestive continuous murmur&#44; confirmed by echocardiography&#46; Ductus with absence of these typical findings&#44; so-called &#8216;silent ductus&#8217;&#44; should not be occluded&#44; although controversy exists with some authors recommending occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Small size PDA without significant left ventricle overflow should be treated to prevent infective endocarditis&#46; Medium and large size defects&#44; which present significant left-to-right shunt&#44; are treated to prevent HF and pulmonary vascular occlusive disease&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Adequate patient age and size have been an issue&#44; and indications have evolved over time and with new and innovative PDA occluding devices&#46; Until recently&#44; transcatheter PDA closure was considered the procedure of choice for infants &#8805;6 kg and adults&#46; Although an exact lower weight limit has not been set for a safe occlusion&#44; only a few studies have reported results in neonates and infants below this weight threshold&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23&#8211;25</span></a> Recently&#44; these limits have been exceeded with the release of the new miniaturized devices adequate for premature infants under 1&#46;5 kg&#46; There is an ongoing prospective trial to compare the classic surgical approach to percutaneous PDA occlusion in preterm infants over 700 g and three days old&#44; using the Amplatzer&#174; Piccolo Occluder&#44; an evolution of the Amplatzer&#174; additional sizes &#40;ADO AS&#41; family devices&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> These advances&#44; although with promising early and mid-term results&#44; need to be confirmed in randomized controlled trials before they can become a standard of care&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patent ductus arteriosus is an uncommon anomaly in adults&#44; but in this age group they present several pathological changes&#44; such as tortuosity&#44; calcification&#44; friability&#44; aneurysm formation and ductal shortening&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> A calcified duct is more fragile and difficult to cross and the treatment option was surgery with cardiopulmonary bypass&#44; to overcome complexity and complications&#46; However&#44; the development of new occlusion devices that can be deployed on the arterial side have enabled percutaneous occlusion in adult patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> Treatment selection must&#44; however&#44; be made on an individual bases&#44; especially in heavily calcified and fragile ducts&#46; Although there are no specific guidelines for device selection&#44; it seems logical that a less rigid device such as ADO II&#44; ADO II AS&#44; vascular plugs and PDA NOc would cause less shear stress on these fragile walls&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Based on personal experience&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;12</span></a> most PDA can be occluded using a percutaneous approach&#44; keeping in mind that the selection of patients and devices remains the major factor for success and effectiveness&#44; so it is important to take into account patient characteristics&#44; PDA shape&#44; size and minimal diameter&#46; Small to very-small PDA &#40;&#60;2&#46;5 and 1&#46;5 mm in diameter respectively&#44; with continuous murmur&#41; can easily be occluded&#44; regardless of their shape&#44; using detachable coils&#44; which are a cheap and effective choice&#46; Device selection for conical PDA is broader&#44; as either coils or ADO devices and similar can be used depending on the size and minimum diameter of the PDA&#46; Although there is no exact threshold&#44; the latter are usually used to occlude PDA over 2&#46;5 mm in diameter&#46; The PDA NOc devices are recommended&#44; in most studies&#44; to occlude small to moderate PDA&#44; as shown by the authors of this study report&#46; ADO devices are used with greater efficiency in ductus of a larger diameter or morphology that is unfavorable to occlusion with coils&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Complete PDA occlusion and absence of complications are the expected results of percutaneous PDA occlusion&#46; Residual shunting is more common with coils and when it occurs&#44; it has to be treated with repeated procedures&#44; as it may lead to endocarditis or to hemolysis&#46; Device embolization is rare and also more frequent with coils&#44; with an occurrence rate &#60;1&#37;&#46; Device-induced pulmonary branch stenosis or aortic coarctation is rarely seen&#44; although D&#246;ppler flow acceleration without invasive gradient may occur&#44; it might resolve spontaneously with growth&#46; Aortography&#44; before and after releasing the implanted device&#44; is the method selected to evaluate immediate result&#44; but echocardiography is more adequate for post-procedural assessment and quantification of incomplete occlusion and late complications&#46; We should however point out&#44; that when using coils&#44; we would recommend continuing catheterization until complete ductal closure is documented by angiography&#44; because of increased risk of embolization and hemolysis&#46; Vascular injury from the delivery system is another feared complication&#44; especially in small infants&#46; Nevertheless&#44; this is rarely seen with experienced operators&#44; also taking into account the evolution in downsizing delivery sheaths over the last five decades&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; transcatheter PDA closure stands as the standard treatment in most cases&#46; Coils and ADO devices or similar are the most frequently used closure devices worldwide&#46; This approach is feasible&#44; effective and safe with current devices and techniques leading to excellent outcomes&#46; Future perspectives foresee the evolution of techniques to address more challenging cases&#44; such as preterm and low birth weight infants and complex cases in adults&#44; with high occlusion rate and few complications&#46; During the past 50 years&#44; we have witnessed a remarkable evolution in techniques&#44; devices and delivery systems&#44; so we can only anticipate further improvements in transcatheter PDA closure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Percutaneous closure of patent ductus arteriosus: A standard procedure with new perspectives
Encerramento percutâneo de canal arterial persistente: um procedimento padrão com novas perspetivas
Fátima F. Pinto
Universidade NOVA de Lisboa, Serviço de Cardiologia Pediátrica, Centro de Referência de Cardiopatias Congénitas, CHULC, EPE – Hospital de Santa Marta, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patent ductus arteriosus &#40;PDA&#41; is one of the most frequent congenital heart defects and may occur as an isolated lesion or in association with others&#46; Its incidence varies from 5&#37; to 10&#37; of all congenital heart disease in term infants&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> increasing to 20&#37; to 60&#37; in preterm neonates&#46; This is attributable to the lack of normal closure mechanisms due to immaturity in the premature neonate&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Most patients have a small to moderate PDA causing restrictive flow with small left-to-right shunt&#44; presenting as symptom-free or with few symptoms&#46; The natural history of these lesions would probably be uneventful&#44; except for the risk of infective endocarditis&#46; Moderate to large PDA will cause an unrestrictive flow&#44; with potential for congestive heart failure &#40;HF&#41; and pulmonary vascular disease&#46; The rational for PDA closure is to prevent late complications such as canaliculitis&#44; HF or Eisenmenger syndrome in late age&#46; Exceptions are neonate or preterm infants with large PDA and the presence of severe pulmonary hypertension&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the first successful reports of surgical treatment of a PDA&#44; by Gross and Hubbard in 1939&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> surgical technique&#8212;either ligation of division&#8212;has been widely used for large and symptomatic PDA&#46; Although it has been shown that surgery is safe and effective with only occasional complications and some cases of recanalization&#44; pediatric cardiologists have always tried to develop a transcatheter method to close PDA and other anomalies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first report on non-surgical closure was by Portsmann et al&#46; in 1967&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> This investigator along with Rashkind et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> pioneered the development of several PDA closure devices&#46; Due to their efforts&#44; PDA percutaneous occlusion became an effective and safe procedure&#44; and is nowadays the standard method for PDA closure&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After these initial devices&#44; various types of occlusion systems have been developed&#46; Gianturco&#44; Jackson coils &#40;both free and detachable&#41; and similar devices have become an established method for PDA transcatheter closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;9</span></a> Since 1992&#44; coils have evolved into the most commonly used devices for small-sized PDA occlusion&#46; The introduction of the Amplatzer&#174; duct occluder family &#40;ADO&#44; Abbott&#44; USA&#41; in 2001&#44; changed the perspective on this procedure&#44; because of increased safety characteristics&#44; like retrievability&#44; repositioning and also the possibility to close defects up to 16 mm in diameter&#46; They are among the most frequently used occluders for large and moderate PDA occlusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#8211;12</span></a> Another recent device is the Nit-Occlud&#174; &#40;NOc&#44; pfm&#44; Germany&#41; coil&#44; which was designed specifically for PDA closure&#46; This coil has undergone several modifications since it was first developed&#44; with the latest version in use since 2001&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;14</span></a> Procedures using these techniques were reported to be safe and effective&#44; and although complications occur&#44; critical complications are rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;14</span></a> Device embolization&#44; the most feared complication&#44; was relatively common in early experience with coils but became rare with the new generation of devices&#46; Reported occlusion rates vary according to operator experience&#44; and post procedure period&#44; from 41&#37; immediately after the procedure to 95 to 100&#37; at three months of follow up&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15&#8211;18</span></a> Nevertheless&#44; several studies have demonstrated that intermediate and long-term outcomes of percutaneous PDA occlusion with current devices are excellent&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the present study&#44; Sarmento et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> present the results with percutaneous PDA occlusion from a single center for twelve years using at least three different devices&#46; The authors claim to report one of the largest series using the PDA NOc devices&#44; which adds value to the study&#46; In their series&#44; the immediate procedural occlusion rate&#44; assessed by angiography&#44; was high &#40;98&#46;6&#37;&#41;&#44; with a low complication rate &#40;1&#46;8&#37;&#41;&#44; and a single case of embolization&#44; in line with other reported data&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;21</span></a> The success rate was associated with vascular accessibility&#44; morphology of the ductus&#44; imaging modality&#44; and adequate selection of the device&#46; The study adds no novelty to the technique&#44; but reports on an important case experience at national level&#46; However&#44; the authors fail to explain the set for &#8220;adequate selection of device&#8221; and the criteria for performing coil&#47;device closure&#46; Also&#44; regarding the results&#44; the reported occlusion rate refers to the immediate result&#44; assessed by aortography&#46; The study would be more robust if the authors had described the immediate or 24-hour occlusion rate assessed by echocardiography&#44; which would enable a more accurate assessment and long-term outcomes&#44; as we would expect from a twelve-year retrospective study&#46; Despite these limitations&#44; the study is of value and it gives us the opportunity to discuss issues germane to transcatheter PDA closure&#44; such as indications&#44; selection of devices&#44; expected results and future perspectives&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Percutaneous PDA occlusion is indicated for lesions presenting with suggestive continuous murmur&#44; confirmed by echocardiography&#46; Ductus with absence of these typical findings&#44; so-called &#8216;silent ductus&#8217;&#44; should not be occluded&#44; although controversy exists with some authors recommending occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Small size PDA without significant left ventricle overflow should be treated to prevent infective endocarditis&#46; Medium and large size defects&#44; which present significant left-to-right shunt&#44; are treated to prevent HF and pulmonary vascular occlusive disease&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Adequate patient age and size have been an issue&#44; and indications have evolved over time and with new and innovative PDA occluding devices&#46; Until recently&#44; transcatheter PDA closure was considered the procedure of choice for infants &#8805;6 kg and adults&#46; Although an exact lower weight limit has not been set for a safe occlusion&#44; only a few studies have reported results in neonates and infants below this weight threshold&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23&#8211;25</span></a> Recently&#44; these limits have been exceeded with the release of the new miniaturized devices adequate for premature infants under 1&#46;5 kg&#46; There is an ongoing prospective trial to compare the classic surgical approach to percutaneous PDA occlusion in preterm infants over 700 g and three days old&#44; using the Amplatzer&#174; Piccolo Occluder&#44; an evolution of the Amplatzer&#174; additional sizes &#40;ADO AS&#41; family devices&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> These advances&#44; although with promising early and mid-term results&#44; need to be confirmed in randomized controlled trials before they can become a standard of care&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patent ductus arteriosus is an uncommon anomaly in adults&#44; but in this age group they present several pathological changes&#44; such as tortuosity&#44; calcification&#44; friability&#44; aneurysm formation and ductal shortening&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> A calcified duct is more fragile and difficult to cross and the treatment option was surgery with cardiopulmonary bypass&#44; to overcome complexity and complications&#46; However&#44; the development of new occlusion devices that can be deployed on the arterial side have enabled percutaneous occlusion in adult patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> Treatment selection must&#44; however&#44; be made on an individual bases&#44; especially in heavily calcified and fragile ducts&#46; Although there are no specific guidelines for device selection&#44; it seems logical that a less rigid device such as ADO II&#44; ADO II AS&#44; vascular plugs and PDA NOc would cause less shear stress on these fragile walls&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Based on personal experience&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;12</span></a> most PDA can be occluded using a percutaneous approach&#44; keeping in mind that the selection of patients and devices remains the major factor for success and effectiveness&#44; so it is important to take into account patient characteristics&#44; PDA shape&#44; size and minimal diameter&#46; Small to very-small PDA &#40;&#60;2&#46;5 and 1&#46;5 mm in diameter respectively&#44; with continuous murmur&#41; can easily be occluded&#44; regardless of their shape&#44; using detachable coils&#44; which are a cheap and effective choice&#46; Device selection for conical PDA is broader&#44; as either coils or ADO devices and similar can be used depending on the size and minimum diameter of the PDA&#46; Although there is no exact threshold&#44; the latter are usually used to occlude PDA over 2&#46;5 mm in diameter&#46; The PDA NOc devices are recommended&#44; in most studies&#44; to occlude small to moderate PDA&#44; as shown by the authors of this study report&#46; ADO devices are used with greater efficiency in ductus of a larger diameter or morphology that is unfavorable to occlusion with coils&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Complete PDA occlusion and absence of complications are the expected results of percutaneous PDA occlusion&#46; Residual shunting is more common with coils and when it occurs&#44; it has to be treated with repeated procedures&#44; as it may lead to endocarditis or to hemolysis&#46; Device embolization is rare and also more frequent with coils&#44; with an occurrence rate &#60;1&#37;&#46; Device-induced pulmonary branch stenosis or aortic coarctation is rarely seen&#44; although D&#246;ppler flow acceleration without invasive gradient may occur&#44; it might resolve spontaneously with growth&#46; Aortography&#44; before and after releasing the implanted device&#44; is the method selected to evaluate immediate result&#44; but echocardiography is more adequate for post-procedural assessment and quantification of incomplete occlusion and late complications&#46; We should however point out&#44; that when using coils&#44; we would recommend continuing catheterization until complete ductal closure is documented by angiography&#44; because of increased risk of embolization and hemolysis&#46; Vascular injury from the delivery system is another feared complication&#44; especially in small infants&#46; Nevertheless&#44; this is rarely seen with experienced operators&#44; also taking into account the evolution in downsizing delivery sheaths over the last five decades&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; transcatheter PDA closure stands as the standard treatment in most cases&#46; Coils and ADO devices or similar are the most frequently used closure devices worldwide&#46; This approach is feasible&#44; effective and safe with current devices and techniques leading to excellent outcomes&#46; Future perspectives foresee the evolution of techniques to address more challenging cases&#44; such as preterm and low birth weight infants and complex cases in adults&#44; with high occlusion rate and few complications&#46; During the past 50 years&#44; we have witnessed a remarkable evolution in techniques&#44; devices and delivery systems&#44; so we can only anticipate further improvements in transcatheter PDA closure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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