Dr. R. Allen Ligon, Jr., a congenital interventional cardiologist at the Children’s Healthcare of Atlanta, talks about fixing PDA in a preemie without surgery.
Interview conducted by Ivanhoe Broadcast News in 2023.
You performed an effective heart vessel closure. All of this falls into the nation. How small was it and can you show me the size of what that looks like?
Ligon: Yeah. Perspective is part of this. To start we do what’s called a PDA or patent ductus arteriosus, it’s a vessel that all of us, yourself included have when you’re inside of your mother. Once you came out, it actually closed on its own. But it’s incredibly common for babies who are born too early or premature babies for that vessel to stay open. They can actually be pretty harmful for not only their lung health but also their heart health. When you ask the question about how small PDA closure has been performed by people such as myself for many years in older kids and even adults who have persistent PDAs. In premature, it’s just a new technique, new technology for us. We’re able to safely and effectively perform minimally invasive cath-based closure on premature infants. The one that you’re referencing was actually born extremely early. You’re supposed to cook until 40 weeks, but she was born in about 22 weeks. Gestation, but at the time of the procedure, she was only a couple of weeks old and she was only 500 grams. That’s one pound and a few ounces. For perspective, I think that not only is the patient herself or the baby was only one pound and a few ounces. But, you can imagine your heart if you hold up your fist. That’s the size of my heart. You can imagine a one-pound infant’s fist and how small it is, that’s how small her heart is. We’re having to effectively close the vessel that is within proximity of her heart.
Tell me about what was exactly wrong with the baby’s heart.
Ligon: We all have a PDA, and it’s crucial when we’re inside of mom. But as we come out, it’s supposed to close on its own. It’s been incredibly common for babies who are born extremely premature like she was for that vessel to stay open. What that can cause is two-fold. It connects the big arteries that come off of the heart, that go to the lungs and go to the body. Due to those being connected, there’s blood flow between those when there shouldn’t be any longer. That does several things in premature infants who are born with very immature lungs. It can add excess flow or blood flow back into the lungs that doesn’t need to be there. At the cost of putting excess blood flow back into the lungs, it also steals from other areas in the body, the belly, the head, all these other organs that need blood flow. It also dilates the heart. Not only were her lungs getting excessive blood flow, it was stealing blood flow from the other organs of her body and also dilating and making her heart too big.
What happens?
Ligon: Due to that steal from other organs, there’s a very high risk that she could have suffered from some medical sequelae that can occur secondary to that. There can be an organ stealing from things that need it. Whether it be her belly, brain, or kidneys. Also, the heart was continuing to get bigger and bigger. Lastly, she had to be on very high ventilatory because she was on a mechanical ventilator that was breathing for her. She had to be in very high settings in order to effectively ventilate her with her immature lungs that were getting too much pulmonary blood flow.
One of my next questions, I think you already answered what is PDA?
Ligon: Patent ductus arteriosus.
Is there any other insight you’d give them on what that entails?
Ligon: Something that is crucial for all of us inside gestation but can be harmful to us especially once we come out of mother and transition from being in the womb to out. Now, a sudden we breathe on our own, and our heart and lung circulation aren’t supposed to mix like that. The fact that she stayed open was causing significant damage to her lungs and to her heart. And so.
When you do this procedure do you put something in?
Ligon: The traditional treatment for this has only been surgery. Cutting open the rib cage and putting a clip on the vessel to make it go away. What you want is for the PDA to close but it hasn’t gone away. A surgeon would just ligate it or put a clip on it and make it go away. Instead of that and a surgical procedure, we’re actually doing minimally invasive catheterizations. Small plastic tubes and using the leg vessels to navigate through the heart inside of the PDA. Once you’re inside the PDA, you can put in a very small device that closes that PDA. For lack of a better term, it creates a very controlled clot to make it go away.
Do you have to get back in there to remove anything? Is it completely done for her? Do you put a pulmonary? Does it stay there forever?
Ligon: Great question. If you’re born with a PDA that stays open, and as you grow, the PDA will grow with you. The moment you put in a device to make it go away, it becomes an inert vessel that’s not going to grow or change. Now, the vessels that it connected can continue to grow, which is important. Because the two vessels that it connects are the most important vessels that go to the lungs and out to the body, the aorta. That’s why it’s absolutely critical that the device stays inside of the PDA and doesn’t protrude out into the aorta or the lung vessels because that can be trading one problem for a very serious problem. As you can imagine in a very small baby, the difference in the millimeter forward or millimeter backward can be a very big deal clinically.
This procedure, how is it accurate? Talk about the accuracy because you just mentioned it needs to be accurate.
Ligon: We here at this institution perform within a catheterization lab like this. We have a ton of protocols that are dedicated to not only this medically fragile population, but the procedure itself in order to really ensure the accuracy. We do this not only under our X-ray vision that’s behind me here but also under echo guidance. That’s an ultrasound that another doctor is there helping me navigate not only throughout the heart but really focused on making sure the device is solely inside of the PDA or the vessel we want to take away and not protruding into those absolutely critical vessels that it connects.
With just general need any further surgery or does she get to go?
Ligon: It’s exciting. She has continued to be followed by a heart doctor and she has shown not only resolution of the damage that it was causing to the heart, but complete resolution of the PDA. She will not need any further surgery from a heart standpoint. Now, Jeil still has a lot of medical issues that need to be addressed. But from a heart or PDA perspective, she will not need any further surgery.
Will this prohibit any disruption in the future? In the future, will she not be able to do or be able to do?
Ligon: I always tell parents this is a very special type of metal, so it’s nothing that would set off airport alarms or anything like that. It can even be MRI-safe, shouldn’t she ever need an MRI. No, from a hard perspective, truthfully, this helped get her through a very fragile time in her life. In fact, when we were first called by the outlying NICU, she was incredibly sick and incredibly unstable because of all that steel I was telling you about. Her blood pressure and her ventilation were very unpredictable. The moment we actually placed the device and took away the PDA, it really led to a lot more clinical stability and so really helped her move along in her very fragile time being so premature.
Remarkable recovery. Can you talk about her recovery?
Ligon: She’s come a long way. She was as small and boring as early as any neonate I’ve ever seen. The fact that she has survived and done so well with all of the things that she’s had to deal with, is truly amazing. I think it’s a testament not only to the excellent care that NICU provided, but some of the specialists who were involved in her care and her wonderful parents who were amazing advocates for her. Admittedly, I like to tell this story because the device that we placed, when you first go through FDA approval, you’re looking for what size they approve it to be done. She was well below the size of what the FDA had approved. I sat with her and I had a very long conversation educating them about this, what we understand, and what we had never done, and at the time no one had ever done one as small as nationwide. It was a very long discussion and it was one that I looked back on and I remember it like yesterday because the mom was very understanding and really, the favorite thing I get to do is when a parent trusts in you 100 percent and gives you their child and says, go help my child, there’s no bigger honor than that. For her to trust in me and my staff and let me say too is so much of that procedure was more than myself, it was my staff really optimizing her and making sure that we do this safely and effectively. For that mom to trust in me and to be able to get that done and navigate the outcome, was a special time.
What is the child doing now and how old is she? Do you know?
Ligon: Yes. So she is home. She is thriving as an outpatient. She follows one of my colleagues, a cardiologist as well as some other sub-specialists because again, she was so pretty mature and so sick, but she is thriving. Truthfully it’s special. Her mom will send us some pictures to be able to see her. She’s above a year of age now and she’s developing along and it’s exciting how well she’s doing.
What are the risks for her or for that kind of procedure, her in general?
Ligon: This is an incredibly medically fragile patient population. To do any procedure on a neonate, such as her size, comes with a lot of hemodynamic instability and a lot of risk. Not only for going asleep because they have to be very still during this process but also something I alluded to earlier. The device goes too far into one of the vessels that it connects. That can be life-threatening, to be honest with you. As you can imagine, as we spoke about how small she was, that can be the difference between a millimeter forward or backward can truly be the difference between a successful procedure and a life-threatening issue. It takes a village to get something like this done precisely, accurately, and effectively.
Is this a game changer for babies born neonates?
Ligon: Absolutely. This technology, we in this field are very driven by the technology that’s available. The only option was surgery. As you can imagine, this medically fragile population had many side effects from those surgeries and it became a question of, is the risk of the treatment is worse than the disease. But now we have a different treatment or I mean, we have a different option that’s better tolerated for these infants and neonates. Because it is, we’re seeing a growth in not only our volume and numbers of this but also how these children are tolerating that and how they’re growing and thriving afterward.
Have you performed any more surgeries like this recently? Can you talk about that?
Ligon: We actually have a specialized group or a specialized team of individuals that are devoted solely to this procedure here at Children’s Healthcare of Atlanta. It’s a neonatal PDA closure program. We get referrals in from new NCUs all across the state and we’re able to perform this for them and get the procedure done and have them back to them usually within three days time. Specifically to your question about the size, we have also done just as small as her since that time. We can do it for any age patient and any size.
Is there anything we left out that you want to add?
Ligon: The focus needs not to be only on the proceduralists who do this, but the team that allows this to happen. This is a procedure that takes a huge amount of specialized individuals to perform something like this. That includes not only from the physician or provider standpoint but nurses, tags, neonatology teams, and respiratory therapists, it’s truly a team effort to get supplementing this done safely and effectively for this patient population and they truly believe it’s the right thing.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Erika Richards Harris
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
