Closure of residual leakage after the use of hybrid umbrella in umbrella technique: A case report

Patent ductus arterious (PDA) is a common congenital heart defect. Some adults with PDA are often associated with severe pulmonary hypertension and frequently have to forgo their chance of surgery because the lung conditions progress to Eisenmenger syndrome (1). Therefore, early treatment should be performed as soon as a diagnosis of PDA is established. Several methods, including surgical ligation and transcatheter occlusion, have been currently employed for the treatment of PDA. However, surgical ligation has major disadvantages, such as significant trauma and other complications associated with thoracotomy. Transcatheter occlusion must be carried out under fluoroscopy and angiography, which causes inevitable radiation injury. Furthermore, closure of a large-sized PDA defect is technically challenging and carries a risk of device embolization (2, 3). The hybrid technique combines the advantages of open heart surgery and interventional cardiac catheterization. It is carried out by performing intraoperative transesophageal echocardiography-guided transthoracic occlusion via a small incision in the left portion of the chest close to the ductus arteriosus (4, 5). However, despite the high accuracy of the technique, residual PDA leakage remains a common complication after hybrid flap closure. This leakage may be the result of malposition of the occluding device or improper choice of device under the guidance of transesophageal echocardiography. Previous reports have documented the successful application of coil-type occlusion to manage residual leakage after the transcatheter occlusion of PDA (6). However, reports on the effectiveness of the umbrellatype occlusion are scanty. Herein, we present our successful closure of residual PDA leakage with a second umbrella, called the “umbrella in umbrella” technique.