Catheterization and Cardiovascular Diagnosis 39:287-290 (1 996) Hemolysis Following Coil Embolization of a Patent Ductus Arteriosus David Shim, MD, Daniel S. Wechsler, MD, PhD, Thomas R. Lloyd, MD, and Robert H. Beekman 111, MD We describe the development of hemolysls from moderate residual shunting across a patent ductus arteriosus following coil embollzatlon. The fall in hemoglobin levels from 11.6 to 6.0 gm/dl necessitated a second coil procedure which resulted in complete clo- sure of the residual shunting and resolution of hemolysls. Therefore, appearance of anemia following coil embolization of patent ductus arteriosus should be monitored closely; however, repeat coil embolizatlon with elimination of residual shunt will lead to prompt recovery of normal hernoglobin levels. zyxwvut Q 1996 WIIOY-LISS, Inc. Key words: patent ductus arterlosus, hemolysis, coil embolizatlon INTRODUCTION zyxwvutsrq Coil embolization of patent ductus arteriosus (PDA) has become the treatment of choice for closure of patent ductus arteriosus in some institutions [ zyxwvu 1,2]. Complica- tions have been few and there are no published reports of hemolysis after ductus coil embolization. We report a case of intravascular hemolysis after coil embolization of PDA . CASEREPORT A heart murmur was noted in a 4-month-old infant during evaluation for bronchiolitis and the patient was referred for cardiac evaluation. A continuous murmur consistent with PDA was present, but no clinical evi- dence of congestive heart failure was found. Echocar- diography confirmed the presence of a restrictive PDA (62-80 mm Hg pressure gradient between the aorta and pulmonary artery), with a dilated left atrium and ventri- cle secondary to volume overload. Examinations at 8 and 14 months of age continued to suggest PDA without congestive heart failure. Elective coil embolization of the PDA was scheduled at 16 months of age. Prior to the procedure, the child’s hemoglobin (Hgb) was 1 1.6 gldl. Cardiac catheterization and coil embolization was per- formed as was routine at our institution [l]. The mini- mum ductal diameter was found to be 2.8 mm, with zyxwv an angiographically large [l] left to right shunt (Fig. 1). A 0.038 in. X 8 cm X 8 mm Gianturco steel embolization coil (Cook Inc., Bloomington, IN) was implanted across the ductus, and a repeat aortogram revealed a moderate persistent shunt 10 minutes after placement. A second 0.038 in. x 5 cm x 5 mm coil was implanted within the first coil, and a repeat aortogram revealed a small resid- ual shunt (Fig. 1). Because such residual shunts typically decrease or resolve with time [3], and because placement of additional coils might dislodge and possibly embolize the first two coils, no further coils were implanted. The patient tolerated the procedure well and was discharged 6 h after leaving the catheterization laboratory. On the evening of the first post-procedure day, the patient’s urine appeared dark, although she was afebrile and otherwise asymptomatic. A urinalysis performed by her pediatrician the following morning revealed hemo- globinuria without red blood cells. Complete blood count revealed a decrease in Hgb to 10.2 g/dl and microcytes were seen on peripheral blood smear. Blood chemistries performed on the third day were remarkable for mark- edly elevated lactate dehydrogenase (5,240 IU/L; normal 300-650) and total serum bilirubin (1.8 mg/dl; normal 0.1-1 .O). Serial laboratory studies over the following week revealed continued decrease in Hgb and increase in reticulocyte count (Fig. 2); therefore, referral was made to Pediatric Hematology. On the eighth post-procedure day, the reticulocyte count was 11% and peripheral blood smear was remarkable for the presence of nucle- ated red blood cells and evidence of hemolysis. Serum From the Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, and Division of Pediatric Hematol- ogy-Oncology, C.S. Molt Children’s Hospital, The University of Mich- igan, Ann Arbor, Michigan. Received March 25, 1996; revision accepted June 6, 1996. Address reprint requests to David Shim, M.D., Division of Pediatric Cardiology, Children’s Hospital Medical Center, zyxw 3333 Burnet Ave- nue, Cincinnati, OH 45229. zyxwv 0 1996 Wiley-Liss, Inc.