What is the initial treatment for patent ductus arteriosus (PDA)?

Initial Treatment for Patent Ductus Arteriosus (PDA)

The initial treatment for patent ductus arteriosus should be percutaneous device closure for most patients with hemodynamically significant PDA, as it is the preferred method with high success rates and fewer complications compared to surgical closure. 1

Assessment and Diagnosis

Before initiating treatment, proper assessment is crucial:

• Echocardiography with color Doppler is the primary diagnostic tool to:

  • Confirm PDA presence
  • Assess size and hemodynamic significance
  • Evaluate left atrial and ventricular volume overload
  • Measure pulmonary artery pressure 1

• Additional diagnostic considerations:

  • Chest X-ray may show cardiomegaly and increased pulmonary vascular markings
  • Look for calcification in the ductus region in adults (increases surgical risk) 1
  • Cardiac catheterization is indicated when pulmonary artery pressure is elevated to assess pulmonary vascular resistance 1

Treatment Algorithm

1. Small, Asymptomatic PDA

• No intervention required for very small "silent" PDAs without murmur 1
• Regular follow-up every 3-5 years is recommended 1

2. Hemodynamically Significant PDA

PDA closure is indicated when there is:

• Left atrial and/or LV enlargement
• Pulmonary arterial hypertension with net left-to-right shunting
• Prior endarteritis 1

Treatment Options:

A. Device Closure (First-line)

• Preferred method for isolated PDA in adults 1
• Advantages:
  • High success rate
  • Fewer complications
  • Avoids risks associated with surgical approach in adults (calcification, tissue friability) 1

B. Surgical Closure

• Reserved for cases where:
  • PDA is too large for device closure
  • Distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis)
  • PDA occurs with other cardiac defects requiring surgery 1
• Consultation with ACHD interventional cardiologists is recommended before choosing surgical closure 1

3. PDA with Pulmonary Arterial Hypertension (PAH)

• Close PDA if PAP < 2/3 of systemic pressure or PVR < 2/3 of SVR 1
• Consider closure in patients with PAH and PAP > 2/3 of systemic pressure if there's still net left-to-right shunt (Qp:Qs > 1.5) or when testing demonstrates pulmonary vascular reactivity 1
• Avoid closure in patients with Eisenmenger physiology (net right-to-left shunt) 1

Special Considerations

For Neonates and Premature Infants

In premature infants, pharmacological closure may be attempted first:

• Indomethacin or ibuprofen (COX inhibitors) can be used 2, 3
• Oral ibuprofen appears as effective as IV administration with fewer side effects 4, 3
• Ibuprofen is associated with lower risk of NEC and transient renal insufficiency compared to indomethacin 3

For Adults

• Calcification and tissue friability in the area of the aortic isthmus and pulmonary artery make surgical manipulation more hazardous 1
• When cardiac operation is required for other reasons, preoperative device closure of the PDA should be considered 1

Follow-up After Closure

• Patients who have undergone surgical/PDA closure can be discharged from follow-up once complete closure is documented by echocardiography 1
• Antibiotic prophylaxis is discontinued 6 months after PDA closure 1
• Follow-up approximately every 5 years for patients who received a device is recommended 1

Potential Complications

• Surgical complications may include recurrent laryngeal nerve or phrenic nerve injury or thoracic duct injury 1
• Device-related complications are rare but may include embolization or residual shunting

By following this evidence-based approach, optimal outcomes can be achieved for patients with patent ductus arteriosus while minimizing morbidity and mortality.