What are the recommended methods for patent ductus arteriosus (PDA) closure?

Patent Ductus Arteriosus Closure: Recommended Methods

Device closure via transcatheter approach is the method of choice for PDA closure in adults and should be prioritized over surgical intervention whenever technically feasible. 1

Primary Closure Method: Transcatheter Device Closure

Percutaneous device closure is the first-line intervention for PDA closure due to superior safety profile and efficacy, particularly in adults where ductal calcification and tissue friability make surgical manipulation hazardous. 1

Device Options:

• Amplatzer Duct Occluder (ADO): Most commonly used device with 99% occlusion rate at 1 week follow-up 2
• Coil devices: Alternative option with 96% occlusion rate at 1 week, particularly for smaller PDAs 2
• Multiple device options available depending on PDA size and morphology 1

Success Rates:

• Transcatheter closure achieves >95% procedural success with minimal complications 2, 3
• Complete occlusion documented in 94-99% of patients at follow-up 2, 4

Surgical Closure: Reserved for Specific Scenarios

Surgery should only be considered when device closure is not technically feasible, specifically for: 1

Surgical Indications:

• PDA too large for device closure 1
• Distorted ductal anatomy precluding device placement (e.g., aneurysm or endarteritis) 1
• Calcified PDA in adults where device placement poses technical challenges 1
• Concomitant cardiac surgery where PDA can be addressed during the same operation 1

Important Surgical Considerations:

• Consult ACHD interventional cardiologists before selecting surgical closure for calcified PDAs 1
• Surgical closure carries >95% success rate but with higher procedural risk in adults due to calcification and tissue friability 1
• Consider preoperative device closure if patient requires cardiac surgery for other indications to avoid cardiopulmonary bypass complications 1

Clinical Indications for PDA Closure

Class I Indications (Must Close):

• Left atrial and/or left ventricular enlargement indicating volume overload 1
• Pulmonary hypertension with PAP <2/3 systemic pressure or PVR <2/3 SVR 1
• Prior endarteritis 1
• Net left-to-right shunt with hemodynamic significance 1

Class IIa Indications (Reasonable to Close):

• Small asymptomatic PDA with continuous murmur (normal LV and PAP) 1
• Elevated PAH with PAP >2/3 systemic but still net left-to-right shunt (Qp:Qs >1.5) or demonstrable pulmonary vascular reactivity 1

Class III Indications (Do NOT Close):

• Silent duct (very small, no murmur) - closure should be avoided 1
• Eisenmenger physiology with net right-to-left shunt - closure is contraindicated due to high mortality 1
• Exercise-induced lower limb desaturation indicating right-to-left shunting 1

Critical Pitfalls to Avoid

Assessment Errors:

• Always measure oxygen saturation in both feet AND both hands to detect differential cyanosis from right-to-left shunting 1
• Perform ambulatory pulse oximetry in addition to resting measurements, as some patients develop desaturation only with exercise 1
• Invasive hemodynamic assessment remains essential for confirming pulmonary vascular resistance and shunt direction when PAH is present 1

Procedural Complications:

• Device embolization is a recognized complication requiring immediate retrieval (percutaneous or surgical hybrid approach) 5
• Residual shunt occurs in up to 10% of cases but typically closes over time 1
• In adults, calcified ductus poses rupture risk during surgical manipulation - catheter intervention is safer 1

Post-Closure Management

• Discharge from follow-up once complete closure documented by echocardiography 1
• Endocarditis prophylaxis discontinued 6 months after complete closure 1
• Follow-up every 5 years for device closure patients due to limited long-term data 1
• Excellent long-term outcomes with normal life expectancy after successful closure 1