What is the recommended treatment for patent ductus arteriosus?

Treatment of Patent Ductus Arteriosus

Percutaneous device closure is the first-line treatment for hemodynamically significant PDA in adults and older children, with surgical closure reserved only for cases where device closure is not technically feasible. 1

Indications for PDA Closure

Closure (either percutaneous or surgical) is indicated for:

• Left atrial and/or left ventricular enlargement 2
• Pulmonary arterial hypertension (PAH) with net left-to-right shunting 2
• Prior history of endarteritis 2
• Any hemodynamically significant left-to-right shunt 1

It is reasonable to close even small asymptomatic PDAs by catheter device. 2

Critical Contraindication

PDA closure is contraindicated in patients with PAH and net right-to-left shunt (Eisenmenger physiology). 2 This represents irreversible pulmonary vascular disease where the PDA serves as a "pop-off" valve.

Treatment Approach by Age Group

Neonates and Premature Infants

For symptomatic PDA in premature infants, pharmacological closure with NSAIDs is first-line therapy:

• Ibuprofen: 10 mg/kg IV initially, followed by 5 mg/kg at 24-hour intervals for two additional doses 3
• Indomethacin: Alternative NSAID, but carries higher risk of renal and gastrointestinal complications 3, 4

Ibuprofen is preferred over indomethacin because it causes significantly less oliguria (5 vs 14 patients, P=0.03) while maintaining equal efficacy for ductal closure (70% vs 66%) 5. However, indomethacin has a protective effect against intraventricular hemorrhage that ibuprofen lacks 4.

Key monitoring requirements:

• Assess renal function before and during treatment 3
• Monitor for bleeding or bruising 3
• Perform serial echocardiograms to assess treatment response 3

Contraindications to NSAID therapy:

• Active bleeding (especially intracranial or gastrointestinal) 3
• Renal dysfunction 3
• Third trimester of pregnancy (maternal use) 6

If first course of medical therapy fails, consider:

• Second course of NSAID therapy 3, 6
• Surgical ligation for symptomatic infants unresponsive to medical therapy 6

Older Children and Adults

Device closure via transcatheter approach is the method of choice 1. This is particularly important in adults where ductal calcification and tissue friability make surgical manipulation significantly more hazardous than in children 2.

Surgical closure is indicated only when:

• PDA is too large for device closure 2
• Distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis) 2
• Calcified PDA in adults where device closure is not feasible 1
• Concomitant cardiac surgery is required for other indications 2

Critical pitfall: In older adults, a calcified ductus poses significant surgical risk with increased risk of rupture during surgical repair 2. Always consult with ACHD interventional cardiologists before selecting surgical closure for calcified PDAs. 2

Surgical Considerations

When surgery is necessary, it should be performed by a surgeon experienced in congenital heart disease surgery. 2

Surgical approaches include:

• Thoracotomy or sternotomy, with or without cardiopulmonary bypass 2
• Ligation and division or patch closure from inside the main pulmonary artery or aorta 2

Surgical success rate exceeds 95% with low early mortality, and recanalization is rare. 2

Potential complications:

• Recurrent laryngeal nerve injury 2
• Phrenic nerve injury 2
• Thoracic duct injury 2
• Air leak with potential fatal tension pneumothorax 7
• Intraoperative hemorrhage 7

Follow-Up Management

For small PDAs without left-heart volume overload:

• Routine follow-up every 3 to 5 years 2

After successful closure:

• Patients can be discharged from follow-up once complete closure is documented by transthoracic echocardiography 2
• Endocarditis prophylaxis should be discontinued 6 months after complete closure 2, 1
• For device closure, follow-up approximately every 5 years is recommended due to lack of long-term data 2, 1

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis with:

• Echocardiography with color Doppler in parasternal short-axis view 2, 3
• Measurement of transpulmonary gradient with continuous-wave Doppler to estimate pulmonary artery pressure 2, 3

Cardiac catheterization is indicated when:

• Significant elevation of pulmonary vascular resistance is suspected 2
• Echocardiography is non-diagnostic 2
• Assessment of shunt direction, PVR, and vascular bed reactivity is needed 2

Cardiac catheterization is NOT indicated for uncomplicated PDA with adequate noninvasive imaging. 2