PDA Closure in Children: Guideline-Based Recommendations
Primary Treatment Approach
Transcatheter device closure is the first-line intervention for PDA closure in children and should be prioritized over surgical approaches whenever technically feasible. 1, 2, 3
Indications for PDA Closure
Class I (Definitive) Indications
Closure is mandatory when any of the following are present:
- Left atrial or left ventricular enlargement attributable to PDA with net left-to-right shunt 1, 3
- Congestive heart failure or failure to thrive 1, 3
- Pulmonary overcirculation (with or without pulmonary hypertension) 1
- Pulmonary artery systolic pressure <50% of systemic pressure AND pulmonary vascular resistance <1/3 systemic 1
Class IIa (Reasonable) Indications
Closure is reasonable for:
- Small PDA with continuous murmur audible by standard auscultation, even if asymptomatic with normal-sized heart chambers 1, 3
Class IIb (May Consider) Indications
Closure may be considered in rare instances:
- Bidirectional PDA shunt with pulmonary hypertension that is reversible to pure left-to-right shunting with pulmonary vasodilator therapy 1
- PA systolic pressure ≥50% systemic and/or pulmonary vascular resistance >1/3 systemic, but only if net left-to-right shunt persists 1
Class III (Contraindicated)
Closure is contraindicated when:
- Net right-to-left shunt (Eisenmenger physiology) with PA systolic pressure >2/3 systemic or pulmonary vascular resistance >2/3 systemic 1, 3
Device Selection and Technical Approach
Preferred Devices
- Amplatzer Duct Occluder: Standard device for PDAs up to 16 mm, with 99.7% complete occlusion at 1-year follow-up 1
- Coil devices: Multiple coil techniques for smaller PDAs 1, 4
- Amplatzer Muscular VSD Occluder: For tubular (type C) PDAs in small children with congestive heart failure, particularly when standard PDA devices fail 5
Technical Considerations
- Minimum weight: While manufacturer recommendations exclude patients <6 kg, successful closure has been reported in infants as small as 2.4-2.5 kg, though technically more challenging 1, 5
- Anticoagulation: Administer 50-100 U/kg unfractionated heparin at time of device implantation 3
Critical Pre-Procedural Assessment
Mandatory Evaluations
Before any closure attempt, perform:
- Differential oxygen saturation measurement in both feet AND both hands to detect right-to-left shunting 1, 2
- Echocardiography with color Doppler in parasternal short-axis view to confirm diagnosis 3, 6
- Continuous-wave Doppler to measure transpulmonary gradient and estimate PA pressure 3
When Cardiac Catheterization is Required
Proceed to invasive hemodynamic assessment when: 3, 6
- Significant elevation of pulmonary vascular resistance is suspected
- Echocardiography is non-diagnostic
- Assessment of shunt direction, PVR, and pulmonary vascular bed reactivity is needed
- Pulmonary vasoreactivity testing is mandatory before considering closure in patients with bidirectional flow 1
Surgical Closure: Reserved Scenarios Only
Surgery should only be considered when: 2, 3
- PDA is too large for device closure
- Distorted ductal anatomy precludes device placement
- Calcified PDA (particularly in adults)
- Concomitant cardiac surgery is required for other indications
Critical caveat: Consult with ACHD interventional cardiologists before selecting surgical closure, especially for calcified PDAs 3
Special Population: Pulmonary Hypertension
Children with Elevated PA Pressures
- Transcatheter closure can be performed safely in children with pulmonary hypertension (PVRI >3 WU·m²) if net left-to-right shunt persists 7
- 72.7% of patients on pulmonary vasodilators pre-closure were successfully weaned post-procedure (median 24 months) 7
- Premature infants with pulmonary hypertension particularly benefit from closure 7
Risk Stratification
- Higher complication risk: Coil devices in hypertensive PDAs (avoid if possible) 7
- ICU admission more likely: Patients on baseline pulmonary vasodilator therapy (83.3% vs 14.3%) 7
Post-Closure Management
Endocarditis Prophylaxis
- Discontinue 6 months after complete closure is documented 2
- Continue prophylaxis if residual shunt persists 1
Follow-Up Schedule
- Serial echocardiograms to monitor for complete closure 3
- Discharge from follow-up once complete closure documented by echocardiography 1, 2, 3
- For small PDAs without left-heart volume overload: routine follow-up every 3-5 years 3
- For device closure patients: follow-up every 5 years due to limited long-term data 2
Expected Outcomes
- Complete occlusion rates: 77.8% at 24 hours, 92.6% at 1 month, 94.4% at long-term follow-up 4
- Residual shunting through Amplatzer devices is common initially but resolves in 99.7% by 1 year 1
Complications and Management
Device-Related Complications (Rare)
- Device embolization: 9.1% in one series, more common with coils 7
- Aortic obstruction (iatrogenic coarctation) in small infants 1
- Left pulmonary artery stenosis: Mild stenosis may occur but typically improves over time 5
- Hemolysis and recanalization: Rare 1