What are the treatment options for patent ductus arteriosus (PDA)?

Treatment of Patent Ductus Arteriosus

Device closure via transcatheter approach is the method of choice for PDA treatment in adults and older children when technically feasible, with closure recommended when there is left atrial or left ventricular enlargement with net left-to-right shunt, pulmonary artery systolic pressure less than 50% systemic, and pulmonary vascular resistance less than one-third systemic. 1

Indications for PDA Closure

Clear Indications (Class I)

• Closure is mandatory when left atrial and/or left ventricular enlargement is present and attributable to PDA with net left-to-right shunt, provided pulmonary artery systolic pressure is <50% systemic and pulmonary vascular resistance is <1/3 systemic 1
• Prior history of endarteritis is an absolute indication for closure 1
• Signs of left ventricular volume overload warrant closure 1

Conditional Indications (Class IIa)

• Small PDAs with continuous murmur (normal LV and pulmonary artery pressure) should be considered for device closure 1
• Elevated pulmonary pressures with preserved left-to-right shunt: Closure may be considered when pulmonary artery pressure is ≥50% systemic or pulmonary vascular resistance is ≥1/3 systemic, but only if there remains net left-to-right shunt (Qp:Qs >1.5) or pulmonary vascular reactivity testing demonstrates reversibility 1

Absolute Contraindications (Class III)

• PDA closure must be avoided in patients with net right-to-left shunt and pulmonary artery systolic pressure >2/3 systemic or pulmonary vascular resistance >2/3 systemic (Eisenmenger physiology) 1
• Silent duct (very small, no murmur) should not be closed 1
• Exercise-induced lower limb desaturation is a contraindication to closure 1

Treatment Modalities

Device Closure (Preferred Method)

Device closure is the method of choice where technically suitable 1. This is particularly important in adults where ductal calcification and tissue friability make surgical manipulation hazardous 1, 2. Success rates exceed 95% with low early mortality 1, 2.

Surgical Closure Indications

Surgery should be performed by a surgeon experienced in congenital heart disease 1, 2 and is indicated only when:

• PDA is too large for device closure 1
• Distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis) 1
• Concomitant cardiac surgery is required for other indications 1
• Consultation with ACHD interventional cardiologists is recommended before surgical closure is selected, especially with calcified PDA 1, 2

Pharmacological Management (Neonates/Infants Only)

For premature infants with hemodynamically significant PDA:

• Ibuprofen: Initial dose 10 mg/kg IV, followed by two doses of 5 mg/kg at 24-hour intervals, with renal function monitoring 2
• Indomethacin: Alternative NSAID but higher risk of renal and gastrointestinal side effects 2, 3
• Surgical ligation indicated when pharmacological treatment fails in symptomatic infants 2, 4

Diagnostic Assessment Before Treatment

Essential Evaluations

• Oxygen saturation measurement in feet and both hands to assess for right-to-left shunting 1, 5
• Echocardiography with color Doppler in parasternal short-axis view is the key diagnostic technique, assessing LV volume overload, pulmonary artery pressure, and right heart changes 1, 2
• Cardiac catheterization is indicated when pulmonary artery pressure is elevated on echocardiography to evaluate degree of shunt, pulmonary vascular resistance, and vascular bed reactivity 1

Critical Pitfall

In older adults, look for calcification in the region of the ductus on chest X-ray, as a calcified ductus poses increased surgical risk and mandates device closure as first option 1

Follow-Up Management

After Successful Closure

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

Small Unclosed PDA

• Routine follow-up every 3-5 years for patients with small PDA without left-heart volume overload 1, 2

Special Considerations by Clinical Presentation

Small PDA (Asymptomatic)

• Normal left ventricle and pulmonary artery pressure 1, 5
• Device closure may be considered if continuous murmur present 1

Moderate PDA

• With predominant LV volume overload: Large LV with normal or reduced function, may present with left heart failure—closure indicated 1
• With predominant pulmonary hypertension: Pressure-overloaded RV, may present with right heart failure—assess pulmonary vascular resistance before closure 1

Large PDA with Eisenmenger Physiology

• Differential cyanosis (lower extremities cyanotic, sometimes left arm) 1
• Closure is contraindicated 1