PDA Closure Prophylaxis
Prophylactic PDA closure is not recommended in preterm infants, as it exposes the majority of infants unnecessarily to medications with significant adverse effects without conferring important short-term benefits, given that 58% of PDAs close spontaneously by day 3-4 of life. 1
Evidence Against Prophylactic Closure
Prophylactic ibuprofen decreases PDA incidence but lacks justification for routine use because it treats many infants whose ductus would have closed spontaneously, while exposing them to risks of oliguria, elevated creatinine, and gastrointestinal hemorrhage. 1
High-quality evidence demonstrates that prophylactic ibuprofen increases the risk of oliguria (NNTH 17) compared to placebo, with no reduction in mortality, chronic lung disease, or necrotizing enterocolitis. 1
Current evidence does not support prophylactic ibuprofen use, and no further trials of prophylactic therapy are recommended until long-term follow-up data become available. 1
Recommended Approach: Early Targeted Treatment
The preferred strategy is early targeted treatment based on echocardiographic criteria within the first 72 hours of life, identifying PDAs with high sensitivity for those unlikely to close spontaneously, rather than treating all at-risk infants prophylactically. 1
When Treatment IS Indicated (Not Prophylaxis)
For adults with PDA, closure (percutaneous or surgical) is indicated for:
- Left atrial and/or left ventricular enlargement, or pulmonary arterial hypertension with net left-to-right shunting. 2
- Prior history of endarteritis. 2
Closure is reasonable for:
- Asymptomatic small PDA by catheter device (Class IIa recommendation). 2
- Patients with pulmonary arterial hypertension and net left-to-right shunt. 2
Closure is contraindicated in:
- Patients with pulmonary arterial hypertension and net right-to-left shunt (Eisenmenger physiology). 2, 3
Treatment Options When Intervention Is Needed
Neonatal/Pediatric Population
If pharmacological treatment is required (not prophylaxis, but for symptomatic or echocardiographically-confirmed hemodynamically significant PDA):
Ibuprofen is preferred over indomethacin due to reduced risk of necrotizing enterocolitis (NNTB 25) and transient renal insufficiency (NNTB 11), with equal efficacy for PDA closure. 4, 5
Oral ibuprofen is as effective as IV ibuprofen and further reduces NEC risk compared to indomethacin (NNTB 8). 4
Dosing regimen: Initial dose 10 mg/kg IV, followed by 5 mg/kg at 24-hour intervals for two additional doses if needed. 3
Monitor renal function before and during treatment, and assess for bleeding or bruising. 3
Adult Population
Device closure via transcatheter approach is the method of choice for adults, as ductal calcification and tissue friability make surgical manipulation hazardous. 2, 3
Surgical closure is reserved for:
- PDA too large for device closure. 2
- Distorted ductal anatomy precluding device closure (aneurysm or endarteritis). 2
- When concomitant cardiac surgery is required for other indications. 2
Critical Pitfalls to Avoid
Do not use NSAIDs (ibuprofen/indomethacin) in the third trimester of pregnancy due to risk of premature ductal closure in the fetus. 6, 7
Avoid ibuprofen at approximately 30 weeks gestation and later as it can cause premature closure of the fetal ductus arteriosus. 7
Do not use ibuprofen in infants with active bleeding (especially intracranial or gastrointestinal) or significant renal dysfunction. 3
Recognize that indomethacin reduces cerebral and renal blood flow, making ibuprofen the preferred agent when pharmacological treatment is necessary. 4, 5
Follow-Up After Closure
Discharge from follow-up once complete closure is documented by transthoracic echocardiography. 2, 3
Discontinue endocarditis prophylaxis 6 months after complete closure. 2
For device closure, follow-up every 5 years is recommended due to lack of long-term data. 2
For small PDAs without left-heart volume overload, routine follow-up every 3-5 years is appropriate. 2, 3