What is the recommended management for adult patent ductus arteriosus (PDA)?

Management of Adult Patent Ductus Arteriosus

Primary Treatment Approach

Transcatheter device closure is the first-line treatment for adult PDA and should be prioritized over surgical intervention whenever technically feasible. 1, 2

Diagnostic Evaluation

Before determining management, perform these critical assessments:

• Measure oxygen saturation in both feet AND both hands to detect differential cyanosis from right-to-left shunting (lower extremities may be cyanotic while upper extremities remain pink in Eisenmenger physiology) 1
• Perform ambulatory pulse oximetry in addition to resting measurements, as some patients with resting oxygen saturation >90% will desaturate to <90% with activity, indicating dynamic shunt reversal 1
• Echocardiography is the key diagnostic tool to assess left atrial/LV enlargement, pulmonary artery pressure, shunt direction, and cardiac chamber dimensions 1
• Cardiac catheterization with invasive hemodynamics is indicated when pulmonary hypertension is suspected on echocardiography to accurately measure pulmonary vascular resistance and assess vasoreactivity 1

Indications for PDA Closure

Class I Recommendations (Definite Closure Indicated)

Close the PDA if ANY of the following are present: 1

• Left atrial or left ventricular enlargement attributable to PDA with net left-to-right shunt
• PA systolic pressure <50% of systemic pressure AND pulmonary vascular resistance <1/3 systemic resistance
• Prior history of endarteritis (infective endocarditis)

Class IIa/IIb Recommendations (Closure May Be Considered)

PDA closure may be considered in these scenarios: 1

• Small asymptomatic PDA with continuous murmur (reasonable to close via catheter device) 1, 3
• Net left-to-right shunt with PA systolic pressure ≥50% systemic OR pulmonary vascular resistance >1/3 systemic but still demonstrating left-to-right flow 1
• Even with elevated pulmonary pressures, closure may prevent further progression of pulmonary arterial hypertension if persistent left-to-right shunting exists 1

Class III (Closure Contraindicated - HARM)

DO NOT close the PDA if: 1

• Net right-to-left shunt (Eisenmenger physiology) with PA systolic pressure >2/3 systemic OR pulmonary vascular resistance >2/3 systemic
• This represents irreversible pulmonary vascular disease where closure would be harmful

Treatment Modality Selection

Transcatheter Device Closure (First-Line)

Device closure should be attempted first for all suitable anatomy because: 1, 2, 3

• Success rates exceed 95% with complete closure approaching 100% in follow-up 4
• In adults, ductal calcification and tissue friability make surgical manipulation significantly more hazardous 1
• Large PDAs up to 16mm can be closed with available devices (AMPLATZER, Cocoon, Cera occluders) 5, 4
• Even off-label use of large occluders (≥16mm) shows effective and safe outcomes in adolescents and adults 5

Surgical Closure (Reserved for Specific Scenarios)

Surgery should ONLY be considered when: 1, 2, 3

• PDA is too large for available device closure
• Distorted ductal anatomy precludes device closure (aneurysm or endarteritis)
• Concomitant cardiac surgery is required for other indications (e.g., coronary artery bypass grafting)
• Critical pitfall: Consult with ACHD interventional cardiologists BEFORE selecting surgical closure for calcified PDAs 1, 2
• Surgery must be performed by a surgeon experienced in congenital heart disease 1

Special Consideration: PDA with Severe Pulmonary Hypertension

For adults with PDA and severe pulmonary arterial hypertension:

• Trial balloon occlusion during cardiac catheterization is essential to assess hemodynamic response 6
• If mean pulmonary arterial pressure decreases significantly after trial occlusion AND systemic oxygen saturation remains >90%, transcatheter closure can proceed safely 6
• If pulmonary arterial pressure increases by >10mmHg after trial occlusion OR oxygen saturation drops below 85%, closure is contraindicated 6
• Successful closure in appropriate candidates results in sustained reduction of mean pulmonary pressure (e.g., from 77mmHg to 33mmHg) 4

Post-Closure Management

Follow-Up Schedule

• Discharge from follow-up once complete closure is documented by transthoracic echocardiography 1, 2, 3
• For device closure: Follow-up every 5 years is recommended due to limited long-term data on device durability 1, 2, 3
• For small unclosed PDAs without volume overload: Routine follow-up every 3-5 years 1, 3

Endocarditis Prophylaxis

• Discontinue antibiotic prophylaxis 6 months after complete PDA closure is documented 1, 2, 3

Critical Pitfalls to Avoid

• Never rely solely on upper extremity oxygen saturation - always check feet and both hands to avoid missing differential cyanosis 1
• Do not assume small PDAs are benign - even small PDAs carry risk of endarteritis and may warrant closure 1, 3, 7
• Avoid surgical closure as first-line in adults - calcification makes surgery hazardous; attempt device closure first 1, 2
• Do not close PDAs with established Eisenmenger physiology - this causes harm 1
• Always perform invasive hemodynamics when pulmonary hypertension is suspected - echocardiography alone may be insufficient for decision-making 1