What is the best course of action for a patient with late presentation patent ductus arteriosus (PDA)?

Late Presentation Patent Ductus Arteriosus

For late presentation PDA in older children and adults, transcatheter device closure is the definitive first-line treatment and should be prioritized over surgical intervention whenever technically feasible. 1, 2

Diagnostic Confirmation

Before proceeding with any intervention, confirm the diagnosis and assess hemodynamic significance:

• Perform echocardiography with color Doppler in the parasternal short-axis view to visualize the PDA and measure the transpulmonary gradient with continuous-wave Doppler to estimate pulmonary artery pressure 1, 3
• Measure oxygen saturation in both feet and both hands to detect differential cyanosis from right-to-left shunting, which would indicate Eisenmenger physiology 2
• Obtain cardiac catheterization when significant pulmonary vascular resistance elevation is suspected, to evaluate shunt direction, PVR, and vascular bed reactivity 4, 1
• Look for ductal calcification on imaging, as this increases surgical risk and makes device closure even more preferable 4, 2

Indications for Closure

Closure is mandatory in the following scenarios:

• Left atrial and/or left ventricular enlargement with net left-to-right shunting 4, 1, 2
• Pulmonary arterial hypertension with net left-to-right shunting 4, 1
• Prior history of endarteritis 4, 1

Closure is reasonable even for:

• Small asymptomatic PDAs with continuous murmur audible on auscultation 3, 2

Closure is absolutely contraindicated when:

• Eisenmenger physiology is present (PAH with net right-to-left shunt) 1, 2

Treatment Algorithm

First-Line: Transcatheter Device Closure

Device closure should be attempted first for the following reasons specific to late presentation:

• In adults, ductal calcification and tissue friability make surgical manipulation significantly more hazardous than device closure 4, 1, 2
• Success rates exceed 95% with complete closure approaching 99-100% at follow-up 1, 5
• The Amplatzer Duct Occluder can close PDAs up to 16 mm with 99.7% complete occlusion at 1-year follow-up 3
• Coil devices are used for smaller PDAs 3, 5

Second-Line: Surgical Closure

Reserve surgery only for specific scenarios where device closure is not feasible:

• PDA too large for device closure (>16 mm) 4, 2
• Distorted ductal anatomy precluding device closure (e.g., aneurysm or endarteritis) 4, 2
• Concomitant cardiac surgery required for other indications 4, 2

Critical surgical considerations:

• Consult with ACHD interventional cardiologists before selecting surgical closure, especially for calcified PDAs 4, 1, 2
• Surgery must be performed by a surgeon experienced in congenital heart disease 4, 2
• Surgical success exceeds 95% with low early mortality, though recanalization is rare 1, 2

Common Pitfalls to Avoid

• Never proceed with closure in Eisenmenger physiology - always measure differential oxygen saturations and perform hemodynamic assessment when PAH is present 2
• Do not assume small PDAs are benign - even small asymptomatic PDAs warrant closure consideration due to endarteritis risk 3, 2
• In adults, do not default to surgery - the calcified ductus poses increased surgical risk, making device closure the safer option 4, 2
• Differentiate PDA from mimics on physical exam: aortopulmonary collateral, coronary arteriovenous fistula, ruptured sinus of Valsalva, or VSD with aortic regurgitation 4

Post-Closure Management

• Discontinue endocarditis prophylaxis 6 months after complete closure is documented 1, 2
• Discharge from follow-up once complete closure is confirmed by transthoracic echocardiography 1, 3, 2
• For device closure patients, follow-up every 5 years is recommended due to limited long-term data on devices 4, 2
• For small PDAs managed conservatively without closure, follow-up every 3-5 years is appropriate 4, 1