Management of patent ductus arteriosus
- Thomas Doyle, MD
Thomas Doyle, MD
- Associate Professor of Pediatrics
- Vanderbilt University School of Medicine
- Ann Kavanaugh-McHugh, MD
Ann Kavanaugh-McHugh, MD
- Associate Professor of Pediatrics
- Vanderbilt University School of Medicine
- Jonathan Soslow, MD
Jonathan Soslow, MD
- Assistant Professor of Pediatric Cardiology
- Vanderbilt University School of Medicine
- Kevin Hill, MD
Kevin Hill, MD
- Associate Professor of Pediatric Cardiology
- Duke University School of Medicine
- Section Editors
- John K Triedman, MD
John K Triedman, MD
- Section Editor — Pediatric Cardiology
- Professor of Pediatrics
- Harvard Medical School
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
The ductus arteriosus (DA) is a fetal vascular connection between the main pulmonary artery and the aorta (figure 1) that diverts blood away from the pulmonary bed. After delivery, the DA undergoes active constriction and eventual obliteration. A patent ductus arteriosus (PDA) occurs when the DA fails to close postnatally. (See "Physiologic transition from intrauterine to extrauterine life".)
The management of PDA in full-term infants, older children, and adults will be reviewed here. PDA in the premature infant, and the pathogenesis, clinical manifestations, and diagnosis of PDA are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants" and "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults" and "Management of patent ductus arteriosus in preterm infants".)
INDICATIONS FOR CLOSURE
In patients with a patent ductus arteriosus (PDA), the primary management decision is whether to actively close the PDA, or to conservatively observe and monitor the patient's cardiac status on a regular basis . (See 'Management approach' below.)
PDA closure is recommended for patients with moderate or large PDAs associated with symptoms of significant left-to-right shunting, clinical evidence of left-sided volume overload (ie, left atrial or ventricular enlargement), or reversible pulmonary arterial hypertension (PAH) . Closure results in resolution of symptoms and a decrease in the likelihood or severity of PAH, and the development of irreversible pulmonary vascular disease (Eisenmenger syndrome). (See "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults", section on 'Moderate PDA' and "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults", section on 'Large PDA'.)
PDA closure is also indicated in patients with a previous episode of endocarditis regardless of the size of PDA in the absence of severe PAH.
- Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008; 118:e714.
- Rigby ML. Closure of a large patent ductus arteriosus in adults: first do no harm. Heart 2007; 93:417.
- Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968; 30:4.
- Huggon IC, Qureshi SA. Is the prevention of infective endarteritis a valid reason for closure of the patent arterial duct? Eur Heart J 1997; 18:364.
- Giroud JM, Jacobs JP. Evolution of strategies for management of the patent arterial duct. Cardiol Young 2007; 17 Suppl 2:68.
- Lloyd TR, Beekman RH 3rd. Clinically silent patent ductus arteriosus. Am Heart J 1994; 127:1664.
- Houston AB, Gnanapragasam JP, Lim MK, et al. Doppler ultrasound and the silent ductus arteriosus. Br Heart J 1991; 65:97.
- Celebi A, Erdem A, Cokuğraş H, Ahunbay G. Infective endarteritis in a 2-month-old infant associated with silent patent ductus arteriosus. Anadolu Kardiyol Derg 2007; 7:325.
- Parthenakis FI, Kanakaraki MK, Vardas PE. Images in cardiology: silent patent ductus arteriosus endarteritis. Heart 2000; 84:619.
- Onji K, Matsuura W. Pulmonary endarteritis and subsequent pulmonary embolism associated with clinically silent patent ductus arteriosus. Intern Med 2007; 46:1663.
- Ozkokeli M, Ates M, Uslu N, Akcar M. Pulmonary and aortic valve endocarditis in an adult patient with silent patent ductus arteriosus. Jpn Heart J 2004; 45:1057.
- Prieto LR, DeCamillo DM, Konrad DJ, et al. Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus. Pediatrics 1998; 101:1020.
- Thilén U, Aström-Olsson K. Does the risk of infective endarteritis justify routine patent ductus arteriosus closure? Eur Heart J 1997; 18:503.
- Fortescue EB, Lock JE, Galvin T, McElhinney DB. To close or not to close: the very small patent ductus arteriosus. Congenit Heart Dis 2010; 5:354.
- Dutta S, Mihailovic A, Benson L, et al. Thoracoscopic ligation versus coil occlusion for patent ductus arteriosus: a matched cohort study of outcomes and cost. Surg Endosc 2008; 22:1643.
- Feltes TF, Bacha E, Beekman RH 3rd, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011; 123:2607.
- Lam JY, Lopushinsky SR, Ma IW, et al. Treatment Options for Pediatric Patent Ductus Arteriosus: Systematic Review and Meta-analysis. Chest 2015; 148:784.
- Magee AG, Huggon IC, Seed PT, et al. Transcatheter coil occlusion of the arterial duct; results of the European Registry. Eur Heart J 2001; 22:1817.
- Celiker A, Aypar E, Karagöz T, et al. Transcatheter closure of patent ductus arteriosus with Nit-Occlud coils. Catheter Cardiovasc Interv 2005; 65:569.
- Kumar RK, Krishnan MN, Venugopal K, et al. Bioptome-assisted simultaneous delivery of multiple coils for occlusion of the large patent ductus arteriosus. Catheter Cardiovasc Interv 2001; 54:95.
- Hijazi ZM, Geggel RL. Transcatheter closure of large patent ductus arteriosus (> or = 4 mm) with multiple Gianturco coils: immediate and mid-term results. Heart 1996; 76:536.
- Galal MO. Advantages and disadvantages of coils for transcatheter closure of patent ductus arteriosus. J Interv Cardiol 2003; 16:157.
- Patent Ductus Arteriosus Closure Devices Instructions for Use. http://professional.sjm.com/resources/ifu/sh/pda-closure (Accessed on February 07, 2014).
- El-Said HG, Bratincsak A, Foerster SR, et al. Safety of percutaneous patent ductus arteriosus closure: an unselected multicenter population experience. J Am Heart Assoc 2013; 2:e000424.
- Zhang DZ, Zhu XY, Lv B, et al. Trial occlusion to assess the risk of persistent pulmonary arterial hypertension after closure of a large patent ductus arteriosus in adolescents and adults with elevated pulmonary artery pressure. Circ Cardiovasc Interv 2014; 7:473.
- Yan C, Zhao S, Jiang S, et al. Transcatheter closure of patent ductus arteriosus with severe pulmonary arterial hypertension in adults. Heart 2007; 93:514.
- Mavroudis C, Backer CL. Pediatric Cardiac Surgery, 3rd ed, Mosby-Year Book Inc, Philadelphia 2003. p.875.
- Bensky AS, Raines KH, Hines MH. Late follow-up after thoracoscopic ductal ligation. Am J Cardiol 2000; 86:360.
- Nezafati MH, Soltani G, Kahrom M. Esophageal stethoscope: an old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure. J Pediatr Surg 2010; 45:2141.
- Vanamo K, Berg E, Kokki H, Tikanoja T. Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus. J Pediatr Surg 2006; 41:1226.
- Chen H, Weng G, Chen Z, et al. Comparison of posterolateral thoracotomy and video-assisted thoracoscopic clipping for the treatment of patent ductus arteriosus in neonates and infants. Pediatr Cardiol 2011; 32:386.
- Nezafati MH, Soltani G, Vedadian A. Video-assisted ductal closure with new modifications: minimally invasive, maximally effective, 1,300 cases. Ann Thorac Surg 2007; 84:1343.
- Omari BO, Shapiro S, Ginzton L, et al. Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion. Ann Thorac Surg 1998; 66:277.
- Clyman RI. Ibuprofen and patent ductus arteriosus. N Engl J Med 2000; 343:728.
- Porstmann W, Wierny L, Warnke H. Closure of persistent ductus arteriosus without thoracotomy. Ger Med Mon 1967; 12:259.
- Wierny L, Plass R, Porstmann W. Transluminal closure of patent ductus arteriosus: long-term results of 208 cases treated without thoracotomy. Cardiovasc Intervent Radiol 1986; 9:279.
- Eerola A, Jokinen E, Boldt T, Pihkala J. The influence of percutaneous closure of patent ductus arteriosus on left ventricular size and function: a prospective study using two- and three-dimensional echocardiography and measurements of serum natriuretic peptides. J Am Coll Cardiol 2006; 47:1060.
- Cambier PA, Kirby WC, Wortham DC, Moore JW. Percutaneous closure of the small (less than 2.5 mm) patent ductus arteriosus using coil embolization. Am J Cardiol 1992; 69:815.
- Ebeid MR, Gaymes CH, Smith JC, et al. Gianturco-Grifka vascular occlusion device for closure of patent ductus arteriosus. Am J Cardiol 2001; 87:657.
- Benson L, McLaughlin PR, Webb GD. The European experience with coil occlusion of PDA: strength in numbers. Eur Heart J 2001; 22:1768.
- Rashkind WJ, Mullins CE, Hellenbrand WE, Tait MA. Nonsurgical closure of patent ductus arteriosus: clinical application of the Rashkind PDA Occluder System. Circulation 1987; 75:583.
- Grifka RG, Vincent JA, Nihill MR, et al. Transcatheter patent ductus arteriosus closure in an infant using the Gianturco-Grifka Vascular Occlusion Device. Am J Cardiol 1996; 78:721.
- Bridges ND, Perry SB, Parness I, et al. Transcatheter closure of a large patent ductus arteriosus with the clamshell septal umbrella. J Am Coll Cardiol 1991; 18:1297.
- Pass RH, Hijazi Z, Hsu DT, et al. Multicenter USA Amplatzer patent ductus arteriosus occlusion device trial: initial and one-year results. J Am Coll Cardiol 2004; 44:513.
- Thanopoulos BD, Hakim FA, Hiari A, et al. Further experience with transcatheter closure of the patent ductus arteriosus using the Amplatzer duct occluder. J Am Coll Cardiol 2000; 35:1016.
- Bilkis AA, Alwi M, Hasri S, et al. The Amplatzer duct occluder: experience in 209 patients. J Am Coll Cardiol 2001; 37:258.
- Thanopoulos BV, Eleftherakis N, Tzannos K, et al. Further experience with catheter closure of patent ductus arteriosus using the new Amplatzer duct occluder in children. Am J Cardiol 2010; 105:1005.
- Patent Ductus Arteriosus (PDA) Closure Device. http://professional.sjm.com/products/sh/heart-occluders/pda-closure-devices (Accessed on February 07, 2014).
- U.S. Food and Drug Administration Medical Devices. August 2013 PMA Approvals. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/PMAApprovals/ucm377425.htm (Accessed on December 09, 2015).
- U.S. Food and Drug Administration summary of safety and effectiveness data. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm366245.htm (Accessed on January 20, 2014).
- Moore JW, Greene J, Palomares S, et al. Results of the combined U.S. Multicenter Pivotal Study and the Continuing Access Study of the Nit-Occlud PDA device for percutaneous closure of patent ductus arteriosus. JACC Cardiovasc Interv 2014; 7:1430.
- Van Hare GF, Ackerman MJ, Evangelista JA, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e281.
- INDICATIONS FOR CLOSURE
- MANAGEMENT APPROACH
- Observation versus PDA closure
- Premature infants
- Term infants <5 kg
- Infants and children >5 kg
- - Occluder choice
- - Surgical ligation
- Adolescents and adults
- - Patients with PAH
- THERAPEUTIC INTERVENTIONS
- Pharmacologic therapy
- - Complications
- Percutaneous closure
- - Coil occlusion
- - Device occlusion
- - MRI compatibility
- Comparison between approaches
- LONG-TERM MANAGEMENT
- Antibiotic prophylaxis
- Sports participation
- SUMMARY AND RECOMMENDATIONS
- Indications for PDA closure