Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults

Thomas Doyle, MD
Ann Kavanaugh-McHugh, MD
Section Editors
Heidi M Connolly, MD, FASE
John K Triedman, MD
Deputy Editor
Carrie Armsby, MD, MPH


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 birth, the DA undergoes active constriction and eventual obliteration. A patent ductus arteriosus (PDA) occurs when the DA fails to completely close postnatally. (See "Physiologic transition from intrauterine to extrauterine life".)

The clinical manifestations and diagnosis of PDA in full term infants, older children, and adults will be reviewed here. PDA in the premature infant and the management of PDA are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants" and "Management of patent ductus arteriosus".)


The ductus arteriosus (DA) is thought to derive from the embryonic left sixth aortic arch (figure 2 and image 1). In the typical left aortic arch, the aortic end of the DA arises distal to the left subclavian artery, and the pulmonary end inserts at the junction of the main and left pulmonary arteries.

The anatomy is more varied in the presence of a right aortic arch. Most commonly, the DA arises from the left innominate artery and inserts into the region of the proximal left pulmonary artery [1]. Less frequently, the DA arises distal to the right subclavian artery and inserts near the proximal right pulmonary artery. In rare instances, there is a bilateral DA, usually in the presence of other complex congenital cardiovascular anomalies.

Regardless of the aortic arch orientation, the vascular structures remain anterior to the trachea and esophagus, and there is no vascular ring. One exception to this general rule occurs when there is a right aortic arch with an aberrant left subclavian artery. In this setting, the DA typically arises from the aberrant subclavian artery and inserts into the proximal left pulmonary artery. This creates a vascular ring with the aorta anterior to and rightward of the trachea and esophagus; the aberrant subclavian artery is posterior, and the DA is along the left side, connecting the subclavian to the pulmonary artery. (See "Vascular rings and slings", section on 'R aortic arch with aberrant L subclavian artery and L ductus arteriosus/ligamentum'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 19, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Knight L, Edwards JE. Right aortic arch. Types and associated cardiac anomalies. Circulation 1974; 50:1047.
  2. Allen HD, Driscoll DJ, Shaddy RE, Feltes T. T Moss and Adams' heart disease in infants, children, and adolescents: including the fetus and young adult, 7th ed, Lippincott Williams and Wilkins, Philadelphia 2007.
  3. Krichenko A, Benson LN, Burrows P, et al. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol 1989; 63:877.
  4. Rudolph AM. The changes in the circulation after birth. Their importance in congenital heart disease. Circulation 1970; 41:343.
  5. Smith GC. The pharmacology of the ductus arteriosus. Pharmacol Rev 1998; 50:35.
  6. Loftin CD, Trivedi DB, Langenbach R. Cyclooxygenase-1-selective inhibition prolongs gestation in mice without adverse effects on the ductus arteriosus. J Clin Invest 2002; 110:549.
  7. Thébaud B, Michelakis ED, Wu XC, et al. Oxygen-sensitive Kv channel gene transfer confers oxygen responsiveness to preterm rabbit and remodeled human ductus arteriosus: implications for infants with patent ductus arteriosus. Circulation 2004; 110:1372.
  8. Coggins KG, Latour A, Nguyen MS, et al. Metabolism of PGE2 by prostaglandin dehydrogenase is essential for remodeling the ductus arteriosus. Nat Med 2002; 8:91.
  9. Nguyen M, Camenisch T, Snouwaert JN, et al. The prostaglandin receptor EP4 triggers remodelling of the cardiovascular system at birth. Nature 1997; 390:78.
  10. Segi E, Sugimoto Y, Yamasaki A, et al. Patent ductus arteriosus and neonatal death in prostaglandin receptor EP4-deficient mice. Biochem Biophys Res Commun 1998; 246:7.
  11. Clyman RI. Mechanisms regulating the ductus arteriosus. Biol Neonate 2006; 89:330.
  12. Heymann MA, Rudolph AM. Control of the ductus arteriosus. Physiol Rev 1975; 55:62.
  13. Gittenberger-de Groot AC, Strengers JL, Mentink M, et al. Histologic studies on normal and persistent ductus arteriosus in the dog. J Am Coll Cardiol 1985; 6:394.
  14. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39:1890.
  15. Reller MD, Strickland MJ, Riehle-Colarusso T, et al. Prevalence of congenital heart defects in metropolitan Atlanta, 1998-2005. J Pediatr 2008; 153:807.
  16. RECORD RG, McKEOWN T. Observations relating to the aetiology of patent ductus arteriosus. Br Heart J 1953; 15:376.
  17. Nora JJ. Multifactorial inheritance hypothesis for the etiology of congenital heart diseases. The genetic-environmental interaction. Circulation 1968; 38:604.
  18. Davidson HR. A large family with patent ductus arteriosus and unusual face. J Med Genet 1993; 30:503.
  19. Char F. Peculiar facies with short philtrum, duck-bill lips, ptosis and low-set ears--a new syndrome? Birth Defects Orig Artic Ser 1978; 14:303.
  20. Satoda M, Pierpont ME, Diaz GA, et al. Char syndrome, an inherited disorder with patent ductus arteriosus, maps to chromosome 6p12-p21. Circulation 1999; 99:3036.
  21. Satoda M, Zhao F, Diaz GA, et al. Mutations in TFAP2B cause Char syndrome, a familial form of patent ductus arteriosus. Nat Genet 2000; 25:42.
  22. Webb GD, Smallhorn FJ, Terrien J, Redington AN. Congenital heart disease. In: Braunwalds' Heart Disease, 8th ed, Libby P, Bonow RO, Mann DL, Zipes DP (Eds), Philadelphia 2008. p.1561.
  23. Goitein O, Fuhrman CR, Lacomis JM. Incidental finding on MDCT of patent ductus arteriosus: use of CT and MRI to assess clinical importance. AJR Am J Roentgenol 2005; 184:1924.
  24. Sadiq M, Latif F, Ur-Rehman A. Analysis of infective endarteritis in patent ductus arteriosus. Am J Cardiol 2004; 93:513.
  25. Silverman NH. Pediatric Echocardiography, Williams & Wilkins, Baltimore 1993. p.173.
  26. Snider AR, Serwer GA, Ritter SB. Echocardiography in Pediatric Heart Disease, Mosby-Year Book, St. Louis 1977. p.455.
  27. Soslow JH, Kavanaugh-McHugh A, Wang L, et al. A clinical prediction model to estimate the risk for coarctation of the aorta in the presence of a patent ductus arteriosus. J Am Soc Echocardiogr 2013; 26:1379.
  28. Serwer GA, Armstrong BE, Anderson PA. Nonivasive detection of retrograde descending aortic flow in infants using continuous wave doppler ultrasonography. Implications for diagnosis of aortic run-off lesions. J Pediatr 1980; 97:394.
  29. Cloez JL, Isaaz K, Pernot C. Pulsed Doppler flow characteristics of ductus arteriosus in infants with associated congenital anomalies of the heart or great arteries. Am J Cardiol 1986; 57:845.
  30. Hiraishi S, Horiguchi Y, Misawa H, et al. Noninvasive Doppler echocardiographic evaluation of shunt flow dynamics of the ductus arteriosus. Circulation 1987; 75:1146.
  31. Mullins CE. Patent ductus arteriosus. In: The Science and Practice of Pediatric Cardiology, Garson A, Bricker JT, McNamara DG (Eds), Lea & Febiger, Philadelphia 1990. p.1055.
  32. Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968; 30:4.
  33. Thilén U, Aström-Olsson K. Does the risk of infective endarteritis justify routine patent ductus arteriosus closure? Eur Heart J 1997; 18:503.
  34. Morris CD, Reller MD, Menashe VD. Thirty-year incidence of infective endocarditis after surgery for congenital heart defect. JAMA 1998; 279:599.
  35. Lankipalli RS, Lax K, Keane MG, et al. Images in cardiovascular medicine. Infected patent ductus arteriosus. Circulation 2005; 112:e364.
  36. 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.
  37. 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.
  38. Chen WJ, Chen JJ, Lin SC, et al. Detection of cardiovascular shunts by transesophageal echocardiography in patients with pulmonary hypertension of unexplained cause. Chest 1995; 107:8.