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Patent Ductus Arteriosus (PDA)

While still in the mother’s womb, a baby doesn’t need his or her lungs to supply oxygen because the baby receives oxygen via the mother’s lungs and placenta. Since a baby’s lungs do not provide oxygen, there is no need for energy to be expended pumping blood to the lungs. The ductus arteriosus is a blood vessel that is present in all babies while still in the womb that allows blood to bypass the pathway to the lungs; it allows blood to flow from the pulmonary artery to the aorta.

When the baby is born and the umbilical cord is cut, the lungs are now needed to supply oxygen. The lungs expand, their blood vessels relax to accept more flow and the ductus arteriosus usually closes within the first hours of life. On occasion, however, the ductus arteriosus does not close on its own. This is referred to as a patent (“open”) ductus arteriosus. While this condition is much more often seen in premature babies, it may also appear in term infants.

Hospital Stay: Hospital Stay: 3 days
Duration: Duration: 1.5 - 2 hrs
Cost Estimate: Cost Estimate: 3825 USD - 5520 USD These are indicative prices in Indian Hospitals

PDA affects girls more often than boys. The condition is more common in premature infants and those with neonatal respiratory distress syndrome. Infants with genetic disorders, such as Down syndrome, or babies whose mothers had rubella during pregnancy are at higher risk for PDA.
PDA is common in babies with congenital heart problems, such as hypoplastic left heart syndrome, transposition of the great vessels, and pulmonary stenosis.

Symptoms:

The symptoms of a patent ductus arteriosus depend on the size of the ductus and how much blood flow it carries. After birth, the pressures and resistance are much tighter in the aorta than the pulmonary artery, so if a ductus arteriosus is present, blood will flow from the aorta into the pulmonary artery. This extra blood flow into the lungs can overload the lungs and put an additional burden on the heart to pump this extra blood.
This situation may not be well tolerated in a premature baby who already has problems related to immaturity of the lungs themselves. These babies may need more support from the ventilator and have symptoms of congestive heart failure. Symptoms such as the following can be noted:

  • Fast breathing
  • Poor feeding habits
  • Rapid pulse
  • Shortness of breath
  • Sweating while feeding
  • Tiring very easily
  • Poor growth

Diagnosis:

Because of turbulent blood flow from the high pressure aorta to the low pressure pulmonary artery, a patent ductus arteriosus causes a characteristic heart murmur that is heard on physical exam. The presence of the characteristic murmur along with symptoms of heart failure in a premature infant most frequently leads to the diagnosis of patent ductus arteriosus.

  1. Chest X-ray will show an enlarged heart and evidence of an excessive amount of blood flow to the lungs.
  2. An Echocardiogram is performed to confirm the diagnosis. This will demonstrate the size of the ductus arteriosus and will demonstrate if the heart chambers have become enlarged due to the extra blood flow.

In older children, though, the chest X-ray is typically normal. An echocardiogram will demonstrate the flow of blood through the patent ductus arteriosus and will typically be performed to confirm the diagnosis.

In a newborn, the patent ductus arteriosus still has the potential to close on its own without intervention. Thus, in newborns, additional time may be allowed for the patent ductus arteriosus to close on its own if the heart failure can be easily managed. If symptoms are severe, such as in a premature infant, or if it is felt that it is unlikely to close on its own, however, medical or surgical closure is pursued.

If a patent ductus arteriosus is still present beyond the newborn period, it will generally never close on its own. Closure is recommended in such cases to prevent the future risk of endocarditis.

In newborns, a medication such as indomethacin or ibuprofen can be given. These medications are given in the stomach and can constrict the muscle in the wall of the patent ductus arteriosus and promote closure. These drugs do have side effects, however, such as kidney injury or bleeding, so not all babies can receive them. Because of the potential side effects, the baby must have lab values checked before medications can be given. If the lab values are not normal or if the medications do not work, surgery can be performed and the patent ductus arteriosus tied off (ligated).

Medications are generally only successful in newborns. In older infants and children, options for closure include surgery or closure in the cardiac catheterization laboratory with a device or coil.

During the cardiac catheterization procedure, the patient is either sedated or placed under general anesthesia (depending on age) and catheters are placed into blood vessels in the groin. The catheters are then positioned in the aorta close to the ductus arteriosus, and a picture (called an angiogram) is taken to define the shape and size of the of the ductus arteriosus. Various devices are now available to close the ductus. If the ductus is small, a coil may be placed within the vessel, but if larger, different types of plug-shaped devices can be used to occlude the vessel.

The ductus arteriosus may also be closed with surgery. A small incision is made between the ribs on the left side, and the ductus arteriosus is tied (ligated) and cut. Surgical closure of the patent ductus arteriosus can be performed at any age, and is specifically recommended in some situations such as a very large patent ductus arteriosus or other unusual anatomy.

Outlook:

If a small PDA stays open, the baby may eventually develop heart symptoms. Babies with a larger PDA could develop heart problems such as heart failure, high blood pressure in the arteries of the lungs, or an infection of the inner lining of the heart if the PDA does not close. The risk of complications with any of these treatments is low, determined mostly by how ill the child is prior to treatment.

It is an unclosed hole in the aorta which should happen naturally and normally on birth.

Before a baby is born, the fetus’s blood does not need to go to the lungs to get oxygenated. The ductus arteriosus is a hole that allows the blood to skip the circulation to the lungs. However, when the baby is born, the blood must receive oxygen in the lungs and this hole is supposed to close. If the ductus arteriosus is still open (or patent) the blood may skip this necessary step of circulation. The open hole is called the patent ductus arteriosus.

The ductus arteriosus is a normal fetal artery connecting the main body artery (aorta) and the main lung artery (pulmonary artery). The ductus allows blood to detour away from the lungs before birth.
Every baby is born with a ductus arteriosus. After birth, the opening is no longer needed and it usually narrows and closes within the first few days.

Sometimes, the ductus doesn’t close after birth. Failure of the ductus to close is common in premature infants but rare in full-term babies. In most children, the cause of PDA isn’t known. Some children can have other heart defects along with the PDA.

Normally the heart’s left side only pumps blood to the body, and the right side only pumps blood to the lungs. In a child with PDA, extra blood gets pumped from the body artery (aorta) into the lung (pulmonary) arteries. If the PDA is large, the extra blood being pumped into the lung arteries makes the heart and lungs work harder and the lungs can become congested.

If the PDA is small, it won’t cause symptoms because the heart and lungs don’t have to work harder. The only abnormal finding may be a distinctive type of murmur (noise heard with a stethoscope).

If the PDA is large, the child may breathe faster and harder than normal. Infants may have trouble feeding and growing at a normal rate. Symptoms may not occur until several weeks after birth. High pressure may occur in the blood vessels in the lungs because more blood than normal is being pumped there. Over time this may cause permanent damage to the lung blood vessels.

If the PDA (ductus) is small, it doesn’t make the heart and lungs work harder. Surgery and other treatments may not be needed. Small PDAs often close on their own within the first few months of life.

Most children can have the PDA closed by inserting catheters (long thin tubes) into the blood vessels in the leg to reach the heart and the PDA, and a coil or other device can be inserted through the catheters into the PDA like a plug. The figure below on the left shows one example of how a catheterization is used to close the ductus. If surgery is needed, an incision is made in the left side of the chest, between the ribs. The ductus is closed by tying it with suture (thread-like material) or by permanently placing a small metal clip around the ductus to squeeze it closed. If there’s no other heart defect, this restores the child’s circulation to normal. In premature newborn babies, medicine can often help the ductus close. After the first few weeks of life, medicine won’t work as well to close the ductus and surgery may be required.

If the PDA is small, it doesn’t have to be closed because it doesn’t make the heart and lungs work harder.

Patients with a moderate- or large-sized PDA may develop problems related to the increased blood flow to the lungs. These patients may have improvement if the PDA is closed. Closing the PDA can now usually be performed by catheter coil placement or other device insertion to plug the abnormal communication (referred to as interventional or therapeutic catheterization.)

Surgery may be the best treatment option for some patients. The surgeon doesn’t have to open the heart to fix the PDA. An incision is made in the left side of the chest, between the ribs. The PDA is closed by tying it with suture (thread-like material) or by permanently placing a small metal clip around the PDA to squeeze it closed. Occasionally in the adult, a surgical patch is used. If there’s no other heart defect, this restores the circulation to normal.

If the PDA is small, or if the PDA has been closed with catheterization or surgery, you may not need any special restrictions and may be able to participate in normal activities without increased risk.
Patients with moderate or large PDAs and patients with pulmonary hypertension may need to restrict activity. They should discuss this with their cardiologist.

Medical Follow-up

Patients with a small PDA need periodic follow-up with a cardiologist. Patients with a PDA that’s been successfully closed rarely require long-term cardiology follow-up unless there’s additional cardiac disease. Only rarely will they need to take medicine after surgical or device closure. Your cardiologist can monitor you with non-invasive tests if needed.

Activity Restrictions

Most patients with a small unrepaired PDA or a repaired PDA don’t need any special precautions and can participate in normal activities without increased risk. After surgery or catheter closure, your cardiologist may advise some limitations on your physical activity for a short time even if there’s no pulmonary hypertension.
Exercise restriction is recommended for patients with pulmonary hypertension related to PDA.

Endocarditis Prevention

Endocarditis prophylaxis is generally not needed more than six months after PDA device closure. However, endocarditis prophylaxis is recommended for PDA patients with a history of endocarditis, for those with prosthetic valve material and for unrepaired PDA with associated pulmonary hypertension and cyanosis. See the section on endocarditis for more information.

Pregnancy

Unless there’s pulmonary hypertension or signs of heart failure, pregnancy is low risk in patients with PDA.

Once a PDA has been closed, it’s unlikely that more surgery will be needed. Rarely, a patient may have a residual hole. Whether it will need to be closed depends on its size.

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