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'''''Patent ductus arteriosus''''' ('''PDA''') is a medical condition in which the ''[[ductus arteriosus]]'' fails to close after [[childbirth|birth]]: this allows a portion of oxygenated [[blood]] from the left [[heart]] to flow back to the lungs by flowing from the [[aorta]], which has a higher pressure, to the [[pulmonary artery]]. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased [[work of breathing]] and [[Failure to thrive|failure to gain weight at a normal rate]]. With time, an uncorrected PDA usually leads to [[pulmonary hypertension]] followed by right-sided [[heart failure]].
'''''Patent ductus arteriosus''''' ('''PDA''') is a medical condition in which the ''[[ductus arteriosus]]'' fails to close after [[childbirth|birth]]: this allows a portion of oxygenated [[blood]] from the left [[heart]] to flow back to the lungs from the [[aorta]], which has a higher [[blood pressure]], to the [[pulmonary artery]], which has a lower blood pressure. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased [[work of breathing]] and [[Failure to thrive|failure to gain weight at a normal rate]]. With time, an uncorrected PDA usually leads to [[pulmonary hypertension]] followed by right-sided [[heart failure]].


The ''ductus arteriosus'' is a [[Fetal circulation|fetal blood vessel]] that normally closes soon after birth. In a PDA, the vessel does not close, but remains ''patent'' (open), resulting in an abnormal transmission of blood from the aorta to the pulmonary artery. PDA is common in newborns with persistent respiratory problems such as [[hypoxia (medical)|hypoxia]], and has a high occurrence in [[premature newborn]]s. Premature newborns are more likely to be hypoxic and have PDA due to underdevelopment of the heart and lungs.
The ''ductus arteriosus'' is a [[Fetal circulation|fetal blood vessel]] that normally closes soon after birth. This closure is caused by vessel constriction immediately after birth as circulation changes occur, followed by the occlusion of the vessel’s lumen in the following days.<ref>{{Citation |last=Clyman |first=Ronald I. |title=Mechanisms Regulating Closure of the Ductus Arteriosus |date=2017 |url=https://linkinghub.elsevier.com/retrieve/pii/B9780323352147000573 |work=Fetal and Neonatal Physiology |pages=592–599.e4 |access-date=2023-11-14 |publisher=Elsevier |language=en |doi=10.1016/b978-0-323-35214-7.00057-3 |isbn=978-0-323-35214-7}}</ref> In a PDA, the vessel does not close, but remains ''patent'' (open), resulting in an abnormal transmission of blood from the aorta to the pulmonary artery. PDA is common in newborns with persistent respiratory problems such as [[hypoxia (medical)|hypoxia]], and has a high occurrence in [[premature newborn]]s. Premature newborns are more likely to be hypoxic and have PDA due to underdevelopment of the heart and lungs.


If [[transposition of the great vessels]] is present in addition to a PDA, the PDA is not surgically closed since it is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, [[prostaglandin]]s are used to keep the PDA open, and NSAIDs are not administered until surgical correction of the two defects is completed.
If the congenital defect [[transposition of the great vessels]] is present in addition to a PDA, the PDA is not surgically closed since it is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, [[prostaglandin]]s are used to keep the PDA open, and NSAIDs are not administered until surgical correction of the two defects is completed.

In full-term newborns, PDA occurs in 1 in 2,000 births, and accounts for 5–10% of congenital heart disease cases. PDA occurs in 20–60% of all premature newborns, where its incidence inversely linked with gestational age and weight.<ref>{{cite journal |last1=Dice |first1=JE |last2=Bhatia |first2=J |title=Patent ductus arteriosus: an overview. |journal=The Journal of Pediatric Pharmacology and Therapeutics |date=July 2007 |volume=12 |issue=3 |pages=138–46 |doi=10.5863/1551-6776-12.3.138 |pmid=23055849 |pmc=3462096 }}</ref>


== Signs and symptoms ==
== Signs and symptoms ==
Common symptoms include:{{cn|date=February 2021}}
Common symptoms include:{{citation needed|date=February 2021}}
* [[dyspnea]] (shortness of breath)
* [[dyspnea]] (shortness of breath)


Signs include:{{cn|date=February 2021}}
Signs include:{{citation needed|date=February 2021}}
* [[tachycardia]] (a heart rate exceeding the normal resting rate)
* [[tachycardia]] (a heart rate exceeding the normal resting rate)
* continuous "machine-like" (also described as "rolling-thunder" and "to-and-fro") [[heart murmur]] (usually from aorta to pulmonary artery, with higher flow during [[systole]] and lower flow during [[diastole]])
* continuous "machine-like" (also described as "rolling-thunder" and "to-and-fro") [[heart murmur]] (usually from aorta to pulmonary artery, with higher flow during [[systole]] and lower flow during [[diastole]])
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* differential [[cyanosis]], i.e. cyanosis of the lower extremities but not of the upper body.
* differential [[cyanosis]], i.e. cyanosis of the lower extremities but not of the upper body.


People with ''patent ductus arteriosus'' typically present in good health, with normal respirations and heart rate. If the PDA is moderate or large, widened [[pulse pressure]] and bounding peripheral pulses are frequently present, reflecting increased left ventricular [[stroke volume]] and diastolic run-off of blood into the (initially lower-resistance) pulmonary vascular bed.<ref>{{Cite web |date=2020-10-06 |title=Medically Sound: Critical Blood Flow Redirection and a Fetus under Pressure – Fetal Heart Defects |url=https://urmedlife.blogspot.com/2020/10/critical-flow-redirection-and-fetus.html |access-date=2020-11-01 |website=Medically Sound}}</ref> [[Eisenmenger's syndrome|Eisenmenger]] physiology is pulmonary hypertension due to a left-to-right shunt. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.{{cn|date=February 2021}}
People with ''patent ductus arteriosus'' typically present in good health, with normal respirations and heart rate. If the PDA is moderate or large, widened [[pulse pressure]] and bounding peripheral pulses are frequently present, reflecting increased left ventricular [[stroke volume]] and diastolic run-off of blood into the (initially lower-resistance) pulmonary vascular bed.<ref>{{Cite web |date=2020-10-06 |title=Medically Sound: Critical Blood Flow Redirection and a Fetus under Pressure – Fetal Heart Defects |url=https://urmedlife.blogspot.com/2020/10/critical-flow-redirection-and-fetus.html |access-date=2020-11-01 |website=Medically Sound}}</ref> [[Eisenmenger's syndrome|Eisenmenger]] physiology is pulmonary hypertension due to a left-to-right shunt. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.<ref name="Kumar Sinha Pandey Thakur 2016 pp. 117–118">{{cite journal | last1=Kumar | first1=Prakash | last2=Sinha | first2=Santosh Kumar | last3=Pandey | first3=Umeshwar | last4=Thakur | first4=Ramesh | last5=Varma | first5=Chandra Mohan | last6=Sachan | first6=Mohit | last7=Goel | first7=Amit | title=Patent Ductus Arteriosus With Eisenmenger Syndrome: Difficult Diagnosis Made Easily With Saline Contrast Echocardiography | journal=Cardiology Research | publisher=Elmer Press, Inc. | volume=7 | issue=3 | year=2016 | doi=10.14740/cr447w | pages=117–8| doi-access=free | pmc=5295518 }}</ref>


==Risk factors==
==Risk factors==
Known [[risk factor]]s include:<ref name="Anilkumar 2013 pp. 417–430">{{cite journal | last=Anilkumar | first=Mehra | title=Patent Ductus Arteriosus | journal=Cardiology Clinics | volume=31 | issue=3 | year=2013 | doi=10.1016/j.ccl.2013.05.006 |pmid=23931103 | pages=417–430}}</ref>
Known [[risk factor]]s include:{{citation needed|date=June 2020}}
* [[Preterm birth]]
* [[Preterm birth]]
* [[Congenital rubella syndrome]]
* [[Congenital rubella syndrome]]
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PDA is usually diagnosed using [[Non-invasive technique|noninvasive techniques]]. [[Echocardiography]] (in which [[sound wave]]s are used to capture the motion of the heart) and associated [[Doppler ultrasonography|Doppler]] studies are the primary methods of detecting PDA. [[Electrocardiography]] (ECG), in which [[electrode]]s are used to record the [[electricity|electrical]] activity of the heart, is not particularly helpful as no specific rhythms or ECG patterns can be used to detect PDA.<ref>{{cite web |url=http://www.mayoclinic.org/diseases-conditions/patent-ductus-arteriosus/basics/tests-diagnosis/con-20028530 |title=Tests and Diagnosis |publisher=[[Mayo Clinic]] |date=16 December 2015 |access-date=1 April 2015}}</ref>
PDA is usually diagnosed using [[Non-invasive technique|noninvasive techniques]]. [[Echocardiography]] (in which [[sound wave]]s are used to capture the motion of the heart) and associated [[Doppler ultrasonography|Doppler]] studies are the primary methods of detecting PDA. [[Electrocardiography]] (ECG), in which [[electrode]]s are used to record the [[electricity|electrical]] activity of the heart, is not particularly helpful as no specific rhythms or ECG patterns can be used to detect PDA.<ref>{{cite web |url=http://www.mayoclinic.org/diseases-conditions/patent-ductus-arteriosus/basics/tests-diagnosis/con-20028530 |title=Tests and Diagnosis |publisher=[[Mayo Clinic]] |date=16 December 2015 |access-date=1 April 2015}}</ref>


A chest [[X-ray]] may be taken, which reveals overall heart size (as a reflection of the combined mass of the cardiac chambers) and the appearance of blood flow to the lungs. A small PDA most often accompanies a normal-sized heart and normal blood flow to the lungs. A large PDA generally accompanies an enlarged [[Cardiac Silhouette|cardiac silhouette]] and increased blood flow to the lungs.{{cn|date=February 2021}}
A chest [[X-ray]] may be taken, which reveals overall heart size (as a reflection of the combined mass of the cardiac chambers) and the appearance of blood flow to the lungs. A small PDA most often accompanies a normal-sized heart and normal blood flow to the lungs. A large PDA generally accompanies an enlarged [[Cardiac Silhouette|cardiac silhouette]] and increased blood flow to the lungs.{{citation needed|date=February 2021}}


<gallery>
<gallery>
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== Prevention ==
== Prevention ==
Some evidence suggests that intravenous NSAIDs, such as [[indomethacin]], administration on the first day of life to all preterm infants reduces the risk of developing a PDA and the complications associated with PDA.<ref name=":0" /> Intravenous Indomethacin treatment in premature infants also may reduce the need for surgical intervention.<ref name=":0">{{cite journal| last=Fowlie| first=PW| author2=Davis PG | author3=McGuire W |title=Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants (Review)|journal=The Cochrane Database of Systematic Reviews|date=19 May 2010|issue=7|doi=10.1002/14651858.CD000174.pub2 |page=CD000174 | pmid=20614421| pmc=7045285}}</ref> Administering ibuprofen probably helps to prevent PDA and reduce the need for surgery but it also likely increases the risk of [[Oliguria|kidney complications]].<ref>{{cite journal |last1=Ohlsson |first1=A |last2=Shah |first2=SS |title=Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. |journal=The Cochrane Database of Systematic Reviews |date=27 January 2020 |volume=1 |pages=CD004213 |doi=10.1002/14651858.CD004213.pub5 |pmid=31985838|pmc=6984616 }}</ref>
Some evidence suggests that intravenous NSAIDs, such as [[indomethacin]], administration on the first day of life to all preterm infants reduces the risk of developing a PDA and the complications associated with PDA.<ref name=":0" /> Intravenous indomethacin treatment in premature infants also may reduce the need for surgical intervention.<ref name=":0">{{cite journal| last=Fowlie| first=PW| author2=Davis PG | author3=McGuire W |title=Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants (Review)|journal=The Cochrane Database of Systematic Reviews|date=19 May 2010| volume=2010|issue=7|doi=10.1002/14651858.CD000174.pub2 |page=CD000174 | pmid=20614421| pmc=7045285}}</ref> Administering ibuprofen probably helps to prevent PDA and reduce the need for surgery but it also likely increases the risk of [[Oliguria|kidney complications]].<ref>{{cite journal |last1=Ohlsson |first1=A |last2=Shah |first2=SS |title=Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. |journal=The Cochrane Database of Systematic Reviews |date=27 January 2020 |volume=1 |issue=1 |pages=CD004213 |doi=10.1002/14651858.CD004213.pub5 |pmid=31985838|pmc=6984616 }}</ref>


== Treatment ==
== Treatment ==
Line 77: Line 79:


=== Conservative ===
=== Conservative ===
Neonates without adverse symptoms may simply be monitored as [[outpatient]]s.{{cn|date=February 2021}}
Neonates without adverse symptoms may simply be monitored as [[outpatient]]s.{{citation needed|date=February 2021}}


=== Surgery ===
=== Surgery ===
Surgically, the DA may be closed by ligation (though support in premature infants is mixed).<ref name="pmid20808624">{{cite journal |vauthors=Mosalli R, Alfaleh K, Paes B |title=Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice |journal=Ann Pediatr Cardiol |volume=2 |issue=2 |pages=120–6 |date=July 2009 |pmid=20808624 |pmc=2922659 |doi=10.4103/0974-2069.58313 }}</ref> This can either be performed manually and be tied shut, or with intravascular coils or plugs that leads to formation of a [[thrombus]] in the DA.{{cn|date=February 2021}}
Surgically, the DA may be closed by ligation (though support in premature infants is mixed).<ref name="pmid20808624">{{cite journal |vauthors=Mosalli R, Alfaleh K, Paes B |title=Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice |journal=Ann Pediatr Cardiol |volume=2 |issue=2 |pages=120–6 |date=July 2009 |pmid=20808624 |pmc=2922659 |doi=10.4103/0974-2069.58313 |doi-access=free }}</ref> This can either be performed manually and be tied shut, or with intravascular coils or plugs that leads to formation of a [[thrombus]] in the DA.{{citation needed|date=February 2021}}


Devices developed by [[Franz Freudenthal]] block the blood vessel with woven structures of [[nitinol]] wire.<ref>{{cite journal|url=https://www.bbc.co.uk/mundo/noticias/2014/10/141002_medico_boliviano_corazon_am|date=2014-10-02 |author=Alejandra Martins |title=The inventions of the Bolivian doctor who saved thousands of children|journal=BBC Mundo|access-date=2015-03-30}}</ref>Newer procedures performed effectively in older, bigger children include catheter PDA occlusion and video-assisted thoracoscopic PDA clipping.<ref> Hines MH, Bensky AS, Hammon JW Jr et al. Video-assisted
Devices developed by [[Franz Freudenthal]] block the blood vessel with woven structures of [[nitinol]] wire.<ref>{{cite journal|url=https://www.bbc.co.uk/mundo/noticias/2014/10/141002_medico_boliviano_corazon_am|date=2014-10-02 |author=Alejandra Martins |title=The inventions of the Bolivian doctor who saved thousands of children|journal=BBC Mundo|access-date=2015-03-30}}</ref> Newer procedures performed effectively in older, bigger children include catheter PDA occlusion and video-assisted thoracoscopic PDA clipping.<ref>{{cite journal |vauthors=Hines MH, Bensky AS, Hammon JW, Pennington DG |title=Video-assisted thoracoscopic ligation of patent ductus arteriosus: safe and outpatient |journal=Ann Thorac Surg |volume=66 |issue=3 |pages=853–8; discussion 858–9 |date=September 1998 |pmid=9768942 |doi=10.1016/s0003-4975(98)00604-3 }}</ref>
thoracoscopic ligation of patent ductus arteriosus: safe and outpatient. Ann Thorac Surg 1998;66:853–8.</ref>


=== Prostaglandin inhibitors ===
=== Prostaglandin inhibitors ===
Because [[prostaglandin E2]] is responsible for keeping the DA open, NSAIDs (which can inhibit prostaglandin synthesis) such as [[indomethacin]] or a special form of [[ibuprofen]] have been used to initiate PDA closure.<ref name=medlineplus/><ref>[http://circ.ahajournals.org/content/114/17/1873.full circ.ahajournals.org]</ref><ref>[http://www.mayoclinic.com/health/patent-ductus-arteriosus/DS00631/DSECTION=treatments-and-drugs MayoClinic > ''Patent ductus arteriosus'' (PDA).] 22 Dec. 2009</ref> Findings from a 2015 systematic review concluded that, for closure of a PDA in preterm and/or low birth weight infants, ibuprofen is as effective as indomethacin. It also causes fewer side effects (such as transient [[acute kidney injury]]) and reduces the risk of [[Necrotizing enterocolitis|necrotising enterocolitis]].<ref>{{Cite journal |vauthors=Ohlsson A, Walia R, Shah SS |title=Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight (or both) infants. |journal = Cochrane Database Syst Rev |issue = 2 |pages = CD003481 |year = 2015 |doi = 10.1002/14651858.CD003481.pub6 |pmid=25692606 }}</ref> A review and meta-analysis showed that [[paracetamol]] may be effective for closure of a PDA in preterm infants.<ref>{{Cite journal |last1=Ohlsson |first1=Arne |last2=Shah |first2=Prakeshkumar S. |date=27 January 2020 |title=Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants |journal=The Cochrane Database of Systematic Reviews |volume=1 |pages=CD010061 |doi=10.1002/14651858.CD010061.pub4 |issn=1469-493X |pmc=6984659 |pmid=31985831}}</ref> A 2018 [[network meta-analysis]] that compared indomethacin, paracetamol and ibuprofen at different doses and administration schemes among them found that a high dose of oral ibuprofen may offer the highest likelihood of closure in preterm infants.<ref>{{Cite journal |last1=Mitra |first1=Souvik |last2=Florez |first2=Ivan D. |last3=Tamayo |first3=Maria E. |last4=Mbuagbaw |first4=Lawrence |last5=Vanniyasingam |first5=Thuva |last6=Veroniki |first6=Areti Angeliki |last7=Zea |first7=Adriana M. |last8=Zhang |first8=Yuan |last9=Sadeghirad |first9=Behnam |date=2018-03-27 |title=Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants |journal=JAMA |language=en |volume=319 |issue=12 |pages=1221–1238 |doi=10.1001/jama.2018.1896 |pmid=29584842 |pmc=5885871 |issn=0098-7484}}</ref><ref>{{Cite journal |last= |date=2018-07-03 |title=Oral ibuprofen may be an option for closing patent ductus arteriosus in premature babies |url=https://evidence.nihr.ac.uk/alert/oral-ibuprofen-may-be-an-option-for-closing-patent-ductus-arteriosus-in-premature-babies |journal=NIHR Evidence |type=Plain English summary |doi=10.3310/signal-000611}}</ref><ref>{{Cite web |date=2020-10-06 |title=Medically Sound: Diagnosing and treating congenital heart defects |url=https://urmedlife.blogspot.com/2020/10/while-murmuring-is-underway-reading.html |access-date=2020-11-01 |website=Medically Sound}}</ref> However, a 2020 systematic review found that early (≤7 days of life) or very early (≤72 hours of life) pharmacological treatment of symptomatic PDA does not reduce death or other poor clinical outcomes in preterm infants but instead increases their exposure to NSAIDS.<ref>{{Cite journal |last1=Mitra |first1=Souvik |last2=Scrivens |first2=Alexandra |last3=von Kursell |first3=Adelaide M |last4=Disher |first4=Tim |date=2020-12-10 |title=Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants |url=https://doi.org/10.1002/14651858.CD013278.pub2 |journal=Cochrane Database of Systematic Reviews |volume=12 |pages=CD013278 |doi=10.1002/14651858.CD013278.pub2 |pmid=33301630 |s2cid=228100506 |issn=1465-1858}}</ref> Vasodilator therapy is suitable for people with Eisenmenger physiology. To assess improvement in people with Eisenmenger physiology, close monitory of toe oxygen saturation is required, for there exists a chance of reversal after a successful right-to-left shunt {{cn|date=February 2021}}
Because [[prostaglandin E2]] is responsible for keeping the DA open, NSAIDs (which can inhibit prostaglandin synthesis) such as [[indomethacin]] or a special form of [[ibuprofen]] have been suggested as therapy to initiate PDA closure.<ref name=medlineplus/><ref>{{cite journal |vauthors=Schneider DJ, Moore JW |title=Patent ductus arteriosus |journal=Circulation |volume=114 |issue=17 |pages=1873–82 |date=October 2006 |pmid=17060397 |doi=10.1161/CIRCULATIONAHA.105.592063 }}</ref><ref>[http://www.mayoclinic.com/health/patent-ductus-arteriosus/DS00631/DSECTION=treatments-and-drugs MayoClinic > ''Patent ductus arteriosus'' (PDA).] 22 Dec. 2009</ref> Findings from a 2015 systematic review concluded that, for closure of a PDA in preterm and/or low birth weight infants, ibuprofen is as effective as indomethacin. It also causes fewer side effects (such as transient [[acute kidney injury]]) and reduces the risk of [[Necrotizing enterocolitis|necrotising enterocolitis]].<ref>{{Cite journal |vauthors=Ohlsson A, Walia R, Shah SS |title=Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight (or both) infants. |journal = Cochrane Database Syst Rev |issue = 2 |pages = CD003481 |year = 2015 |doi = 10.1002/14651858.CD003481.pub6 |pmid=25692606 }}</ref> The evidence supporting the effectiveness and safety of paracetamol (acetaminophen) is less clear.<ref>{{Cite journal |last1=Ohlsson |first1=Arne |last2=Shah |first2=Prakeshkumar S. |date=2018-04-06 |title=Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants |journal=The Cochrane Database of Systematic Reviews |volume=4 |issue=4 |pages=CD010061 |doi=10.1002/14651858.CD010061.pub3 |pmc=6494526 |pmid=29624206}}</ref> A review and meta-analysis showed that [[paracetamol]] may be effective for closure of a PDA in preterm infants.<ref>{{Cite journal |last1=Ohlsson |first1=Arne |last2=Shah |first2=Prakeshkumar S. |date=27 January 2020 |title=Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD010061 |doi=10.1002/14651858.CD010061.pub4 |pmc=6984659 |pmid=31985831}}</ref> A 2018 [[network meta-analysis]] that compared indomethacin, paracetamol and ibuprofen at different doses and administration schemes among them found that a high dose of oral ibuprofen may offer the highest likelihood of closure in preterm infants.<ref>{{Cite journal |last1=Mitra |first1=Souvik |last2=Florez |first2=Ivan D. |last3=Tamayo |first3=Maria E. |last4=Mbuagbaw |first4=Lawrence |last5=Vanniyasingam |first5=Thuva |last6=Veroniki |first6=Areti Angeliki |last7=Zea |first7=Adriana M. |last8=Zhang |first8=Yuan |last9=Sadeghirad |first9=Behnam |date=2018-03-27 |title=Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants |journal=JAMA |language=en |volume=319 |issue=12 |pages=1221–38 |doi=10.1001/jama.2018.1896 |pmid=29584842 |pmc=5885871 }}</ref><ref>{{Cite journal |last= |date=2018-07-03 |title=Oral ibuprofen may be an option for closing patent ductus arteriosus in premature babies |url=https://evidence.nihr.ac.uk/alert/oral-ibuprofen-may-be-an-option-for-closing-patent-ductus-arteriosus-in-premature-babies |journal=NIHR Evidence |type=Plain English summary |doi=10.3310/signal-000611|s2cid=240438747 }}</ref><ref>{{Cite web |date=2020-10-06 |title=Medically Sound: Diagnosing and treating congenital heart defects |url=https://urmedlife.blogspot.com/2020/10/while-murmuring-is-underway-reading.html |access-date=2020-11-01 |website=Medically Sound}}</ref> However, a 2020 systematic review found that early (≤7 days of life) or very early (≤72 hours of life) pharmacological treatment of symptomatic PDA does not reduce death or other poor clinical outcomes in preterm infants but instead increases their exposure to NSAIDS.<ref>{{Cite journal |last1=Mitra |first1=Souvik |last2=Scrivens |first2=Alexandra |last3=von Kursell |first3=Adelaide M |last4=Disher |first4=Tim |date=2020-12-10 |title=Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants |url=https://doi.org/10.1002/14651858.CD013278.pub2 |journal=Cochrane Database of Systematic Reviews |volume=2020 |issue=12 |pages=CD013278 |doi=10.1002/14651858.CD013278.pub2 |pmid=33301630 |pmc=8812277 |s2cid=228100506 }}</ref> Vasodilator therapy is suitable for people with Eisenmenger physiology. To assess improvement in people with Eisenmenger physiology, close monitory of toe oxygen saturation is required, for there exists a chance of reversal after a successful right-to-left shunt {{citation needed|date=February 2021}}


While [[indometacin]] can be used to close a PDA, some neonates require their PDA be kept open. Keeping a ''ductus arteriosus patent'' is indicated in neonates born with concurrent heart malformations, such as [[transposition of the great vessels]]. Drugs such as [[alprostadil]], a [[Prostaglandin E1|PGE-1]] analog, can be used to keep a PDA open until the primary defect is corrected surgically.{{cn|date=February 2021}}
While [[indometacin]] can be used to close a PDA, some neonates require their PDA be kept open. Keeping a ''ductus arteriosus patent'' is indicated in neonates born with concurrent heart malformations, such as [[transposition of the great vessels]]. Drugs such as [[alprostadil]], a [[Prostaglandin E1|PGE-1]] analog, can be used to keep a PDA open until the primary defect is corrected surgically.{{citation needed|date=February 2021}}


== Prognosis ==
== Prognosis ==
If left untreated, the disease may progress from left-to-right shunt ([[Acyanotic heart defect|acyanotic heart]]) to right-to-left shunt ([[Cyanotic heart defect|cyanotic heart]]), called [[Eisenmenger's syndrome]]. [[Pulmonary hypertension]] is a potential long-term outcome, which may require a heart and/or lung [[Organ transplantation|transplant]]. Another complication of PDA is [[intraventricular hemorrhage]].{{cn|date=February 2021}}
If left untreated, the disease may progress from left-to-right shunt ([[Acyanotic heart defect|acyanotic heart]]) to right-to-left shunt ([[Cyanotic heart defect|cyanotic heart]]), called [[Eisenmenger's syndrome]]. [[Pulmonary hypertension]] is a potential long-term outcome, which may require a heart and/or lung [[Organ transplantation|transplant]]. Another complication of PDA is [[intraventricular hemorrhage]].{{citation needed|date=February 2021}}


==History==
==History==
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== Adult ==
== Adult ==
Since PDA is usually identified in infants, it is less common in adults, but it can have serious consequences, and is usually corrected surgically upon diagnosis.{{cn|date=February 2021}}
Since PDA is usually identified in infants, it is less common in adults, but it can have serious consequences, and is usually corrected surgically upon diagnosis.{{citation needed|date=February 2021}}


==See also==
==See also==
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| meshNumber = C14.240.400.340
| meshNumber = C14.240.400.340
| DiseasesDB = 9706
| DiseasesDB = 9706
| ICD11 = {{ICD11|LA8B.4}}
| ICD10 = {{ICD10|Q|25|0|q|20}}
| ICD10 = {{ICD10|Q|25|0|q|20}}
| ICD9 = {{ICD9|747.0}}
| ICD9 = {{ICD9|747.0}}

Latest revision as of 15:21, 29 November 2024

Patent ductus arteriosus
Other namesPersistent ductus arteriosus
Diagram of a cross-section through a heart with PDA
SpecialtyCardiac surgery, paediatrics
SymptomsShortness of breath, failure to thrive, tachycardia, heart murmur
ComplicationsHeart failure, Eisenmenger's syndrome, pulmonary hypertension
CausesIdiopathic
Risk factorsPreterm birth, congenital rubella syndrome, chromosomal abnormalities, genetic conditions
Diagnostic methodEchocardiography, Doppler, X-ray
PreventionScreening at birth, high index of suspicion in neonates at risk
TreatmentNonsteroidal anti-inflammatory drugs (NSAIDs), surgery

Patent ductus arteriosus (PDA) is a medical condition in which the ductus arteriosus fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs from the aorta, which has a higher blood pressure, to the pulmonary artery, which has a lower blood pressure. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased work of breathing and failure to gain weight at a normal rate. With time, an uncorrected PDA usually leads to pulmonary hypertension followed by right-sided heart failure.

The ductus arteriosus is a fetal blood vessel that normally closes soon after birth. This closure is caused by vessel constriction immediately after birth as circulation changes occur, followed by the occlusion of the vessel’s lumen in the following days.[1] In a PDA, the vessel does not close, but remains patent (open), resulting in an abnormal transmission of blood from the aorta to the pulmonary artery. PDA is common in newborns with persistent respiratory problems such as hypoxia, and has a high occurrence in premature newborns. Premature newborns are more likely to be hypoxic and have PDA due to underdevelopment of the heart and lungs.

If the congenital defect transposition of the great vessels is present in addition to a PDA, the PDA is not surgically closed since it is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the PDA open, and NSAIDs are not administered until surgical correction of the two defects is completed.

In full-term newborns, PDA occurs in 1 in 2,000 births, and accounts for 5–10% of congenital heart disease cases. PDA occurs in 20–60% of all premature newborns, where its incidence inversely linked with gestational age and weight.[2]

Signs and symptoms

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Common symptoms include:[citation needed]

Signs include:[citation needed]

People with patent ductus arteriosus typically present in good health, with normal respirations and heart rate. If the PDA is moderate or large, widened pulse pressure and bounding peripheral pulses are frequently present, reflecting increased left ventricular stroke volume and diastolic run-off of blood into the (initially lower-resistance) pulmonary vascular bed.[4] Eisenmenger physiology is pulmonary hypertension due to a left-to-right shunt. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.[5]

Risk factors

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Known risk factors include:[6]

Diagnosis

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Phonocardiograms from normal and abnormal heart sounds

PDA is usually diagnosed using noninvasive techniques. Echocardiography (in which sound waves are used to capture the motion of the heart) and associated Doppler studies are the primary methods of detecting PDA. Electrocardiography (ECG), in which electrodes are used to record the electrical activity of the heart, is not particularly helpful as no specific rhythms or ECG patterns can be used to detect PDA.[7]

A chest X-ray may be taken, which reveals overall heart size (as a reflection of the combined mass of the cardiac chambers) and the appearance of blood flow to the lungs. A small PDA most often accompanies a normal-sized heart and normal blood flow to the lungs. A large PDA generally accompanies an enlarged cardiac silhouette and increased blood flow to the lungs.[citation needed]

  • Illustration of PDA
    Illustration of PDA
  • PDA
    PDA
  • An echocardiogram of a stented persisting ductus arteriosus: One can see the aortic arch and the stent leaving. The pulmonary artery is not seen.
    An echocardiogram of a stented persisting ductus arteriosus: One can see the aortic arch and the stent leaving. The pulmonary artery is not seen.
  • An echocardiogram of a coiled PDA: One can see the aortic arch, the pulmonary artery, and the coil between them.
    An echocardiogram of a coiled PDA: One can see the aortic arch, the pulmonary artery, and the coil between them.

Prevention

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Some evidence suggests that intravenous NSAIDs, such as indomethacin, administration on the first day of life to all preterm infants reduces the risk of developing a PDA and the complications associated with PDA.[8] Intravenous indomethacin treatment in premature infants also may reduce the need for surgical intervention.[8] Administering ibuprofen probably helps to prevent PDA and reduce the need for surgery but it also likely increases the risk of kidney complications.[9]

Treatment

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Symptomatic PDA can be treated with both surgical and non-surgical methods.[10]

Conservative

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Neonates without adverse symptoms may simply be monitored as outpatients.[citation needed]

Surgery

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Surgically, the DA may be closed by ligation (though support in premature infants is mixed).[11] This can either be performed manually and be tied shut, or with intravascular coils or plugs that leads to formation of a thrombus in the DA.[citation needed]

Devices developed by Franz Freudenthal block the blood vessel with woven structures of nitinol wire.[12] Newer procedures performed effectively in older, bigger children include catheter PDA occlusion and video-assisted thoracoscopic PDA clipping.[13]

Prostaglandin inhibitors

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Because prostaglandin E2 is responsible for keeping the DA open, NSAIDs (which can inhibit prostaglandin synthesis) such as indomethacin or a special form of ibuprofen have been suggested as therapy to initiate PDA closure.[3][14][15] Findings from a 2015 systematic review concluded that, for closure of a PDA in preterm and/or low birth weight infants, ibuprofen is as effective as indomethacin. It also causes fewer side effects (such as transient acute kidney injury) and reduces the risk of necrotising enterocolitis.[16] The evidence supporting the effectiveness and safety of paracetamol (acetaminophen) is less clear.[17] A review and meta-analysis showed that paracetamol may be effective for closure of a PDA in preterm infants.[18] A 2018 network meta-analysis that compared indomethacin, paracetamol and ibuprofen at different doses and administration schemes among them found that a high dose of oral ibuprofen may offer the highest likelihood of closure in preterm infants.[19][20][21] However, a 2020 systematic review found that early (≤7 days of life) or very early (≤72 hours of life) pharmacological treatment of symptomatic PDA does not reduce death or other poor clinical outcomes in preterm infants but instead increases their exposure to NSAIDS.[22] Vasodilator therapy is suitable for people with Eisenmenger physiology. To assess improvement in people with Eisenmenger physiology, close monitory of toe oxygen saturation is required, for there exists a chance of reversal after a successful right-to-left shunt [citation needed]

While indometacin can be used to close a PDA, some neonates require their PDA be kept open. Keeping a ductus arteriosus patent is indicated in neonates born with concurrent heart malformations, such as transposition of the great vessels. Drugs such as alprostadil, a PGE-1 analog, can be used to keep a PDA open until the primary defect is corrected surgically.[citation needed]

Prognosis

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If left untreated, the disease may progress from left-to-right shunt (acyanotic heart) to right-to-left shunt (cyanotic heart), called Eisenmenger's syndrome. Pulmonary hypertension is a potential long-term outcome, which may require a heart and/or lung transplant. Another complication of PDA is intraventricular hemorrhage.[citation needed]

History

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Robert Edward Gross, MD performed the first successful ligation of a patent ductus arteriosus on a seven-year-old girl at Children's Hospital Boston in 1938.[23]

Adult

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Since PDA is usually identified in infants, it is less common in adults, but it can have serious consequences, and is usually corrected surgically upon diagnosis.[citation needed]

See also

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References

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  1. ^ Clyman, Ronald I. (2017), "Mechanisms Regulating Closure of the Ductus Arteriosus", Fetal and Neonatal Physiology, Elsevier, pp. 592–599.e4, doi:10.1016/b978-0-323-35214-7.00057-3, ISBN 978-0-323-35214-7, retrieved 14 November 2023
  2. ^ Dice, JE; Bhatia, J (July 2007). "Patent ductus arteriosus: an overview". The Journal of Pediatric Pharmacology and Therapeutics. 12 (3): 138–46. doi:10.5863/1551-6776-12.3.138. PMC 3462096. PMID 23055849.
  3. ^ a b MedlinePlus - Patent ductus arteriosus Update Date: 21 December 2009
  4. ^ "Medically Sound: Critical Blood Flow Redirection and a Fetus under Pressure – Fetal Heart Defects". Medically Sound. 6 October 2020. Retrieved 1 November 2020.
  5. ^ Kumar, Prakash; Sinha, Santosh Kumar; Pandey, Umeshwar; Thakur, Ramesh; Varma, Chandra Mohan; Sachan, Mohit; Goel, Amit (2016). "Patent Ductus Arteriosus With Eisenmenger Syndrome: Difficult Diagnosis Made Easily With Saline Contrast Echocardiography". Cardiology Research. 7 (3). Elmer Press, Inc.: 117–8. doi:10.14740/cr447w. PMC 5295518.
  6. ^ Anilkumar, Mehra (2013). "Patent Ductus Arteriosus". Cardiology Clinics. 31 (3): 417–430. doi:10.1016/j.ccl.2013.05.006. PMID 23931103.
  7. ^ "Tests and Diagnosis". Mayo Clinic. 16 December 2015. Retrieved 1 April 2015.
  8. ^ a b Fowlie, PW; Davis PG; McGuire W (19 May 2010). "Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants (Review)". The Cochrane Database of Systematic Reviews. 2010 (7): CD000174. doi:10.1002/14651858.CD000174.pub2. PMC 7045285. PMID 20614421.
  9. ^ Ohlsson, A; Shah, SS (27 January 2020). "Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants". The Cochrane Database of Systematic Reviews. 1 (1): CD004213. doi:10.1002/14651858.CD004213.pub5. PMC 6984616. PMID 31985838.
  10. ^ Zahaka, KG and Patel, CR. "Congenital defects'". Fanaroff, AA and Martin, RJ (eds.). Neonatal-perinatal medicine: Diseases of the fetus and infant. 7th ed. (2002):1120–1139. St. Louis: Mosby.
  11. ^ Mosalli R, Alfaleh K, Paes B (July 2009). "Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice". Ann Pediatr Cardiol. 2 (2): 120–6. doi:10.4103/0974-2069.58313. PMC 2922659. PMID 20808624.
  12. ^ Alejandra Martins (2 October 2014). "The inventions of the Bolivian doctor who saved thousands of children". BBC Mundo. Retrieved 30 March 2015.
  13. ^ Hines MH, Bensky AS, Hammon JW, Pennington DG (September 1998). "Video-assisted thoracoscopic ligation of patent ductus arteriosus: safe and outpatient". Ann Thorac Surg. 66 (3): 853–8, discussion 858–9. doi:10.1016/s0003-4975(98)00604-3. PMID 9768942.
  14. ^ Schneider DJ, Moore JW (October 2006). "Patent ductus arteriosus". Circulation. 114 (17): 1873–82. doi:10.1161/CIRCULATIONAHA.105.592063. PMID 17060397.
  15. ^ MayoClinic > Patent ductus arteriosus (PDA). 22 Dec. 2009
  16. ^ Ohlsson A, Walia R, Shah SS (2015). "Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight (or both) infants". Cochrane Database Syst Rev (2): CD003481. doi:10.1002/14651858.CD003481.pub6. PMID 25692606.
  17. ^ Ohlsson, Arne; Shah, Prakeshkumar S. (6 April 2018). "Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants". The Cochrane Database of Systematic Reviews. 4 (4): CD010061. doi:10.1002/14651858.CD010061.pub3. PMC 6494526. PMID 29624206.
  18. ^ Ohlsson, Arne; Shah, Prakeshkumar S. (27 January 2020). "Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants". The Cochrane Database of Systematic Reviews. 1 (1): CD010061. doi:10.1002/14651858.CD010061.pub4. PMC 6984659. PMID 31985831.
  19. ^ Mitra, Souvik; Florez, Ivan D.; Tamayo, Maria E.; Mbuagbaw, Lawrence; Vanniyasingam, Thuva; Veroniki, Areti Angeliki; Zea, Adriana M.; Zhang, Yuan; Sadeghirad, Behnam (27 March 2018). "Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants". JAMA. 319 (12): 1221–38. doi:10.1001/jama.2018.1896. PMC 5885871. PMID 29584842.
  20. ^ "Oral ibuprofen may be an option for closing patent ductus arteriosus in premature babies". NIHR Evidence (Plain English summary). 3 July 2018. doi:10.3310/signal-000611. S2CID 240438747.
  21. ^ "Medically Sound: Diagnosing and treating congenital heart defects". Medically Sound. 6 October 2020. Retrieved 1 November 2020.
  22. ^ Mitra, Souvik; Scrivens, Alexandra; von Kursell, Adelaide M; Disher, Tim (10 December 2020). "Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants". Cochrane Database of Systematic Reviews. 2020 (12): CD013278. doi:10.1002/14651858.CD013278.pub2. PMC 8812277. PMID 33301630. S2CID 228100506.
  23. ^ fa.hms.harvard.edu; Robert E. Gross, Harvard Medical School Office for Faculty Affairs.
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