The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
Epidemiology
The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
Anatomy
Pathophysiology
The ductus arteriosus allows blood to flow from the pulmonary artery directly into the aorta. This shunting of blood helps bypass the non-functional fetal lungs. In a healthy newborn, the ductus arteriosus typically closes shortly after birth due to various factors, including changes in oxygen levels and the release of certain substances.
The closure is part of the natural transition from fetal to neonatal circulation. In individuals with a patent ductus arteriosus, the ductus arteriosus fails to close after birth, leading to a persistent connection between the pulmonary artery and the aorta.
This results in abnormal blood flow, allowing oxygenated blood from the aorta to mix with deoxygenated blood from the pulmonary artery. The increased blood flow to the lungs may result in pulmonary overcirculation and increased pressure in the pulmonary arteries. Over time, this increased workload on the heart can lead to left atrial and ventricular enlargement.
Etiology
Premature Birth: PDA is more commonly associated with premature infants. The ductus arteriosus is more likely to remain open in babies born before full term, especially those born extremely preterm.
Maternal Factors: Certain maternal conditions or medications during pregnancy may contribute to the likelihood of PDA. For example, maternal rubella infection during early pregnancy has been associated with an increased risk of PDA in the offspring.
Genetic Factors: There may be a genetic predisposition to PDA, and it can sometimes occur as part of a genetic syndrome or chromosomal abnormality. However, in many cases, PDA occurs sporadically without a clear genetic link.
Hypoxia and Respiratory Distress Syndrome: Conditions that result in hypoxia or respiratory distress syndrome in the newborn may influence the persistence of the ductus arteriosus.
Mechanical Factors: Mechanical factors, such as umbilical catheterization or certain ventilation strategies in the neonatal intensive care unit, can influence the likelihood of PDA.
Genetics
Prognostic Factors
For infants with only an isolated patent ductus arteriosus, the prognosis is generally favorable. In premature infants, the prognosis is influenced by the presence of other concurrent health conditions. Following the closure of the PDA, the majority of children can anticipate an average life expectancy.
Clinical History
PDA is often present at birth, as the ductus arteriosus is a normal fetal structure that should close shortly after delivery. The onset is, therefore, typically in the immediate postnatal period. The duration of PDA can vary. In some cases, the ductus arteriosus may close on its own during the first few days or weeks of life. In other cases, particularly if the PDA is large or if the infant is premature, it may persist for a more extended period.
Respiratory Symptoms:
Shortness of breath.
Tachypnea
Increased work of breathing.
Circulatory Symptoms:
Increased heart rate.
Poor weight gain or growth.
Sweating, especially during feeds.
Difficulty Feeding:
Infants with PDA may find feeding challenging due to respiratory symptoms or increased fatigue during feeding.
Physical Examination
A continuous, machinery-like murmur is a classic finding. It is often heard best at the upper left sternal border and radiates to the back. The peripheral pulses, especially in the femoral arteries, may feel stronger or more bounding than usual due to the increased volume of blood being pumped into the systemic circulation.
In some cases, a palpable thrill may be felt over the left upper chest or upper back. On examination, the chest may show signs of increased precordial activity, particularly over the left side. Enlargement of the left side of the heart may be evident upon inspection and palpation.
Cyanosis may be present in severe cases, especially if there is significant right-to-left shunting of blood. Infants with PDA may have difficulty feeding and may exhibit poor weight gain or failure to thrive.
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Aortopulmonary defect
Coronary artery fistula
Pulmonary arteriovenous fistula
Sinus of valsalva aneurysm
Persistent truncus arteriosus
Total anomalous pulmonary venous return
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
For infants with greater gestational maturity, a conservative approach to managing a patent ductus arteriosus (PDA) may suffice as a means of providing support while awaiting spontaneous closure. This conservative strategy involves meticulous fluid restriction (maintaining a range of 110 to 130 ml/kg/d while closely monitoring urine output) and elevating PEEP to address pulmonary edema.
The use of diuretics is a subject of contention due to a lack of conclusive evidence supporting their efficacy in improving outcomes for very premature infants. Additionally, diuretics may impede the closure of PDA and lead to electrolyte imbalances, posing challenges in the management of extremely premature infants.
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
Administration of a pharmaceutical agent
Pharmacologic intervention with ibuprofen, indomethacin, or acetaminophen is a recommended consideration for preterm infants exhibiting symptoms. Typically, infants weighing over 1000 grams at birth are less likely to necessitate pharmacologic therapy for ductal closure.
Although closure in these infants may take longer than in healthy-term infants, with a median time of 7 days, the majority of cases resolve spontaneously before hospital discharge without requiring medication.Â
In cases where infants exhibit symptoms despite conservative management measures such as increasing positive end-expiratory pressure and fluid restriction are applied. Indomethacin is usually administered in three doses, 12 hours apart, with a potential fourth dose given 24 hours after the third to ensure closure.
Similarly, ibuprofen is typically given in three doses, 24 hours apart, and both medications demonstrate comparable efficacy, ranging from 66% to 70%. In instances of resistance to treatment, a second course may be considered, but caution should be exercised, and accumulative effects on renal function should be assessed before proceeding.Â
While ibuprofen and indomethacin share similar side effects, indomethacin is associated with heightened concerns regarding gut perfusion and necrotizing enterocolitis. However, a large multicenter randomized controlled trial has not shown an increase in necrotizing enterocolitis in infants fed small amounts of milk during indomethacin treatment compared to those who were fasted.Â
Acetaminophen emerges as a promising alternative for PDA treatment. Several small studies have demonstrated its close equivalence to indomethacin and ibuprofen. However, its efficacy may be diminished in infants previously treated with indomethacin or ibuprofen, particularly in the smallest infants.Â
The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
The ductus arteriosus allows blood to flow from the pulmonary artery directly into the aorta. This shunting of blood helps bypass the non-functional fetal lungs. In a healthy newborn, the ductus arteriosus typically closes shortly after birth due to various factors, including changes in oxygen levels and the release of certain substances.
The closure is part of the natural transition from fetal to neonatal circulation. In individuals with a patent ductus arteriosus, the ductus arteriosus fails to close after birth, leading to a persistent connection between the pulmonary artery and the aorta.
This results in abnormal blood flow, allowing oxygenated blood from the aorta to mix with deoxygenated blood from the pulmonary artery. The increased blood flow to the lungs may result in pulmonary overcirculation and increased pressure in the pulmonary arteries. Over time, this increased workload on the heart can lead to left atrial and ventricular enlargement.
Premature Birth: PDA is more commonly associated with premature infants. The ductus arteriosus is more likely to remain open in babies born before full term, especially those born extremely preterm.
Maternal Factors: Certain maternal conditions or medications during pregnancy may contribute to the likelihood of PDA. For example, maternal rubella infection during early pregnancy has been associated with an increased risk of PDA in the offspring.
Genetic Factors: There may be a genetic predisposition to PDA, and it can sometimes occur as part of a genetic syndrome or chromosomal abnormality. However, in many cases, PDA occurs sporadically without a clear genetic link.
Hypoxia and Respiratory Distress Syndrome: Conditions that result in hypoxia or respiratory distress syndrome in the newborn may influence the persistence of the ductus arteriosus.
Mechanical Factors: Mechanical factors, such as umbilical catheterization or certain ventilation strategies in the neonatal intensive care unit, can influence the likelihood of PDA.
For infants with only an isolated patent ductus arteriosus, the prognosis is generally favorable. In premature infants, the prognosis is influenced by the presence of other concurrent health conditions. Following the closure of the PDA, the majority of children can anticipate an average life expectancy.
PDA is often present at birth, as the ductus arteriosus is a normal fetal structure that should close shortly after delivery. The onset is, therefore, typically in the immediate postnatal period. The duration of PDA can vary. In some cases, the ductus arteriosus may close on its own during the first few days or weeks of life. In other cases, particularly if the PDA is large or if the infant is premature, it may persist for a more extended period.
Respiratory Symptoms:
Shortness of breath.
Tachypnea
Increased work of breathing.
Circulatory Symptoms:
Increased heart rate.
Poor weight gain or growth.
Sweating, especially during feeds.
Difficulty Feeding:
Infants with PDA may find feeding challenging due to respiratory symptoms or increased fatigue during feeding.
A continuous, machinery-like murmur is a classic finding. It is often heard best at the upper left sternal border and radiates to the back. The peripheral pulses, especially in the femoral arteries, may feel stronger or more bounding than usual due to the increased volume of blood being pumped into the systemic circulation.
In some cases, a palpable thrill may be felt over the left upper chest or upper back. On examination, the chest may show signs of increased precordial activity, particularly over the left side. Enlargement of the left side of the heart may be evident upon inspection and palpation.
Cyanosis may be present in severe cases, especially if there is significant right-to-left shunting of blood. Infants with PDA may have difficulty feeding and may exhibit poor weight gain or failure to thrive.
Aortopulmonary defect
Coronary artery fistula
Pulmonary arteriovenous fistula
Sinus of valsalva aneurysm
Persistent truncus arteriosus
Total anomalous pulmonary venous return
For infants with greater gestational maturity, a conservative approach to managing a patent ductus arteriosus (PDA) may suffice as a means of providing support while awaiting spontaneous closure. This conservative strategy involves meticulous fluid restriction (maintaining a range of 110 to 130 ml/kg/d while closely monitoring urine output) and elevating PEEP to address pulmonary edema.
The use of diuretics is a subject of contention due to a lack of conclusive evidence supporting their efficacy in improving outcomes for very premature infants. Additionally, diuretics may impede the closure of PDA and lead to electrolyte imbalances, posing challenges in the management of extremely premature infants.
Pharmacologic intervention with ibuprofen, indomethacin, or acetaminophen is a recommended consideration for preterm infants exhibiting symptoms. Typically, infants weighing over 1000 grams at birth are less likely to necessitate pharmacologic therapy for ductal closure.
Although closure in these infants may take longer than in healthy-term infants, with a median time of 7 days, the majority of cases resolve spontaneously before hospital discharge without requiring medication.Â
In cases where infants exhibit symptoms despite conservative management measures such as increasing positive end-expiratory pressure and fluid restriction are applied. Indomethacin is usually administered in three doses, 12 hours apart, with a potential fourth dose given 24 hours after the third to ensure closure.
Similarly, ibuprofen is typically given in three doses, 24 hours apart, and both medications demonstrate comparable efficacy, ranging from 66% to 70%. In instances of resistance to treatment, a second course may be considered, but caution should be exercised, and accumulative effects on renal function should be assessed before proceeding.Â
While ibuprofen and indomethacin share similar side effects, indomethacin is associated with heightened concerns regarding gut perfusion and necrotizing enterocolitis. However, a large multicenter randomized controlled trial has not shown an increase in necrotizing enterocolitis in infants fed small amounts of milk during indomethacin treatment compared to those who were fasted.Â
Acetaminophen emerges as a promising alternative for PDA treatment. Several small studies have demonstrated its close equivalence to indomethacin and ibuprofen. However, its efficacy may be diminished in infants previously treated with indomethacin or ibuprofen, particularly in the smallest infants.Â
Â
medtigo
Patent ductus arteriosus
Updated :
January 25, 2024
The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
The patent ductus arteriosus is a congenital heart defect that involves a persistent opening between two major blood vessels leading from the heart. Normally, the ductus arteriosus is a fetal blood vessel that connects the pulmonary artery and the aorta.
It allows blood to bypass the lungs during fetal development because the fetus obtains oxygen from the mother’s blood through the placenta rather than from breathing air.
In a typical scenario, the ductus arteriosus closes shortly after birth as a part of the normal physiological changes that occur during the transition from fetal to neonatal circulation. However, in some cases, the ductus arteriosus remains open, allowing blood to flow in an abnormal pattern.
The ductus arteriosus allows blood to flow from the pulmonary artery directly into the aorta. This shunting of blood helps bypass the non-functional fetal lungs. In a healthy newborn, the ductus arteriosus typically closes shortly after birth due to various factors, including changes in oxygen levels and the release of certain substances.
The closure is part of the natural transition from fetal to neonatal circulation. In individuals with a patent ductus arteriosus, the ductus arteriosus fails to close after birth, leading to a persistent connection between the pulmonary artery and the aorta.
This results in abnormal blood flow, allowing oxygenated blood from the aorta to mix with deoxygenated blood from the pulmonary artery. The increased blood flow to the lungs may result in pulmonary overcirculation and increased pressure in the pulmonary arteries. Over time, this increased workload on the heart can lead to left atrial and ventricular enlargement.
Premature Birth: PDA is more commonly associated with premature infants. The ductus arteriosus is more likely to remain open in babies born before full term, especially those born extremely preterm.
Maternal Factors: Certain maternal conditions or medications during pregnancy may contribute to the likelihood of PDA. For example, maternal rubella infection during early pregnancy has been associated with an increased risk of PDA in the offspring.
Genetic Factors: There may be a genetic predisposition to PDA, and it can sometimes occur as part of a genetic syndrome or chromosomal abnormality. However, in many cases, PDA occurs sporadically without a clear genetic link.
Hypoxia and Respiratory Distress Syndrome: Conditions that result in hypoxia or respiratory distress syndrome in the newborn may influence the persistence of the ductus arteriosus.
Mechanical Factors: Mechanical factors, such as umbilical catheterization or certain ventilation strategies in the neonatal intensive care unit, can influence the likelihood of PDA.
For infants with only an isolated patent ductus arteriosus, the prognosis is generally favorable. In premature infants, the prognosis is influenced by the presence of other concurrent health conditions. Following the closure of the PDA, the majority of children can anticipate an average life expectancy.
PDA is often present at birth, as the ductus arteriosus is a normal fetal structure that should close shortly after delivery. The onset is, therefore, typically in the immediate postnatal period. The duration of PDA can vary. In some cases, the ductus arteriosus may close on its own during the first few days or weeks of life. In other cases, particularly if the PDA is large or if the infant is premature, it may persist for a more extended period.
Respiratory Symptoms:
Shortness of breath.
Tachypnea
Increased work of breathing.
Circulatory Symptoms:
Increased heart rate.
Poor weight gain or growth.
Sweating, especially during feeds.
Difficulty Feeding:
Infants with PDA may find feeding challenging due to respiratory symptoms or increased fatigue during feeding.
A continuous, machinery-like murmur is a classic finding. It is often heard best at the upper left sternal border and radiates to the back. The peripheral pulses, especially in the femoral arteries, may feel stronger or more bounding than usual due to the increased volume of blood being pumped into the systemic circulation.
In some cases, a palpable thrill may be felt over the left upper chest or upper back. On examination, the chest may show signs of increased precordial activity, particularly over the left side. Enlargement of the left side of the heart may be evident upon inspection and palpation.
Cyanosis may be present in severe cases, especially if there is significant right-to-left shunting of blood. Infants with PDA may have difficulty feeding and may exhibit poor weight gain or failure to thrive.
Aortopulmonary defect
Coronary artery fistula
Pulmonary arteriovenous fistula
Sinus of valsalva aneurysm
Persistent truncus arteriosus
Total anomalous pulmonary venous return
For infants with greater gestational maturity, a conservative approach to managing a patent ductus arteriosus (PDA) may suffice as a means of providing support while awaiting spontaneous closure. This conservative strategy involves meticulous fluid restriction (maintaining a range of 110 to 130 ml/kg/d while closely monitoring urine output) and elevating PEEP to address pulmonary edema.
The use of diuretics is a subject of contention due to a lack of conclusive evidence supporting their efficacy in improving outcomes for very premature infants. Additionally, diuretics may impede the closure of PDA and lead to electrolyte imbalances, posing challenges in the management of extremely premature infants.
Pharmacologic intervention with ibuprofen, indomethacin, or acetaminophen is a recommended consideration for preterm infants exhibiting symptoms. Typically, infants weighing over 1000 grams at birth are less likely to necessitate pharmacologic therapy for ductal closure.
Although closure in these infants may take longer than in healthy-term infants, with a median time of 7 days, the majority of cases resolve spontaneously before hospital discharge without requiring medication.Â
In cases where infants exhibit symptoms despite conservative management measures such as increasing positive end-expiratory pressure and fluid restriction are applied. Indomethacin is usually administered in three doses, 12 hours apart, with a potential fourth dose given 24 hours after the third to ensure closure.
Similarly, ibuprofen is typically given in three doses, 24 hours apart, and both medications demonstrate comparable efficacy, ranging from 66% to 70%. In instances of resistance to treatment, a second course may be considered, but caution should be exercised, and accumulative effects on renal function should be assessed before proceeding.Â
While ibuprofen and indomethacin share similar side effects, indomethacin is associated with heightened concerns regarding gut perfusion and necrotizing enterocolitis. However, a large multicenter randomized controlled trial has not shown an increase in necrotizing enterocolitis in infants fed small amounts of milk during indomethacin treatment compared to those who were fasted.Â
Acetaminophen emerges as a promising alternative for PDA treatment. Several small studies have demonstrated its close equivalence to indomethacin and ibuprofen. However, its efficacy may be diminished in infants previously treated with indomethacin or ibuprofen, particularly in the smallest infants.Â
Â
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