The premature neonate with a significant PDA usually is treated with intravenous indomethacin. This has been quite successful in most patients. Whether results with intravenous indomethacin are superior to those with surgical closure of the PDA, even in the premature neonate in whom the safety of the surgery is a concern, is not clear. Recently, intravenous ibuprofen has been approved by the US Food and Drug Association (FDA) and may be equal in efficacy with indomethacin and possibly has fewer adverse effects.
- In the symptomatic neonate, diuretics and cautious fluid restriction may be sufficient for initial therapy if symptoms are mild and the baby is not extremely premature. Spontaneous closure is common. If significant respiratory distress or impaired systemic oxygen delivery is present, therapy is usually prudent. Intravenous indomethacin (or the new preparation of intravenous ibuprofen) is frequently effective in closing a PDA if it is administered in the first 10-14 days of life. (Another option is surgical ligation, discussed in Surgical Care.)
- After the first birthday, the most common treatment for a PDA is occlusion at cardiac catheterization. In fact, as catheterization techniques advance, the ability to close defects in smaller infants has also been reported with high levels of success.
- Over the last 4 decades, many techniques and devices have been used for PDA occlusion. For many years, the most common device used for PDA occlusion is a Gianturco spring occluding coil. In experienced hands with proper patient selection, this has become a procedure associated with high success and low morbidity. Coil occlusion is best suited to close PDAs with a minimal internal diameter of less than 2.5 mm. Success is usual with a PDA diameter of 2.5-3 mm, but larger PDAs probably are best served by alternate techniques.
- More recently, the Amplatzer PDA device has expanded the ability to close PDAs at cardiac catheterization. This device is more reliable and easier to implant in larger PDAs than spring occluding coils. Other occlusion devices remain under investigation. Most patients with an isolated PDA can have successful treatment by catheterization after the first few months of life.
- Typically, complete occlusion is achieved at catheterization. Occasionally, a tiny residual left-to-right shunt remains at the end of the procedure, which closes by thrombus formation over the following days or weeks. Left-to-right shunt rarely persists through a partially occluded PDA. Usually, the magnitude of the shunt is significantly smaller than prior to occlusion. Due to concerns about the long-term risk of endocarditis, this residual defect should be closed. Often, this can be accomplished with a second catheter procedure. Rare reports describe association of a persistently patent ductus after occlusion attempts with hemolysis or endocarditis.
- Procedural risks of PDA occlusion by catheter are few and largely influenced by the experience of the physician performing the procedure. These risks include embolization of the device being used to occlude the PDA, blood vessel injury, and stroke. In the case of device embolization, the device usually can be retrieved by transcatheter techniques, and a second device can be successfully placed in the PDA.
SURGICAL CARE
Surgical ligation or surgical ligation and division remain the standard treatment of large PDAs that require treatment in infancy. This is a particularly successful procedure in the hands of an experienced pediatric cardiovascular surgeon. The techniques are reviewed in Patent Ductus Arterious: Surgical Perspective.
When performed by an experienced pediatric cardiac surgeon, PDA ligation is a low-risk procedure with excellent results. This is true even in the smallest premature babies. The risks include hemorrhage, vessel damage, ligation of the wrong vessel (left pulmonary artery or aorta), recurrent laryngeal nerve or phrenic nerve damage, or infection.
While indomethacin therapy is preferred in most intensive care nurseries as the first-line approach to effect PDA closure, the benefits of this approach over surgical ligation are not obvious. In most studies that attempt to evaluate differences in the outcomes for indomethacin therapy and surgical closure, results are similar.
CONSULTATIONS
- Pediatric cardiologist
- Pediatric cardiovascular surgeon
