Patent Ductus

Arteriosus
in Premature Babies
Dominic C. Sia, M.D.

Neonatal
Circulation
Right to left flow
Systemic
resistance
Pulmonary
Resistance

Postnatally

PGE2
PGE2
O2

O2
Nitric Oxide

Prenatal Cortisol
PDA remains
patent

Closure of
PDA

PDA Closure
24 hrs - 50%
48 hrs - 90%
72 hrs - 99.9%

ligamentum arteriosum
o

1-3 months

PDA Obliteration

PDA Obliteration

PDA
When the DA has not closed by 72 hrs
Preterm infants, especially those <30 weeks
or <1000 gms (50%)
o
o

increased sensitivity to PGE2 and NO

delayed ductal obliteration

PDA Consequences

Pulmonary Edema
Pulmonary Hemorrhage
Bronchopulmonary Dysplasia
incidence of Necrotizing Enterocolitis
incidence of Intraventricular Hemorrhage

Signs and Symptoms

2-3 days after birth up to 1 week of life
o

later in those treated with surfactant

prominent left ventricular impulse

bounding pulses
widened pulse pressure (>25 mmHg)
murmur
o
o
o

can be initially silent

initially systolic becoming continuous
machinery like

Signs and Symptoms

deterioration of respiratory status

circulatory instability
cardiac enlargement
tachypnea/apnea
increased CO2 retention
increased requirements for mechanical
ventilation

diagnosis confirmed by echocardiography

Echocardiography

Significant PDA
Transductal diameter > 1.5mm (@7-31 hrs of life)
Left atrial to aortic root ratio (LA/AO ratio) >1.4 or >1.5
Left ventricular output to superior vena cava ratio
o

(LVO/SVC ratio) >4

B-type Natriuretic Peptide

Chest radiography
o

cardiomegaly or pulmonary congestion

Grading System
o
o

oxygenation index - chest radiography

degree of respiratory support - end-organ function

Management
Conservative
Prophylactic Indomethacin/Ibuprofen
Medical Treatment
o
o

Indomethacin
Ibuprofen

Surgical Treatment

Management
Conservative

Neutral Thermal Environment

Adequate Oxygenation
PEEP
Hct at 35-40
Avoid exacerbating factors
o
o
o

furosemide
excessive fluids (>170 cc/kg/day)
no evidence that fluid restriction reduces PDA

Management
Medical
Indomethacin
o
o
o
o

3 doses at 12 or 24 hr intervals (0.2 mg/kg)

increased risk for NEC, Renal failure, Platelet dysfunction and
BPD
Dopamine may prevent Renal tubular dysfunction
Regular measurement of creatinine and platelets

Ibuprofen
o
o
o
o

10 mg/kg 1st dose then 5 mg/kg 2 doses daily

less oliguria
increased risk for NEC and platelet dysfunction
increased risk for kernicterus

Management
Surgical

complications
o
o
o
o
o
o
o
o
o
o

blood pressure fluctuations

respiratory compromise
infection
intraventricular hemorrhage
chylothorax
recurrent laryngeal nerve paralysis
BPD
death
neurosensory impairment
ROP

Controversies
Conservative Management
o high rate of spontaneous closure
o established adverse effects of intervention
o lack of evidence that treatment results in a

decrease in neonatal morbidity and mortality

Prophylactic Indomethacin
o 0.1 mg/kg/day q24 hrs after birth x 3 days
o no effect on mortality, pulmonary outcome

or

reducing the risk of NEC

o early treatment more likely to be successful

Controversies
Medical vs Surgical Treatment
o no difference in mortality
o higher adverse events with

surgery

Sources

Clyman, RI. Ibuprofen and patent ductus arteriosus. N Engl J Med 2000; 343:728.
Clyman, R, Cassady, G, Kirklin, JK, et al. The role of patent ductus arteriosus ligation in
bronchopulmonary dysplasia: reexamining a randomized controlled trial. J Pediatr 2009;
154:873.
Bose, CL, Laughon, MM. Patent ductus arteriosus: lack of evidence for common treatments.
Arch Dis Child Fetal Neonatal Ed 2007; 92:F498.
Brooks, JM, Travadi, JN, Patole, SK, et al. Is surgical ligation of patent ductus arteriosus
necessary? The Western Australian experience of conservative management. Arch Dis Child
Fetal Neonatal Ed 2005; 90:F235.
Noori, S, McCoy, M, Friedlich, P, et al. Failure of ductus arteriosus closure is associated with
increased mortality in preterm infants. Pediatrics 2009; 123:e138.
Kabra, NS, Schmidt, B, Roberts, RS, et al. Neurosensory impairment after surgical closure of
patent ductus arteriosus in extremely low birth weight infants: results from the Trial of
Indomethacin Prophylaxis in Preterms. J Pediatr 2007; 150:229.
Chorne, N, Leonard, C, Piecuch, R, Clyman, RI. Patent ductus arteriosus and its treatment as
risk factors for neonatal and neurodevelopmental morbidity. Pediatrics 2007; 119:1165.
Vida, V. L., Lago, P., Salvatori, S., Boccuzzo, G., Padalino, M. A., Milanesi, O., Speggiorin, S.,
Stellin, G. (2009). Is there an optimal timing for surgical ligation of patent ductus arteriosus in
preterm infants?. Ann. Thorac. Surg. 87: 1509-1516
Noori, S., McCoy, M., Friedlich, P., Bright, B., Gottipati, V., Seri, I., Sekar, K. (2009). Failure of
Ductus Arteriosus Closure Is Associated With Increased Mortality in Preterm Infants. Pediatrics
123: e138-e144

Sources

El-Khuffash, A, Barry, D, Walsh, K, Davis, P G, Molloy, E J (2008). Biochemical markers may

identify preterm infants with a patent ductus arteriosus at high risk of death or severe
intraventricular haemorrhage. Arch. Dis. Child. Fetal Neonatal Ed. 93: F407-F412
Gaca, A. M., Jaggers, J. J., Dudley, L. T., Bisset, G. S. III (2008). Repair of Congenital Heart
Disease: A Primer--Part 2. Radiology 248: 44-60
Roberts, P., Adwani, S., Archer, N., Wilson, N. (2007). Catheter closure of the arterial duct in
preterm infants. Arch. Dis. Child. Fetal Neonatal Ed. 92: F248-F250 [Abstract] [Full Text]
Chorne, N., Leonard, C., Piecuch, R., Clyman, R. I. (2007). Patent Ductus Arteriosus and Its
Treatment as Risk Factors for Neonatal and Neurodevelopmental Morbidity. Pediatrics 119:
1165-1174
Patole, S K, Kumaran, V, Travadi, J N, Brooks, J M, Doherty, D A (2007). Does patent ductus
arteriosus affect feed tolerance in preterm neonates?. Arch. Dis. Child. Fetal Neonatal Ed. 92:
F53-F55
Manzar, S. (2006). High-Dose Indomethacin for Patent Ductus Arteriosus Closure: How Strong
Is the Evidence?. Pediatrics 117: 1863-1863
Sperandio, M., Beedgen, B., Linderkamp, O. (2006). High-Dose Indomethacin for Patent
Ductus Arteriosus Closure: How Strong Is the Evidence?: In Reply. Pediatrics 117: 1863-1864
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answers?. Arch. Dis. Child. Fetal Neonatal Ed. 90: F190-f190

Thank You