Paeds · cardiology
Patent ductus arteriosus
Also known as Patent ductus arteriosus · PDA · Persistent ductus arteriosus · Ductus Botalli
Paediatric cardiology fellowship guide to patent ductus arteriosus in term infants, children and adolescents: the persistent fetal communication between pulmonary artery and descending aorta, the continuous machinery murmur, the haemodynamic burden grading, the echocardiographic and angiographic assessment, the observe–transcatheter–surgical management ladder with the Amplatzer Duct Occluder, the infective-endocarditis-prophylaxis reframe, and the Eisenmenger boundary beyond which closure becomes harmful.
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Target exams
Red flags
- A previously continuous murmur that shortens, softens or disappears as the child develops differential cyanosis and a loud pulmonary component
- Failure to thrive with recurrent lower-respiratory infections and a hyperdynamic precordium in an infant with a large left-to-right shunt
- A small child being booked for duct closure without first confirming a structurally normal heart and excluding a duct-dependent circulation
- Bounding pulses with a widened pulse pressure and a low diastolic pressure out of proportion to the murmur
- An adult with a long-standing large duct and rising pulmonary pressure — closing it past the Eisenmenger boundary is harmful
Life stages
Care settings
Clinical exam formats
Board mappings
- Fetal and transitional circulation and the anatomy of the ductus arteriosus
- Recognising the continuous machinery murmur of a PDA
- Distinguishing a pathological duct from an innocent murmur
- Haemodynamic grading and echocardiographic assessment of the duct
- The observe–transcatheter–surgical management ladder
- Pulmonary vascular disease, Eisenmenger physiology and the contraindication to closure
- Applied cardiovascular physiology of the persistent ductus
- Auscultation: continuous murmur, bounding pulses and widened pulse pressure
- Infective endocarditis prophylaxis: why it is no longer routine for PDA
- Short case: the child with a continuous machinery murmur
- Long case: an adolescent with a late-presenting large PDA and the closure decision
- Cardiology: congenital left-to-right shunts and the PDA
- Patient investigation: echocardiographic assessment of ductal size and shunt
- Patient management: the stepwise closure pathway and shared decision-making
- Cardiovascular pathophysiology: the postnatal duct that fails to close
- Transcatheter device closure and the Amplatzer Duct Occluder
- Pulmonary vascular disease and the timing of closure
- Cardiovascular examination station: continuous murmur assessment
- Communication: counselling on transcatheter closure versus surveillance
- Pediatric Cardiology: patent ductus arteriosus
- Transcatheter and surgical closure of the ductus
- Pulmonary hypertension complicating unrepaired congenital heart disease
- Patient Care: selection of infants and children for duct closure
- Medical Knowledge: shunt physiology, auscultation and device therapy
- Systems-Based Practice: ambulatory cardiology follow-up and endocarditis guidance
- Medical Expert: patent ductus arteriosus across paediatrics and transition
- Communicator: explaining the closure decision and procedural risk
- Health Advocate: avoiding unnecessary procedures and antibiotic prophylaxis
Overview & Definition
A four-year-old is referred by a general practitioner who heard a "continuous machinery murmur" at a routine check. The child is thriving, the pulses are a little full, and the echocardiogram shows a 2 mm duct with continuous left-to-right flow and a mildly dilated left atrium. This everyday referral is the face of the congenital patent ductus arteriosus in modern paediatric cardiology, and the decisions — whether to close, when, and how — are made on haemodynamic grounds, not on the presence of a murmur alone.
[1] [5]The ductus arteriosus is the fetal vessel connecting the main pulmonary artery to the descending aorta, allowing the right ventricular output to bypass the high-resistance lungs and reach the placenta via the umbilical circulation. It is meant to close after birth — functionally within the first day as oxygen rises and prostaglandins fall, and anatomically over two to three weeks as intimal proliferation converts it to the ligamentum arteriosum. A patent ductus arteriosus is persistence of this channel beyond the expected closure window in a term infant or older child. It is one of the commonest congenital heart defects and exists on a spectrum from an incidental silent echo finding to a large shunt causing heart failure and, eventually, pulmonary vascular disease.
[1] [2]The cardiology PDA must be distinguished from the preterm PDA, which is a failure of the structurally immature duct to close and is managed with cyclo-oxygenase inhibitors and, rarely, ligation. The congenital PDA discussed here is the term-infant and childhood entity managed by paediatric cardiology with surveillance, transcatheter device occlusion or, less often now, surgery. Holding the two apart matters because the management ladders, the evidence base and the complications are different, and a candidate who blurs them answers badly.
[1]The modern story of the congenital PDA is one of devices replacing surgery and surveillance replacing reflex closure. The Amplatzer Duct Occluder, introduced in the late 1990s, made outpatient same-day closure the default for the moderate duct, while the realisation that infective endocarditis prophylaxis did not work for the duct pushed practice away from closing every silent duct. Today the burden of proof sits with the decision to intervene, and the skill is matching the haemodynamic burden to the right rung of the ladder.
[4] [8] [11]References12ShowHide
- [1]Schneider DJ, Moore JW Patent ductus arteriosus Circulation, 2006.PMID 17060397
- [2]Reller MD, Strickland MJ, Riehle-Colarusso T, et al Prevalence of congenital heart defects in metropolitan Atlanta, 1998-2005 J Pediatr, 2008.PMID 18657826
- [3]van der Linde D, Konings EEM, Slager MA, et al Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis J Am Coll Cardiol, 2011.PMID 22078432
- [4]Masura J, Walsh KP, Thanopoulous B, et al Catheter closure of moderate- to large-sized patent ductus arteriosus using the new Amplatzer duct occluder: immediate and short-term results J Am Coll Cardiol, 1998.PMID 9525563
- [5]Pass RH Amplatzer Duct Occluder device: a new technology for the closure of the moderate-to-large-sized patent ductus arteriosus Expert Rev Med Devices, 2006.PMID 16681450
- [6]Tomasulo CE, Gillespie MJ, Munson D, et al Incidence and fate of device-related left pulmonary artery stenosis and aortic coarctation in small infants undergoing transcatheter patent ductus arteriosus closure Catheter Cardiovasc Interv, 2020.PMID 32339400
- [7]Orb Q, Dunya G, Padia R, et al Long-term Outcomes of Vocal Fold Paralysis Following Patent Ductus Arteriosus Ligation in Neonates Laryngoscope, 2023.PMID 36054344
- [8]Wilson W, Taubert KA, Gewitz M, et al Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group Circulation, 2007.PMID 17446442
- [9]Stout KK, Daniels CJ, Aboulhosn JA, et al 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines J Am Coll Cardiol, 2019.PMID 30121239
- [10]Baumgartner H, De Backer J, Babu-Narayan SV, et al 2020 ESC Guidelines for the management of adult congenital heart disease Eur Heart J, 2021.PMID 32860028
- [11]Gałeczka M, Szkutnik M, Białkowski J, et al. Transcatheter patent ductus arteriosus closure: what have we learned after over 25 years? A single--center experience with 1036 patients Kardiol Pol, 2021.PMID 33599452
- [12]Bhat YA, Almesned A, Alqwaee A, et al Catheter Closure of Clinically Silent Patent Ductus Arteriosus Using the Amplatzer Duct Occluder II-Additional Size: A Single-Center Experience Cureus, 2021.PMID 34589368