eMedicine Specialties > Emergency Medicine > Cardiovascular

Patent Ductus Arteriosus: Follow-up

Author: Girish Sethuraman, MD, MPH, Clinical Assistant Instructor, Staff Physician, Department of Emergency Medicine, Kings County Hospital, Downstate Medical Center
Coauthor(s): Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Apr 14, 2008

Follow-up

Further Inpatient Care

  • Small PDAs in full-term infants may spontaneously close without intervention. Large PDAs are unlikely to close.
  • Patients who present with CHF need medical therapy for CHF followed by a definitive procedure to close the PDA by either surgery or catheterization.
  • Surgical repair is recommended for patients with small-to-large PDA because of the risk for endocarditis. Complications of surgical ligation are mostly related to the left lateral thoracotomy. Surgical morbidity and mortality rates are negligible, and early postoperative complications are associated with other complications of prematurity.

Further Outpatient Care

  • Prophylaxis for infective endocarditis (subacute bacterial endocarditis [SBE]) should be followed at times of predictable risk (bacteremia) until the patient can undergo repair. (Specific recommendations for prophylactic antibiotics can be found in any current infectious disease or antibiotic reference.)

Transfer

  • Transfer to a tertiary care center is mandatory for a patient in extremis presenting in florid CHF once stabilized with diuretics and positive pressure ventilation, as indicated.

Complications

  • PGE1 should be used to maintain patency of the ductus arteriosus once it is established that a ductal dependent lesion exists. However, PGE is a pulmonary vasodilator and could cause exacerbation of CHF by means of increasing pulmonary blood flow.
  • Left heart failure
  • Pulmonary hypertension
  • Right heart hypertrophy and failure
  • Eisenmenger physiology
  • Bacterial endocarditis
  • Myocardial ischemia
  • Necrotizing enterocolitis

Prognosis

  • An excellent prognosis is expected for uncomplicated PDA.
  • Severity of the symptoms and associated cardiac anomalies modify the outcome.
  • Spontaneous closure in those older than 3 months is rare.
  • In those younger than 3 months, spontaneous closure in premature infants is 75%.
  • Postoperative results are best if closed while the patient is younger than 3 years.
  • An increased incidence of elevated pulmonary vascular resistance and pulmonary hypertension occurs if closed in those older than 3 years.
  • No firm statistics exist, but survival rates are decreased in patients with large shunts.

Patient Education

  • Parents should be aware that this lesion does not have any significant inheritance pattern.

Miscellaneous

Medicolegal Pitfalls

  • Treating CHF as an upper respiratory infection (URI) (failure to diagnose PDA)
  • Identification of additional cardiac malformations, such as coarctation or interrupted aortic arch or pulmonary atresia, is the most important requirement prior to pharmacological or surgical closure of the PDA.
  • A ductal dependent lesion, as outlined above, requires the persistence of a PDA to ensure adequate pulmonary blood flow.
  • Failure to administer prophylactic antibiotics for medical procedures with a bacteremia risk
 


More on Patent Ductus Arteriosus

Overview: Patent Ductus Arteriosus
Differential Diagnoses & Workup: Patent Ductus Arteriosus
Treatment & Medication: Patent Ductus Arteriosus
Follow-up: Patent Ductus Arteriosus
Multimedia: Patent Ductus Arteriosus
References
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References

  1. [Best Evidence] Ohlsson A, Walia R, Shah S. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. Jan 23 2008;CD003481. [Medline].

  2. [Best Evidence] Malviya M, Ohlsson A, Shah S. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. 2008;(1):CD003951. [Medline].

  3. Benders MJ, van de Bor M, van Bel F. Doppler sonographic study of the effect of indomethacin on cardiac and pulmonary hemodynamics of the preterm infant. Eur J Ultrasound. May 1999;9(2):107-16. [Medline].

  4. Bensky AS, Raines KH, Hines MH. Late follow-up after thoracoscopic ductal ligation. Am J Cardiol. Aug 1 2000;86(3):360-1. [Medline].

  5. Brook MM, Heymann MA. Patent ductus arteriosus. In: Heart Disease in Infants, Children and Adolescents. Vol I Section III, Part A. 1995:746-64/chap 54.

  6. Burke RP, Jacobs JP, Cheng W, et al. Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants. Pediatrics. Aug 1999;104(2 Pt 1):227-30. [Medline].

  7. Castaneda AR, Jonas RA, Meyer JE. Surgery for infants with congenital heart disease. In: Kirklin JW, Barrett-Boyes BG, eds. Cardiac Surgery. 1993:841-61.

  8. Fyler DC. Patent ductus arteriosus. In: Nadas Pediatric Cardiology. 1992:525-34.

  9. McConnell ME, Adkins SB 3rd, Hannon DW. Heart murmurs in pediatric patients: when do you refer?. Am Fam Physician. Aug 1999;60(2):558-65. [Medline].

  10. Park MK. Specific congenital heart defects: patent ductus arteriosus. In: Pediatric Cardiology for Practitioners. 1988:134-7.

  11. Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation. Oct 24 2006;114(17):1873-82. [Medline].

  12. Silverman NH. Patent ductus arteriosus. In: Pediatric Echocardiography. 1993:167-77.

  13. Snider AR, Serwer GA. Abnormal vascular connections and structures: patent ductus arteriosus. In: Echocardiography in Pediatric Heart Disease. 1990:264-71. [Medline].

  14. Wyllie J. Treatment of patent ductus arteriosus. Semin Neonatol. Dec 2003;8(6):425-32. [Medline].

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Further Reading

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Keywords

PDA, patent ductus arteriosus, ductal closure, bacterial endocarditis, late congestive heart failure, CHF, development of pulmonary vascular obstructive disease, circulatory abnormalities, ventilatory abnormalities, congenital heart diseases

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Contributor Information and Disclosures

Author

Girish Sethuraman, MD, MPH, Clinical Assistant Instructor, Staff Physician, Department of Emergency Medicine, Kings County Hospital, Downstate Medical Center
Girish Sethuraman, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Charles V Pollack, Jr, MD, MA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: sanofi-aventis Honoraria Consulting; sanofi-aventis Honoraria Speaking and teaching; Schering-Polugh Honoraria Consulting; Schering-Plough Honoraria Speaking and teaching; The Medicines Company Honoraria Consulting; GlaxoSmithKline Grant/research funds Other

 
 
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