eMedicine Specialties > Emergency Medicine > Cardiovascular

Patent Ductus Arteriosus: Treatment & Medication

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

Treatment

Prehospital Care

Prehospital care for a suspected PDA consists of supplemental oxygen for any hypoxia and supportive care.

Emergency Department Care

  • General measures
    • Pulmonary support
    • Oxygen to correct hypoxemia
    • Sodium and fluid restriction
    • Correction of anemia
  • Medical management consists of amelioration of CHF symptoms.
  • No exercise restriction is required in the absence of pulmonary hypertension.
  • Prophylaxis against infective endocarditis is recommended.

Consultations

Pediatric surgery

  • Indications for surgical treatment include the following: failure of indomethacin treatment, contraindications to medical therapy (eg, thrombocytopenia, renal insufficiency), signs and symptoms of CHF, and PDA found in an older infant. Infants found to have an asymptomatic PDA after the neonatal period should undergo surgical ligation preferably before the age of 1 year to prevent future complications of a PDA.
  • Ductal closure is indicated for cardiovascular compromise (ie, pulmonary complications) and for reduction of the risk of infective endocarditis (subacute bacterial endocarditis).
  • Contraindications to surgery include pulmonary vascular obstructive disease.
  • Ligation (with or without division of the PDA) without cardiopulmonary bypass can be performed through a left posterolateral thoracotomy.
  • Video-assisted thoracoscopic surgery (VATS) ligation of PDA is less invasive than the posterolateral thoracotomy. It has been shown to be safe and effective.
  • Timing of surgery is at 1-2 years or whenever the diagnosis is made in an older infant.
  • In infants with CHF, failure to thrive, pulmonary hypertension, or recurrent pneumonia, the operation is more urgent (ie, within 3-6 months).

Pediatric cardiology

  • Transcatheter occlusion has been performed in the cardiac catheterization laboratory and is an effective alternative to surgical intervention and is increasingly becoming the treatment of choice for most PDAs in children and adults. This involves coil embolization or the use of an occluder device.

Medication

Medication use in PDA is based upon the clinical status of the patient. Prostaglandins are utilized to maintain the patency of the ductus arteriosus until surgical ligation is performed.
 
When surgical ligation is not indicated, prostaglandin inhibitors (eg, NSAIDs) are used to close the ductus arteriosus.

Indomethacin is currently the drug of choice for closure of the ductus in premature infants.

Other studies have shown equal effectiveness with ibuprofen. The dose used for ibuprofen is 10 mg/kg bolus followed by 5 mg/kg/d for 2 additional days.

Ibuprofen was initially thought to have less adverse effects such as decreased incidence of oliguria, gastrointestinal toxicity, and cerebral hypoperfusion. The use of ibuprofen has been shown to increase the incidence of pulmonary hypertension and chronic lung disease. Intravenous ibuprofen is currently not available in the United States.

A Cochrane Database of Systematic Reviews article has showed no statistically significant difference in closure between ibuprofen and indomethacin.1 A decision to use one drug versus another should be based upon the infant's presentation and comorbidities.

A similar Cochrane Database of Systematic Reviews article looking at initial treatment of symptomatic PDA in preterm infants showed no difference in risks or benefits of surgery versus the use of cyclooxygenase inhibitors.2

Prostaglandin

Promote vasodilatation by direct effect on the vasculature and smooth muscle of the ductus arteriosus.


Alprostadil (Prostin VR Pediatric)

Used to maintain patency of the ductus arteriosus when a cyanotic lesion or interrupted aortic arch presents in a newborn. PGE1 is most effective in premature infants.

Adult

Pediatric

Initial infusion: 0.05-0.1 mcg/kg/min IV
Maintenance infusion: 0.01-0.4 mcg/kg/min IV; titrate to lowest effective dose
Usual maintenance dose is 0.1 mcg/kg/min IV but is often possible to reduce the dosage by 50-90%

Documented hypersensitivity; respiratory distress syndrome; persistent fetal circulation

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Adverse effects and toxicity include apnea, seizures, fever, hypotension, pulmonary overcirculation, and inhibition of platelet aggregation; because of the potential risk of apnea with the use of PGE1, neonates usually are intubated prophylactically; use cautiously in neonates with bleeding tendencies; prolonged use occasionally is necessary (in hypoplastic left heart syndrome transplant candidates) and may be associated with third spacing of fluid

Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents inhibit the production of prostaglandins by decreasing the activity of cyclo-oxygenase. The result is a functional closure of the PDA in 80% of patients.


Indomethacin (Indocin)

Promotes closure of the PDA. Onset of action is generally within min.

Adult

Pediatric

0.2 mg/kg IV, then 0.1 mg/kg q12h IV for 2 doses
Alternative dosing:
<7 days: 0.2 mg/kg IV, then 0.1 mg/kg IV at 12 and 36 h after initial dose
>7 days: 0.2 mg/kg IV, then 0.2 mg/kg IV at 12 and 36 h after initial dose

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; GI bleeding; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if leukopenia, granulocytopenia, or thrombocytopenia persists)

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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