Every year, around 1.35 million babies are born with congenital heart disease. Patient Ductus Arteriosus, or PDA, is one of the most common types of congenital heart disease, accounting for 5-10% of congenital heart disease in infants born at full term and 20-60% of infants born preterm. The global prevalence of PDA is around 1 in 1000 live births.
This article offers a comprehensive global overview of Patient Ductus Arteriosus, exploring its causes, symptoms, diagnostic approaches, and treatment options, including both conventional and integrative medicine.
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What is Patent Ductus Arteriosus?
There are a number of transitions that occur in the body immediately after birth as a newborn moves from life inside the uterus to life outside the uterus. One of these transitions is the closure of the ductus arteriosus.
Definition and Anatomy
Prior to birth, the oxygenation of the fetal blood occurs in the placenta as opposed to the lungs. Instead of flowing through the lungs to get oxygen, a hole connects the aorta and pulmonary arteries, allowing the blood to bypass the lungs. After birth, this hole gets smaller and, within a few days, closes altogether.
Every baby is born with the ductus arteriosus open, but the majority of these close spontaneously. Sometimes, this opening fails to close, resulting in a PDA.
Epidemiology
A 2023 retrospective study showed the global incidence of PDA to be 1.004 per 1000 live births globally, but only 0.25 per 1000 live births in Africa. The highest incidence of congenital heart disease is in Asian countries, and Europe had a higher incidence than North America. Lack of diagnostic facilities may decrease reporting in some countries.
Causes of Patent Ductus Arteriosus
Most of the time, the cause of patent ductus arteriosus is unknown, but there are a few factors that can increase the risk.
Common Causes
PDA is significantly more common in infants born prematurely. Between 20 and 50% of babies born before 32 weeks of gestation and as many as 60% of infants born before 29 weeks of gestation will have a PDA. Preterm infants are more likely to have spontaneous closure of the PDA than their term counterparts.
There may be a genetic link for PDA, as around 5% of infants with a sibling with PDA will be diagnosed with one. There is a proposed link with a gene on the 12th chromosome known as PDA1. Some chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 13, or trisomy 18 may also be more likely to be associated with PDA.
Rare Causes
In rare cases, other exposures, especially in the first 4 weeks of pregnancy, may be associated with PDA. Some of these exposures include:
- Congenital rubella infection
- Fetal alcohol exposure
- Amphetamine exposure
- Phenytoin exposure
Other potential contributing factors include low oxygen levels, low birth weight, and high altitude.
Global Variations in Causes
Some of the potential causes of PDA may be more common in different regions or parts of the world. Altitude is one geographic risk factor that may increase the risk of PDA.
Socioeconomic status may influence the likelihood of being exposed to pollutants or having other health disparities, which may increase the likelihood of PDA. Lower socioeconomic status may correlate with increased risk of congenital heart disease.
Symptoms of Patent Ductus Arteriosus
The symptoms associated with patent ductus arteriosus can vary. Mild symptoms are more common, while the less common, more severe symptoms, can have more impact on health.
Common Symptoms
The most common symptom of a PDA is a heart murmur, and many small PDAs don’t cause symptoms at all. Larger PDAs may cause symptoms such as rapid breathing, a rapid heart rate, or a wider pulse pressure (wider gap between the systolic and diastolic blood pressure). Low blood pressure is more common in very small infants.
Severe Symptoms
In more severe cases, congestive heart failure may develop leading to swelling, shortness of breath, or an enlarged liver. Infants with large PDAs may not eat well and may have poor growth while older children may get tired more easily than their peers. Infants may also have increased sweating when eating or crying.
Symptom Variations Globally
Countries with less diagnostic capabilities may see a higher percentage of their infants diagnosed with PDA present with more severe symptoms as smaller PDA lesions may be less likely to be diagnosed.
Diagnostic Approaches for PDA
Several diagnostic tools can be used for PDA.
Conventional Diagnostic Methods
In many cases, the diagnosis of PDA starts with the detection of a heart murmur. The next step is generally an echocardiogram, or ultrasound of the heart. Electrocardiograms (EKG or ECG) may have some diagnostic value, but generally detect more severe cases through detecting an enlarged heart. A chest x-ray might show fluid overload.
Advanced Diagnostic Techniques
Echocardiography is the primary imaging test used for the diagnosis of PDA, but in some cases, a CT scan may be useful. PDA can also be diagnosed on cardiac catheterization, though this test is not necessary for the diagnosis and may be used if other potential diagnoses are being considered. Cardiac MRI is also a potential diagnostic tool though it is not commonly used.
Diagnostic Challenges Worldwide
One of the challenges associated with PDA diagnosis is determining the significance of the diagnosis. Often, PDA does not cause any hemodynamic instability, so determining when to treat the condition can be a challenge. Limited diagnostic resources in some areas of the world can also increase diagnostic challenges.
Treatment Options for Patent Ductus Arteriosus
There are many treatment options for patent ductus arteriosus, but the first step is to determine whether it is necessary to treat the condition. Recommendations for when to close the PDA have changed over time. If a PDA is causing significant symptoms or hemodynamic instability, it is more likely that treatment is necessary.
Conventional Treatments
Traditional treatments for PDA closure have included medical treatments and surgery.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin or ibuprofen are two medications that may be used to close the ductus arteriosus, as they are prostaglandin inhibitors. Each of these medications has potential risks and advantages. Both medications are administered intravenously for the treatment of PDA. In infants with congestive heart failure or fluid overload, diuretic medications may be used. The success rate for PDA closure with indomethacin approaches 90% though this rate may drop with larger PDA.
Surgical ligation is another potential treatment, especially for large PDA. This procedure would be performed by an experienced pediatric cardiovascular surgery specialist. The procedure can either be done through a thoracotomy or with the assistance of a scope. Infants with other congenital heart abnormalities or those with severe pulmonary vascular disease may not be candidates for closure of the PDA. Surgery is most effective in children under 3 years of age though a PDA that persists to adulthood is always treated surgery unless pulmonary hypertension has developed.
Minimally Invasive Procedures
Another technique for closing the PDA is using a cardiac catheter to deploy an occluding device. There are several devices that can be used to accomplish this, depending on the size of the PDA and other factors. The transcatheter approach to treatment is growing in frequency worldwide.
Integrative Medicine Approaches
There are no current lifestyle modifications or herbal treatments for the treatment of PDA. In some cases, fluid restriction and watchful waiting may be used in the premature infant while waiting for spontaneous closure. Any treatment should be under the supervision of a physician.
Global Perspectives on Treatment
Scoring systems have been proposed to determine which infants may benefit from closure of the PDA. Treatment options may vary depending on the resources available in the area. Infants with hemodynamically significant PDA may benefit from more expedient treatment than infants with non hemodynamically significant PDA.
Prognosis and Long-Term Management
The prognosis for PDA is quite favorable in infants who have no other congenital heart abnormalities or comorbidities.
Outcomes with Timely Treatment
After treatment, most of these children will have a normal life expectancy and have minimal long-term effects. Untreated, PDA can lead to pulmonary hypertension, respiratory distress, or congestive heart failure, which can lead to increased risk of death and disability.
Long-Term Monitoring
In the absence of other cardiac abnormalities, most patients do not require any long-term monitoring. Many patients who are hospitalized for closure of a PDA and have minimally invasive procedure can go home the same day.
Global Variations in Long-Term Care
As with diagnosis and treatment, long-term monitoring and care of patients with PDA depend on the availability of resources regionally
Future Directions and Research
There is an ongoing effort to have a more global understanding of PDA and a consensus on treatment.
Emerging Treatments and Technologies
Combination therapies using acetaminophen and NSAIDs are being studied as a potential treatment for extremely low gestational age neonates (ELGANs) as a potential treatment to decrease the risks associated with NSAIDs alone in this fragile population. Ongoing research into additional occlusion devices for use with a transcatheter approach is also being used to find optimal treatment options in some populations such as extremely low birth weight infants.
Ongoing Research Initiatives
Research into both pharmacologic and surgical treatment options for PDA is ongoing, as treatment strategy optimization is a focus of management in premature infants. Despite the condition being studied for many years, there is still not a consensus on how when and how to treat.
Global Collaboration in PDA Research
The PIVOTAL network is one group of healthcare organizations, researchers, and providers that are working to determine how best to treat preterm infants with PDA.
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Key Takeaways
- Patent ductus arteriosus is one of the most common types of congenital heart disease.
- Patent ductus arteriosus is more common in premature infants especially lower gestational age and lower birth weight infants.
- Patent ductus arteriosus often presents with a murmur, but more severe cases may present with hemodynamic instability.
- Patent ductus arteriosus can be treated with medication or surgical approaches.
- Patent ductus arteriosus has a good prognosis when treated in a timely manner.
- Most patients with treated patent ductus arteriosus do not require long-term management.
Patent ductus arteriosus affects infants worldwide, and understanding global perspectives can improve understanding and help guide treatment for this treatable condition. If you want to learn more about other health topics, consider reading some of our other educational articles and subscribe to our newsletter. Has someone you know been affected by PDA? Share your experience or your questions with us.
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