PATENT DUCTUS ARTERIOSUS

INTRODUCTION

The most common cardiac disease affecting neonates is patent ductus arteriosus
(PDA). Despite several research about it, the option to treat PDA is still heavily debated
by cardiologists, surgeons, and neonatologists.

Numerous studies have discovered a link between untreated PDAs and

substantial newborn morbidities. PDA and the associated left-to-right shunt might limit
systemic perfusion if left untreated. The volume of the shunt must be determined before
deciding on a treatment plan for premature newborns with PDA. While PDA is
correlated with greater morbidity, therapeutic approaches have been connected to
negative results leading to disagreement over whether or not to treat the PDA (Parker
et. Al., 2021).

 Patent ductus arteriosus accounts for 5 to 10% of congenital cardiac

abnormalities and the male: female ratio is 1:3. PDA is particularly common in preterm
births, even in newborns born with a low birth weight, however, around a third of PDAs
will close naturally. A large PDA can cause heart failure, worsening of preterm lung
disease, pulmonary bleeding, renal insufficiency, feeding intolerance, necrotizing
enterocolitis, and ultimately fatal in premature neonates. (Beerman, 2020).

DEFINITION

Patent ductus arteriosus (PDA) is a cardiac abnormality that appears in the days
or weeks following birth. The ductus arteriosus is a natural feature of fetal blood
circulation before a newborn is born, it's an additional blood vessel that links the
pulmonary artery to the aorta. The pulmonary artery is responsible for transporting
blood from the heart to the lungs. The aorta transports blood from the heart to the rest
of the body. The ductus arteriosus allows blood to circulate around (bypass) the lungs
prior to birth. This is because the infant receives oxygen from the mother.

This opening between the aorta and the pulmonary artery is present in all
newborns. However, it frequently closes on its own shortly after birth, after the baby can
breathe on its own. It is referred to as patent ductus arteriosus if it remains open
(patent). Extra blood rushes to the lungs as a result of PDA. A big PDA sends an
excessive amount of blood to the lungs. To accommodate the increased blood, the
blood arteries and lungs must work much harder. This might cause an accumulation of
fluid in the lungs. Breathing and feeding may be more difficult for the newborn. (Stanford
Children’s Health, n.d.).

A small patent ductus arteriosus may not cause any symptoms and may never
require treatment. However, if left untreated, a large patent ductus arteriosus can cause
poorly oxygenated blood to flow in the incorrect way, weakening the heart muscle and
leading to heart failure and other issues. A PDA is termed small if its dimension is less
than 1.5 mm, moderate if it is between 1.5 and 3 mm, and large if it surpasses 3 mm.
(Arlettaz, 2017).

SYMPTOMATOLOGY

SIGNS AND SYMPTOMS RATIONALE

Poor eating With PDA, extra blood flows to the
lungs.  The blood vessels and the lungs
have to work much harder to handle the
extra blood. This can lead to fluid buildup
in the lungs. The baby can have a harder
time breathing and feeding. (URMC,
2021).
Breathlessness The PDA allows oxygen-rich aorta blood
to mix with oxygen-poor pulmonary artery
flow. As a result, too much blood enters
the lungs, putting strain on the heart and
raising blood pressure in the pulmonary
arteries (Baffa, G., 2017)
Sweating Excessive blood flow to the lungs can
cause fast breathing or tachypnea.
Because of the increased blood flow and
water in the lungs, an infant with a
 congenital heart disease may have to
work harder to breathe during periods of
activity, such as when feeding. (Pediatric
Cardiology Associates of Houston, 2021).
Respiratory distress Blood flows in the opposite direction as it
does in the fetus when the ductus
arteriosus remains open: from the aorta
to the lungs. Blood can build up in the
baby's lungs due to this excess blood and
the usual flow of blood from the heart to
the lungs. If the PDA is excessively large,
the increased blood flow is too much for
the baby to tolerate, making breathing
difficult (Cleveland clinic, 2019).
Heart murmur Gibson defined the typical murmur in
1898. As a result, the hallmark physical
finding of patent ductus arteriosus (PDA)
has been termed a continuous
mechanical murmur. In systole, the
murmur may be more prominent. The
murmur is usually loudest in the left upper
chest (Kim, 2018).
Bounding peripheral pulses Due to the continuous drainage of blood
from the aorta into the pulmonary artery,
bounding pulses are induced by a
relatively low systemic arterial blood
pressure (Kim, 2018).
Widened pulse pressure A wider pulse pressure (> 30mmHg)
results from a small increase in systolic
blood pressure to compensate for the
decrease in distal blood flow caused by
run-off through the PDA during diastole,
 as well as a decreased diastolic blood
pressure (Gillam and Mahajan, 2021).

ETIOLOGICAL FACTORS

PREDISPOSING RATIONALE
Age At 3 days of life, up to 80% of severely
preterm newborns, especially those with
respiratory distress syndrome, may have
a PDA (Gillam and Mahajan, 2021).
Gender The male-female ratio is 1:3. Patent
ductus arteriosus accounts for 5 to 10%
of congenital cardiac abnormalities
(Beerman, 2020).
Family history and other genetic Genetic disorder - PDA occurs with
conditions increased frequency in several genetic
syndromes, including those with defined
chromosomal aberrations, single-gene
mutations and X-linked mutations.
(Schneider & Moore, 2016).

PRECIPITATING
Premature birth
Rubella Infection during pregnancy
Being born at a high altitude
RATIONALE
The incidence of PDA is greater in pre-
term neonates, it is highly associated to
the lack of normal closure mechanisms
due to immaturity (Dice & Bhatia, 2016).
The rubella virus crosses the placenta
and spreads through the baby's
circulatory system, damaging blood
vessels and organs, including the heart
(Mayo Clinic 2021).
Failure of lower oxygen tension to
 constrict the ductus leads to patency of
ductus arteriosus while the presence of
high pulmonary vascular resistance and
right atrial pressure at high altitude
inhibits early closure of foremen ovale
(Hasan, 2016).
Respiratory distress syndrome RDS causes PDA primarily through
hypoxemia, while pulmonary
hyperperfusion caused by PDA
decreases surfactant formation in alveolar
cells, implying that the link between PDA
and RDS is complex and bidirectional (Liu
et. Al., 2021).

PATHOPHYSIOLOGY

Diagram

Narrative

During fetal development, oxygenated blood travels from the placenta via the
umbilical vein, through the inferior vena cava (IVC), and to the right side of the heart. A
portion of this oxygenated blood is sent through the patent foramen ovale for delivery to
the brain, and the remainder is pumped by the right ventricle through the main
pulmonary artery. The PDA provides a low-resistance pathway to the aorta, and the
majority of the blood pumped from the right ventricle to the pulmonary artery will follow
this route, delivering oxygen and nutrients from the placenta to the organs and tissues
and then returning to the placenta through the umbilical arteries. Many factors may
cause failure of PDA closure; these may include misinterpretation of chemical or
environmental signals, failure to respond to oxygen, complications from disease
processes, and underdeveloped smooth muscle. The signals that normally lead to
constriction of the PDA and functional closure in the first days of life are not interpreted
in the same way in premature infants. Throughout development, tissue responsiveness
to different signals changes as the fetus matures. This process is programmed to help
orchestrate the extremely complex series of events required for successful fetal
development. When an infant is born prematurely, some tissues are not yet sensitive to
the signals in the extrauterine environment that allow them to properly adapt. The tissue
in the PDA has not yet developed optimal sensitivity to increased oxygen content in the
blood, which is important for stimulating constriction. Instead, the PDA is still very
sensitive to circulating prostaglandins that cause it to remain open. Circulating
prostaglandins decrease significantly after delivery in both term and preterm infants.
However, the premature ductal tissue may still respond, even to low concentrations of
prostaglandins, causing a failure of constriction. Certain disease processes, such as
sepsis and NEC, are accompanied by a surge of prostaglandins. This surge can cause
a functionally closed, constricted PDA to reopen and further complicate the disease
process. Some characteristics of the cardiopulmonary system of premature infants
make them especially susceptible to problems from the PDA. The lower vascular tone of
the pulmonary vessels at earlier gestational ages facilitates left to- right shunting when
the PDA is open, and this shunting perpetuates the failure of the ductus to constrict.
Thus, when the PDA exists, premature infants are more likely than term infants to go
into congestive heart failure. Additionally, the permeability of the capillaries in the
pulmonary bed is greater in premature infants, leaving them more susceptible to
developing pulmonary edema from the over circulation that accompanies left-to-right
shunting.

DIAGNOSTIC TESTS
 Electrocardiogram. This test records the electrical activity of the heart, which
can aid in the diagnosis of cardiac abnormalities or irregular heartbeats (Mayo
Clinic, 2021).
 Echocardiogram. Sound waves provide images of the heart that can aid in
identifying a PDA, determining whether the heart chambers are enlarged, and
determining how well the heart pumps. This test also aids in the evaluation of the
heart valves and the detection of any potential cardiac abnormalities by the
doctor (Mayo Clinic, 2021)
  Chest X-ray. The state of your or your baby's heart and lungs can be seen via an
X-ray scan. Other than a heart abnormality, an X-ray may identify other issues
(Mayo Clinic, 2021).
 Cardiac Catherization. This test isn't normally required to diagnose a PDA on its
own, but it may be used to look for other congenital heart problems that were
discovered during an echocardiography or if a catheter surgery is being explored
to treat a PDA. A thin, flexible tube (catheter) is placed into a blood vessel in the
groin or arm of you or your child and guided into the heart. The doctor may be
able to do operations to close the patent ductus arteriosus using catheterization
(Mayo Clinic, 2021).

MEDICAL MANAGEMENT

MEDICATIONS

 Indomethacin. The injection of indomethacin is used to treat patent ductus

arteriosus (PDA) in preterm infants weighing between 500 and 1750 grams. PDA
is a heart condition in which the ductus arteriosus, a blood artery, fails to close
properly after birth. This blood vessel is only used before the baby is delivered; it
is no longer needed after the baby is born. The injection of indomethacin causes
the PDA to contract, which closes the blood artery. When previous medical
treatments for PDA have failed after 48 hours, this medication is given (Mayo
Clinic, 2021).
 Ibuprofen. By blocking the cyclooxygenase site of the prostaglandin synthase
enzyme, this drug prevents arachidonic acid from converting to prostaglandin,
inducing PDA closure. Ibuprofen can be just as effective as indomethacin in
closing the PDA. Ibuprofen also reduces the incidence of NEC and severe renal
damage. The long-term benefits of ibuprofen over indomethacin have not been
well researched, hence no evidence is currently available (Parkerson et. Al.,
2021).

SURGICAL MANAGEMENT
  Transcatheter closure. Transcatheter closure has become the treatment of
choice for PDA in children over the age of one year, and some writers believe it
is also the best option for term newborns and newborn infants. There are a
number of catheter-delivered occlusion devices available (eg, coils, septal duct
occluder).

RT MANAGEMENT

 Adjusting mechanical ventilator settings, in addition to medications, may help to

reduce respiratory impairment caused by pulmonary edema. PDA's respiratory
problems are most commonly linked to pulmonary edema caused by pulmonary
over circulation. The treatment of pulmonary edema might be difficult. In order to
reduce extravascular volume while retaining enough intravascular volume, a
balance must be achieved. Similar to the approach used to control bleeding from
a wound, continuous positive pressure can be utilized in the lung to reduce
capillary leakage.
 Applying pressure to the interstitial area that inhibits fluid movement can help
transfer the fluid into the intravascular space. PEEP (positive end-expiratory
pressure) is commonly used to achieve this. PEEP creates a positive pressure
that prevents fluid from moving outward.

OTHER MANAGEMENT

 Fluid restriction and diuretics. To minimize volume overload and the resulting
congestive heart failure, the attentive care begins with better delivery room
management at birth and involves judicious fluid restriction with high
humidification (Sung et. Al., 2020). Fluid restriction (110 to 130ml/kg/d while urine
output is monitored) is part of conservative management. Diuretics are
contentious since there is little evidence that they improve outcomes in very
premature children, may hinder PDA closure, and induce electrolyte imbalances
that are difficult to treat in the extremely premature infant (Gillam et. Al., 2021).

REFERENCES
Arlettaz, R. (2017). Echocardiographic Evaluation of Patent Ductus Arteriosus in
Preterm Infants. Frontiers in Pediatrics. Retrieved from
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Beerman, L. B. (2020). Patent Ductus Arteriosus (PDA). MSD Manual. Retrieved from
https://www.msdmanuals.com/professional/pediatrics/congenital-cardiovascular-
anomalies/patent-ductus-arteriosus-pda.

Cleveland Clinic (2019). Patent Ductus Arteriosus (PDA). Retrieved from

https://my.clevelandclinic.org/health/diseases/17325-patent-ductus-arteriosus-pda

Gillam, K. M. and Mahajan K. Patent Ductus Arteriosus (2021). In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430758/

Kim, L. (2018). Patent Ductus Arteriosus (PDA) Clinical Presentation. Medscape.

Retrieved from https://emedicine.medscape.com/article/891096-clinical

Liu, C., Zhu, X., Li, D., & Shi, Y. (2021). Related Factors of Patent Ductus Arteriosus in
Preterm Infants: A Systematic Review and Meta-Analysis. Frontiers in
pediatrics, 8, 605879. https://doi.org/10.3389/fped.2020.605879

Mayo Clinic (2021). Indomethacin (Intravenous Route). Retrieved from

https://www.mayoclinic.org/drugs-supplements/indomethacin-intravenous-
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Mayo Clinic (2021). Patent ductus arteriosus (PDA). Retrieved from

https://www.mayoclinic.org/diseases-conditions/patent-ductus-
arteriosus/diagnosis-treatment/drc-20376150

Parkerson S, Philip R, Talati A and Sathanandam S (2021) Management of Patent

Ductus Arteriosus in Premature Infants in 2020. Front. Pediatr. 8:590578. doi:
10.3389/fped.2020.590578

Stanford Children’s Health (n.d.). Patent Ductus Arteriosus (PDA). Retrieved from
https://www.stanfordchildrens.org/en/topic/default?id=patent-ductus-arteriosus-
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Sung, S. I., Chang, Y. S., Ahn, S. Y., Jo, H. S., Yang, M., & Park, W. S. (2020).
Conservative Non-intervention Approach for Hemodynamically Significant Patent
Ductus Arteriosus in Extremely Preterm Infants. Frontiers in pediatrics, 8, 605134.
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