What is patent ductus arteriosus?
Patent ductus arteriosus (PDA) is a congenital heart defect – a structural heart problem that is present at birth.
Patent ductus arteriosus is an abnormal connection between the aorta and the pulmonary artery in the heart. The pulmonary artery carries blood from the heart’s right lower chamber (ventricle) to the lungs, where it is loaded up with oxygen. From the lungs, the blood returns to the heart’s left ventricle and is pumped out through the aorta to the body.
While the baby is in the womb, the aorta and the pulmonary artery are connected by a temporary blood vessel, the ductus arteriosus, as part of the normal fetal circulation. While in the womb, the baby receives oxygen from the mother’s circulation, so blood does not need to flow through the lungs. The ductus arteriosus streamlines fetal circulation by flowing blood directly to the aorta, bypassing the lungs. After birth, the ductus arteriosus usually seals off so that blood from these two vessels does not mix. In patients with PDA, the ductus arteriosus stays open (patent), and blood can flow from the aorta into the pulmonary artery.
How common is PDA?
Patent ductus arteriosus is one of the most common congenital heart defects. About 3,000 newborns are diagnosed with PDA each year in the United States. Premature babies are more likely to have PDA, and the condition occurs twice as often in girls as in boys.
Why does a baby have a ductus arteriosus?
Before birth, the fetus receives oxygen from the mother and the placenta, the organ that connects the growing baby to the mother’s uterus. Since the fetus does not need to use his or her lungs, very little blood needs to go to them to help them grow. The ductus arteriosus allows most of the blood to bypass the lungs and go to the rest of the body.
When the baby is born, his or her lungs take over and the body stops producing the chemicals that have kept the ductus arteriosus open. Under normal circumstances, the ductus arteriosus gradually narrows and closes in the first few hours or days after birth.
If it doesn’t close, the baby has patent (open) ductus arteriosus. This defect occurs more often in premature babies, but may also occur in full-term infants. The cause of PDA is not known in most cases.
What happens when the ductus arteriosus stays open?
When the ductus arteriosus stays open, blood goes in the opposite direction than it does in the fetus: from the aorta to the lungs. This extra blood, along with the normal flow of blood from the heart to the lungs, can cause a build-up of blood in the baby’s lungs. If the PDA is large, this extra blood flow is too much for the baby to handle and makes it harder for him or her to breathe. Because PDA increases the amount of work for the heart, the baby can have heart failure.
In many cases, the PDA is not large enough to cause symptoms of heart failure in infancy. However, if there is enough blood flow to cause a heart murmur (an abnormal noise), the PDA should be closed. A heart murmur can be heard with a stethoscope when the baby has a PDA.
In some cases, symptoms can occur later in life because of the increased blood flow into the lungs over many years. These symptoms include heart rhythm abnormalities, pulmonary hypertension (high blood pressure in the lung’s blood vessels), and heart failure. Another important reason to close a PDA in children is to prevent bacterial endocarditis, an infection of the blood vessels surrounding the PDA.
What problems does PDA cause in an adult?
Because most patients with PDA are diagnosed and treated when they are infants, this is a relatively rare congenital heart defect among adults. Most PDAs in adults are small to moderate; it is unusual to find a large PDA in an adult. Symptoms of untreated PDA in an adult include shortness of breath and heart palpitations. An adult with untreated PDA is at high risk for bacterial endocarditis, an infection of the lining of the heart, valves, or arteries; an enlarged heart (cardiomyopathy); pulmonary hypertension (high blood pressure in the lungs); congestive heart failure; and death.
Diagnosis and Tests
How is patent ductus arteriosus (PDA) diagnosed?
A PDA is often diagnosed in premature babies while they are still in the hospital. The baby is believed to have a PDA when:
- He or she needs more oxygen or more help breathing than expected;
- He or she has more episodes of apnea (pauses in breathing);
- His or her heart rate increases; or,
- He or she does not gain weight.
In older children, PDA is suspected when a heart murmur is heard. Some patients, especially infants, may have symptoms of heart failure, such as rapid breathing, sweating, difficulty feeding, and poor weight gain. Many children may have no symptoms at all.
If the doctor thinks your child might have a PDA, he or she will order an echocardiogram (an ultrasound of the heart). During an echocardiogram, sound waves are used to produce a picture of the child’s heart. This will help the doctor determine if there is a PDA and how much blood is flowing through it. This test is painless for the child.
How is PDA diagnosed in an adult?
Shortness of breath, heart palpitations and a heart murmur heard through the stethoscope will give the physician cause to suspect a heart defect and order some specific testing. This may include:
- An echocardiogram: an ultrasound of the heart that clearly shows the heart’s structure and size. Doppler can also be used to assess the direction and velocity of blood flow through the PDA.
- An electrocardiogram (ECG): a recording of the heart’s electrical activity that helps the physician detect abnormalities in the heart rhythm.
- Oximetry (which can be obtained on both fingers and toes): a noninvasive procedure to measure the amount of oxygen in the blood and can identify patients in whom pulmonary hypertension has advanced and resulted in the reversal of blood flow through the PDA.
Management and Treatment
How is patent ductus arteriosus (PDA) treated?
In most infants and children, PDA is closed with a catheterization procedure. A catheter is a long, thin, flexible, hollow tube. To close a PDA, the catheter is inserted in a blood vessel in the child’s groin and advanced toward the heart. The catheter has a “coil” or “plug” that is placed in the PDA to stop the blood flow through it. This is an outpatient procedure, meaning that the child will spend only a few hours in the hospital and will go home the same day.
The catheterization procedure is usually very successful. In more than 95% of patients, the PDA is closed completely, and there is a very small risk of complications.
This procedure can also be performed in premature babies while they are still in the hospital (if they are not very, very small). Very small babies with very large PDAs may need surgery to close the PDA.
How is PDA treated in adults?
Closure of the defect is generally recommended (as long as advanced pulmonary hypertension is not present) because of the high risk for cardiac complications and early death related to PDA. Closing the PDA can reduce complications, restore normal circulation, eliminate symptoms and reduce the risk of death.
An open surgical procedure was the standard for decades. In this procedure, the surgeon opens the chest and closes the opening with stitches or permanent titanium clips. Today, adult congenital heart disease experts prefer to reserve an open surgical procedure for those patients with large PDAs. More than 95 percent of PDAs can now be closed by catheter-based techniques.
Video-assisted thoracic surgical (VATS) repair is a newer approach for repairing PDAs. This is a minimally invasive technique in which the surgeon operates through a small incision in the chest using video guidance to perform the repair. VATS combines the advantages of a surgical repair with the benefits of a small-incision approach.
Transcatheter occlusion is the least invasive option for closing a PDA and has become the procedure of choice for PDA repair. In this procedure, a single or multiple coils or a fitted plug is delivered to the site of the PDA by a catheter. The device is positioned in the opening between the two blood vessels and released from the catheter. The plug or coil expands to occlude (block) the pathway; the plug device acts like a drain-stopper to block the opening. More than 85 percent of patients have complete occlusion of the defect within one year of the procedure.
Repairing a PDA in an adult is a more complicated procedure than performing the procedure in children. Adults with PDAs should be under the care of an adult congenital heart disease specialist with experience in treating this particular defect. The specialist will evaluate all considerations, such as the size of the PDA, complications related to the PDA and the patient’s overall health, to make a recommendation on which approach is most likely to have the best outcome. Today, devices and techniques have advanced to the point that percutaneous closure should be the first choice for almost all patients.
Outlook / Prognosis
What is the prognosis after PDA closure?
Closing the PDA restores normal circulation to the heart and reduces the risk of endocarditis, pulmonary hypertension, aneurysm formation and death. But closing the defect may not reverse the damage already done to the heart, such as congestive heart failure, pulmonary vascular disease or calcium deposits at the site of the defect. Endocarditis prophylaxis (antibiotics) is recommended for 6 months following closure of a PDA or for life if any residual defect is present.
Patients with repaired PDAs should remain under the care of a cardiologist experienced in adult congenital heart problems.
How to find a doctor if you have adult congenital heart disease
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, read more about our Sydell and Arnold Miller Family Heart & Vascular Institute outcomes.
The Center for Adult Congenital Heart Disease in the Sydell and Arnold Miller Family Heart & Vascular Institute is a specialized center involving a multi-disciplinary group of specialists, including cardiologists, cardiac surgeons and nurses from Cardiovascular Medicine, Pediatric Cardiology, Pediatric and Congenital Heart Surgery, Cardiothoracic Surgery, Diagnostic Radiology, Pulmonary, Allergy and Critical Care Medicine, and Transplantation Center, who provide a comprehensive approach to diagnosing and treating adult congenital heart disease.
Learn more about specialized teams of doctors who treat congenital heart disease.
You may also use our MyConsult second opinion consultation using the Internet.
For younger patients with congenital heart disease:
See: About Us to learn more about the Sydell and Arnold Miller Family Heart & Vascular Institute.
If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
Becoming a Patient
Congenital heart disease is diagnosed by a murmur on a physical exam and several diagnostic tests:
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- Darst JR, Collins KK, Miyamoto SDCardiovascular Diseases. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds. CURRENT Diagnosis & Treatment: Pediatrics, 22e. New York, NY: McGraw-Hill; 2013.
- American Heart Association. About Congenital Heart Defects Accessed 3/12/2015.
- Centers for Disease Control and Prevention. Facts about Congenital Heart Defects Accessed 3/12/2015.
- National Heart, Lung, and Blood Institute. What are Congenital Heart Defects? Accessed 3/12/2015.
- Hirsh JC, Devaney EJ, Ohye RG, Bove EL. Chapter 19B. The Heart: II. Congenital Heart Disease. In: Doherty GM. eds. CURRENT Diagnosis & Treatment: Surgery, 13e. New York, NY: McGraw-Hill; 2010.
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