Summary
The ductus arteriosus normally closes in the first days after birth, but in preterm infants it frequently stays open, and a hemodynamically significant patent ductus arteriosus imposes a left-to-right shunt that floods the lungs and steals flow from the systemic circulation [1][2]. Management has shifted over the past decade from routine early closure toward selective treatment of the ducts that are actually causing harm, and transcatheter device closure has become a real option even in the smallest infants [1][3].
- Not every patent ductus arteriosus needs treatment. Many close spontaneously, and treating a small non-significant duct exposes the infant to risk without benefit [1][2].
- Hemodynamic significance is a composite judgment from ductal size, the direction and pattern of flow, left atrial and ventricular volume loading, and the systemic steal seen as diastolic flow reversal in the abdominal aorta [1][2].
- First-line pharmacologic closure uses a cyclooxygenase inhibitor. When medical therapy fails or is contraindicated, the choice is between surgical ligation and transcatheter device closure [1][2].
- Transcatheter closure with a dedicated device is now feasible in infants under 2 kg and under 1 kg in experienced centers, changing the risk calculus that once favored ligation by default [3][4].
Caution. A ductus kept open on purpose is a different clinical problem from one that fails to close. In duct-dependent congenital heart disease, closure is catastrophic, and prostaglandin E1 is used to maintain patency until the anatomy is defined. Confirm the circulation is not duct-dependent before treating a duct as an unwanted shunt.
Indications
The decision to close rests on hemodynamic significance, not on the mere presence of a duct on echocardiogram [1][2]. The features below move a duct from incidental to significant.
| Feature |
Marker of significance |
| Ductal diameter |
Larger unrestrictive duct, often indexed to body size [2] |
| Transductal flow |
Pulsatile, low-velocity, unrestrictive left-to-right pattern [1] |
| Left heart loading |
Enlarged left atrium and left ventricle from volume overload [2] |
| Systemic steal |
Absent or reversed diastolic flow in the descending aorta [1][2] |
| Clinical impact |
Ventilator dependence, feeding intolerance, or failure to wean [2] |
Screen the left-sided chamber dimensions against normal ranges for body size rather than reading raw measurements, since a small preterm infant has small chambers at baseline.
Interpret chamber and valve dimensions against body size in Echo Z-Scores →
Management
In a duct-dependent lesion, patency is the goal, and prostaglandin E1 is infused to keep the ductus open until surgical or catheter palliation. The infusion carries dose-dependent apnea, fever, and hypotension, so airway readiness matters at higher doses.
When the goal is closure of an unwanted shunt, the sequence is conservative management first, pharmacologic closure with a cyclooxygenase inhibitor next, and mechanical closure when those fail or are contraindicated [1][2]. Ibuprofen and indomethacin are the standard agents, with acetaminophen as an alternative in specific circumstances [2].
Transcatheter device closure has moved from a procedure reserved for older infants to one performed in extremely low birth weight infants at experienced centers, with high closure rates and an acceptable complication profile [3][4]. Renal and end-organ function after device closure in this population has been examined directly and supports the approach as an alternative to surgical ligation rather than a last resort [4]. The choice between device closure and ligation now depends on institutional expertise, infant size, and anatomy rather than on a categorical preference [1][3].
References
- Backes CH, Hill KD, Shelton EL, et al. Patent ductus arteriosus: a contemporary perspective for the pediatric and adult cardiac care provider. J Am Heart Assoc. 2022;11(17):e025784. doi:10.1161/JAHA.122.025784
- Jain A, Shah PS. Diagnosis, evaluation, and management of patent ductus arteriosus in preterm neonates. JAMA Pediatr. 2015;169(9):863-872. doi:10.1001/jamapediatrics.2015.0987
- Sathanandam S, Justino H, Waller BR, et al. Role of transcatheter patent ductus arteriosus closure in extremely low birth weight infants. Catheter Cardiovasc Interv. 2019;93(1):89-96. doi:10.1002/ccd.27808
- Herron C, Sathanandam S, Absi M, et al. Renal function after transcatheter Piccolo patent ductus arteriosus closure. Am J Cardiol. 2022;181:112-118. doi:10.1016/j.amjcard.2022.07.013