pediatrics
Patent Ductus Arteriosus (PDA)
Treatment of PDA
Supportive medical therapy In symptomatic preterm infants, cyclo-oxygenase (COX) inhibitor therapy (eg,indomethacin,ibuprofen lysine) Sometimes transcatheter closure or surgical repair Typical medical management of patent ductus arteriosus includes fluid restriction, a diuretic (usually a thiazide), maintenance of hematocrit ≥ 35 %, providing a neutral thermal environment, and, for ventilated patients, use of positive end-expiratory pressure (PEEP) to improve gas exchange. Treatment differs depending on whether the infant is preterm or full term. Fluid restriction may facilitate ductal closure. In preterm infants without respiratory or other compromise, a patent ductus arteriosus is typically not treated. In preterm infants with a hemodynamically significant PDA and compromised respiratory status, the PDA can sometimes be closed by using a COX inhibitor (eitheribuprofen lysineorindomethacin[see tablefor doses]). COX inhibitors work by blocking the production of prostaglandins. Three doses ofindomethacinare given IV every 12 to 24 hours based on urine output; doses are withheld if urine output is < 0.6 mL/kg/hour. An alternative isibuprofen lysine10 mg/kg orally followed by 2 doses of 5 mg/kg at 24-hour intervals. Transcatheter closure of the PDA in the smallest of preterm infants (< 1000 grams) is being done in an increasing number of centers ( Treatment reference ). Age at Dose 1 Age at Dose 1 Dose 1 Dose 1 Dose 2 Dose 2 Dose 3 Dose 3 <48 hours 0.2 mg/kg IV 0.1 mg/kg IV 0.1 mg/kg IV 2–7 days 0.2 mg/kg IV 0.2 mg/kg IV 0.2 mg/kg IV >7 days 0.2 mg/kg IV 0.25 mg/kg IV 0.25 mg/kg IV * Dose intervals are based on urine output (see text). In full-term infants, COX inhibitors are usually ineffective. Transcatheter closure has become the treatment of choice for PDA in children>1 year, and some authors consider transcatheter closure to be the preferred route in term neonates and young infants as well. A variety of catheter-delivered occlusion devices are available (eg, coils, septal duct occluder). In infants<1 year who have ductal anatomy unfavorable for transcatheter closure, surgical division and ligation may be preferred over the transcatheter approach. For a patent ductus arteriosus with a shunt large enough to cause symptoms of heart failure or pulmonary hypertension, closure should be done after medical stabilization. For a persistent PDA without heart failure or pulmonary hypertension, closure can be done electively any time after 1 year. Delaying the procedure minimizes the risk of a vascular complication and allows time for spontaneous closure. Outcomes after PDA closure are excellent. Prevention is not needed preoperatively and is required only for the first 6 months after closure or if there is a residual defect adjacent to a transcatheter-placed device or surgical material. 1.Philip R, Tailor N, Johnson JN, et al: Single-Center Experience of 100 Consecutive Percutaneous Patent Ductus Arteriosus Closures in Infants ≤1000 Grams.Circ Cardiovasc Interv14(6):e010600, 2021. doi:10.1161/CIRCINTERVENTIONS.121.010600 