Patent Ductus Arteriosus in Preterm Infants¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Apply current evidence that prophylactic PDA treatment is NOT recommended
[ ] Evaluate echocardiographic markers of hemodynamic significance (LA:Ao ratio, ductal diameter, flow pattern)
[ ] Analyze clinical markers suggesting hemodynamic impact (ventilator dependence, pulmonary hemorrhage)
[ ] Differentiate infants likely to close spontaneously from those who may benefit from intervention

Management Decisions¶

[ ] Formulate individualized management approach balancing conservative care vs intervention
[ ] Evaluate options for PDA closure: medical (indomethacin, ibuprofen, acetaminophen) vs procedural
[ ] Determine candidacy for transcatheter closure (Piccolo device) vs surgical ligation

Communication & Counseling¶

[ ] Counsel families on natural history and controversy surrounding PDA management
[ ] Discuss risks and benefits of intervention vs conservative approach

Systems-Based Practice¶

[ ] Coordinate multidisciplinary decision-making with neonatology
[ ] Ensure appropriate echocardiographic surveillance protocol

Key Guidelines¶

2025 AAP Clinical Report: Patent Ductus Arteriosus in Preterm Infants Pediatrics. 2025;155(5):e2025071425

Key Points¶

Management remains CONTROVERSIAL
Many PDAs close spontaneously (especially >1000g)
Delayed closure common in extreme preterms (<28 weeks)
No treatment approach proven superior for outcomes

Diagnosis¶

Clinical Signs¶

Wide pulse pressure
Continuous or systolic murmur
Bounding pulses
Active precordium
May be asymptomatic

Echocardiography (Essential)¶

Confirms presence and size
Assesses hemodynamic significance
Targeted neonatal echo (TnECHO) increasingly important

Hemodynamically Significant PDA (hsPDA)¶

Markers of Significance¶

Echo Finding	Threshold
Ductal diameter	>1.5 mm OR >1.4 mm/kg
LA:Ao ratio	>1.4
Diastolic flow in descending aorta	Reversed/absent
Ductal flow pattern	Unrestrictive (pulsatile)

Clinical Markers¶

Respiratory support requirements
Hemodynamic instability
Difficulty weaning ventilator

Treatment Approaches¶

Strategy	Recommendation
Prophylactic treatment	NOT recommended at any GA/weight
Early treatment (day 1-3)	No proven benefit over expectant
Targeted treatment of hsPDA	Reasonable; individualize
Conservative/expectant	Acceptable; many close spontaneously

Pharmacologic Options¶

Indomethacin¶

Traditional agent
Effective closure rates
Side effects: Renal dysfunction, NEC risk, GI bleeding, platelet dysfunction

Ibuprofen¶

Standard first-line agent
Similar efficacy to indomethacin
Fewer renal side effects
IV or oral formulations

Acetaminophen¶

Emerging alternative
Increasing use, especially in extreme preterms
May be effective when COX inhibitors contraindicated
More data emerging for <24 weeks GA

Success Rates¶

Pharmacologic closure: 50-70% for hsPDA
Multiple courses may be needed
Lower success in extreme preterms

Procedural Closure¶

Transcatheter Closure¶

Rapidly increasing (0% in 2011 → 20% in 2022)
Amplatzer Piccolo Occluder approved for preterms
Can be done at very low weights (<1000g)
Requires experienced operators

Surgical Ligation¶

Decreasing (25% → 4% over same period)
Reserved for:
Failed pharmacotherapy
Contraindications to medications
Hemodynamically unstable
Associated with higher morbidity

Key Uncertainties¶

Question	Status
Optimal timing of intervention	UNCLEAR
Impact on BPD	Not clearly demonstrated
Impact on NEC	Not clearly demonstrated
Impact on mortality	Not clearly demonstrated
Long-term neurodevelopment	Needs more study

Feeding During Treatment¶

Safe to continue small-volume feeds (15 mL/kg/day) during pharmacotherapy - No increased NEC risk vs fasting - Avoids gut atrophy

Board Pearls¶

Pearl: Prophylactic PDA treatment is NOT recommended

No proven benefit at any gestational age or weight

Pearl: Conservative management is acceptable

Many PDAs close spontaneously, especially if >1000g

Pearl: Transcatheter closure rapidly increasing; surgical ligation declining

Piccolo device approved for preterms; cath 0→20%, surgery 25→4%

Self-Assessment¶

Q1: A 26-week premature infant on day 3 of life has a moderate-sized PDA on echo with LA:Ao ratio of 1.5 and reversed diastolic flow in descending aorta. The infant is stable on low ventilator settings. What is the most appropriate initial management?

Answer

**Answer**: Options include targeted pharmacotherapy (ibuprofen) OR continued observation with close monitoring **Rationale**: This is an hsPDA by echo criteria, but the infant is clinically stable. Per 2025 AAP guidelines, both targeted treatment and conservative management are acceptable approaches. There is no definitive evidence that treating improves long-term outcomes. Discussion with family about options is appropriate.

Q2: Which pharmacologic agent for PDA closure has the most favorable side effect profile?