Patent ductus arteriosus (PDA)

Definition

Patent ductus arteriosus (PDA) is a persistent opening between two major blood vessels leading from the heart. This heart defect present at birth (congenital) often closes on its own or is readily treatable. Left untreated, a patent ductus arteriosus can cause too much blood to flow through the heart, weakening the heart muscle and causing heart failure and other complications.

A small patent ductus arteriosus often doesn't cause symptoms. A doctor may discover it during a routine exam. An infant with a larger patent ductus arteriosus often has trouble gaining weight and has other signs and symptoms. An older child who has a patent ductus arteriosus may not be as active as normal, may tire more easily and may have frequent lung infections. Occasionally, a small patent ductus arteriosus may not be detected until adulthood.

Treatment options for repairing a patent ductus arteriosus include monitoring, medications and surgery.

Symptoms

Patent ductus arteriosus symptoms vary with the size of the defect and the gestational age of the infant at birth. A small PDA may cause no signs or symptoms, and may go undetected for some time, even until adulthood.

A large PDA can cause signs of heart failure soon after birth. A premature infant may have other problems associated with being born too soon, and related testing may uncover a heart defect.

Your doctor may first suspect a heart defect during a regular checkup while listening to your baby's heart through a stethoscope.

A large PDA, found during infancy or childhood, may cause:

• Poor eating, poor growth
• Sweating with crying or play
• Persistent fast breathing or breathlessness
• Easy tiring
• Rapid heart rate
• Frequent lung infections
• A bluish or dusky skin tone

When to see a doctor
Call your doctor if your infant or child:

• Tires easily when eating or playing
• Is not gaining weight
• Becomes breathless when eating or crying
• Always breathes rapidly or is short of breath
• Turns dusky or blue when crying or eating

Causes

A patent ductus arteriosus that doesn't close on its own is more common in premature babies, but rare in infants born at full term.

As a baby develops in the womb, a vascular connection (ductus arteriosus) between two major blood vessels leading from the heart — the aorta and pulmonary artery — is a normal and necessary part of your baby's blood circulation while in the womb. But, this connection is supposed to close within two or three days after birth once the newborn's heart adapts to life outside the womb. In premature infants, the connection often closes on its own within a few weeks of birth. But if it remains open, it's referred to as a patent ductus arteriosus.

The abnormal opening causes too much blood to circulate to the lungs and heart. If not treated, the blood pressure in the lungs may increase (pulmonary hypertension) and the heart may weaken.

Congenital heart defects arise from problems early in the heart's development — but there's often no clear cause. Genetics and environmental factors may play a role.

Patent ductus arteriosus

Patent ductus arteriosus

Patent ductus arteriosus, a common congenital heart defect, is an abnormal opening between the aorta and the pulmonary artery. ...

Risk factors

Risk factors for having a patent ductus arteriosus include:

• Being born too soon (premature). Patent ductus arteriosus (PDA) occurs more commonly in babies who are born too early than in babies who are born full term.
• Having other heart defects. Babies who have other heart problems when they're born (congenital heart defects) are also more likely to have a patent ductus arteriosus.
• Family history and other genetic conditions. If you have a family history of heart defects, it's more likely your child may have a patent ductus arteriosus. Other genetic conditions, such as Down syndrome, have also been linked to an increased chance of having a PDA.
• Rubella infection during pregnancy. Becoming infected with rubella (German measles) while pregnant can increase the risk of heart defects. The rubella virus crosses the placenta and spreads through the baby's circulatory system damaging blood vessels and organs, including the heart.
• Poorly controlled diabetes during pregnancy. Uncontrolled diabetes in the mother in turn affects her baby's blood sugar, causing various damaging effects to the developing baby.
• Drug or alcohol use or exposure to certain substances during pregnancy. Use of certain medications, alcohol or drugs or exposure to certain chemicals or radiation during pregnancy can harm the developing baby.

Complications

A small patent ductus arteriosus may not cause any complications. Larger defects that are untreated could cause:

• High blood pressure in the lungs (pulmonary hypertension). If too much blood continues to circulate through the heart's main arteries through a patent ductus arteriosus, it can lead to pulmonary hypertension. Pulmonary hypertension can cause permanent lung damage. A large patent ductus arteriosus can lead to Eisenmenger's syndrome, an irreversible type of pulmonary hypertension.
• Heart failure. A patent ductus arteriosus can eventually cause the heart muscle to weaken, leading to heart failure. Heart failure is a chronic condition in which the heart can't pump effectively.
• An infection of the heart (endocarditis). People with structural heart problems, such as a patent ductus arteriosus, are at a higher risk of infectious endocarditis than is the general population. Infectious endocarditis is an inflammation of the inner lining of the heart caused by a bacterial infection.
• Irregular heartbeat (arrhythmia). Enlargement of the heart due to a patent ductus arteriosus increases the risk of arrhythmias. This increased risk usually occurs only with a large patent ductus arteriosus.

Patent ductus arteriosus and pregnancy
Pregnancy is often a concern for women born with a heart defect. Most women with a small patent ductus arteriosus can tolerate pregnancy without any problems. However, having a larger defect or having complications, such as heart failure, arrhythmias or pulmonary hypertension, can increase your risk of complications during pregnancy. A woman with Eisenmenger's syndrome shouldn't become pregnant because it can endanger the woman's life.

Anyone with a congenital heart defect, repaired or not, who is considering starting a family, should carefully discuss it beforehand with his or her doctor. In some cases, preconception consultations with doctors who specialize in cardiology, genetics and high-risk obstetric care are needed. Some heart medications can cause serious problems for a developing baby and may need to be stopped or adjusted before you become pregnant.

Preparing for your appointment

A patent ductus arteriosus may be found while your baby is still in the hospital after birth, sometimes when having tests for other reasons. Your child may also have a PDA discovered later, sometimes because of a heart murmur. You may have an appointment with your child's pediatrician or with a pediatric cardiologist to discuss potential health problems resulting from your child's PDA. If you suspect your child has a PDA or another type of congenital heart disease, make an appointment to see your child's pediatrician to discuss your concerns.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your child's doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your child's diet. If your child is having imaging tests, for example, he or she may need to fast beforehand.
• Write down any symptoms your child is experiencing, including any that may seem unrelated to patent ductus arteriosus or another heart defect.
• Write down key personal information, including a family history of heart defects and any major stresses or recent life changes.
• Bring copies of past medical records, including reports of any previous surgeries.
• Make a list of all current medications, as well as any vitamins or supplements, that your child is taking.
• Be prepared to discuss your child's diet and exercise habits. If your child doesn't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges your child might face in getting started.
• Write down questions to ask the doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For patent ductus arteriosus, some basic questions to ask your doctor include:

• Is the PDA causing any problems?
• Are my child's symptoms related to the PDA or due to other causes?
• What kinds of tests are necessary?
• What type of treatment is necessary? Will my child need surgery?
• What's an appropriate level of physical activity?
• How will my child need to be screened for complications due to PDA?
• What are the alternatives to the primary approach that you're suggesting?
• Should my child see a cardiologist specializing in congenital heart defects?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first notice your child's symptoms?
• Have the symptoms been continuous or occasional?
• How severe are the symptoms?
• What, if anything, seems to improve the symptoms?
• What, if anything, appears to worsen the symptoms?
• What medications have you or your child taken or surgeries has your child had to treat the condition?

Tests and diagnosis

Your child's doctor may first suspect your child has a patent ductus arteriosus based on listening to your child's heartbeat. Patent ductus arteriosus can cause a heart murmur that the doctor can hear through a stethoscope. If the doctor hears a heart murmur or finds other signs or symptoms of a heart defect, he or she may request one or more of these tests:

• Echocardiogram. An echocardiogram uses sound waves to produce a video image of the heart. This image can help doctors see the heart chambers and evaluate how well the heart is pumping. This test also checks the heart valves and looks for any other heart defects.
• Chest X-ray. An X-ray image helps the doctor see the condition of your baby's heart and lungs and the amount of blood in the lungs. An X-ray may identify conditions other than a heart defect, as well.
• Electrocardiogram (ECG). This test records the electrical activity of the heart. This test helps diagnose heart defects or rhythm problems.
• Cardiac catheterization. This test isn't usually necessary for diagnosing a PDA alone, but may be done to examine other congenital heart defects found during an echocardiogram. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your child's groin or arm and guided through it into the heart. Through catheterization, doctors can perform procedures to close the patent ductus arteriosus.

• Cardiac computerized tomography (CT) or magnetic resonance imaging (MRI). These tests can be used to diagnose heart problems, usually in adults. A patent ductus arteriosus might be discovered when a cardiac CT or MRI is being performed for another reason. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest.

  In a cardiac MRI, you lie on a table inside a long tube-like machine that produces a magnetic field. The magnetic field aligns atomic particles in some of your cells. When radio waves are broadcast toward these aligned particles, they produce signals that vary according to the type of tissue they are. The signals create images of your heart.

Treatments and drugs

Treatments for patent ductus arteriosus depend on the age of the person being treated.

• Watchful waiting. In a premature baby, the patent ductus arteriosus often closes on its own in the weeks after birth. Doctors will monitor your baby's heart during those weeks to make sure the open blood vessel is closing properly. For full-term babies, children and adults who have a small PDA that's not causing other health problems, it's possible your doctor will recommend monitoring the condition and not having any other procedures to close the PDA.
• Nonsteroidal anti-inflammatory drugs. For premature babies, it's possible your baby's doctors may use nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or indomethacin, to help close a PDA. NSAIDs block the hormone-like chemicals in the body that keep the PDA open. NSAIDs won't close a PDA in full-term babies, children or adults.

• Open-heart surgery. If medications haven't closed the PDA, and your baby's condition has caused health problems, open-heart surgery may be recommended.

  During the surgery, a surgeon will make a small cut between your child's ribs to reach your child's heart and repair the open duct using stitches or clips. After the surgery, your child will remain in the hospital for several days for observation. It usually takes a few weeks for your child to fully recover. Open-heart surgery may also be recommended for adults who have a PDA that's causing health problems.

• Catheter procedures. Catheter procedures, which are less invasive than open-heart surgeries, aren't an immediate option for premature babies because they are too small. However, if your baby doesn't have any health problems related to his or her PDA, your baby's doctor may recommend waiting until your baby is about 6 months old to perform a catheter procedure to correct the PDA. Catheter procedures tend to have fewer complications and a shorter recovery time than open-heart surgeries. Catheter procedures can also be used to treat full-term babies, children and adults.

  In a catheter procedure, a thin tube (catheter) is inserted into a blood vessel in the groin and threaded up to the heart. Through the catheter, a plug or coil is inserted to close the ductus arteriosus.

  This procedure might be done on an outpatient basis, meaning your child probably wouldn't need to stay overnight in the hospital. Complications from catheter procedures include bleeding, infection, or movement of the plug or coil from where it was placed in the heart.

Preventive antibiotics
In the past, it was recommended that people who've had a PDA take antibiotics before dental work and certain types of surgical procedures to prevent an infection of the heart (infective endocarditis).

Preventive antibiotics are no longer recommended for most people with a patent ductus arteriosus. However, some people still need antibiotics, such as those who:

• Have other heart conditions or artificial valves
• Have a large defect that's causing a low blood oxygen level
• Have had a heart valve repaired with artificial material

If you've ever been told that you or your child needs to take antibiotics before any procedures, talk with your doctor about whether antibiotics are truly needed.

Lifestyle and home remedies

If you or your child has a congenital heart defect, or has had surgery to correct one, you may have some concerns about aftercare. Here are some issues you may be thinking about:

• Preventing infection. For most people with a patent ductus arteriosus, regularly brushing and flossing teeth in combination with getting regular dental checkups is the best way to help prevent infection. In some cases, you or your child may need to take preventive antibiotics before certain dental and surgical procedures. Your doctor will help you learn if this is necessary.
• Exercising and play. Parents of children with congenital heart defects often worry about the risks of rough play and vigorous activity even after successful treatment. Although some children may need to limit the amount or type of exercise, most children with patent ductus arteriosus will lead normal lives. Your doctor can advise you about which activities are safe for your child.

Prevention

In most cases, you can't do anything to prevent having a baby with a patent ductus arteriosus, or any other heart defect. However, it's important to do everything possible to have a healthy pregnancy. Here are the basics:

• Get early prenatal care, even before you're pregnant. Quitting smoking, reducing stress, stopping birth control — these are all things to talk to your doctor about before you get pregnant. Also, be sure you talk to your doctor about any medications you're taking.
• Eat a balanced diet. Include a vitamin supplement that contains folic acid. Also, limit caffeine.
• Exercise regularly. Work with your doctor to develop an exercise plan that's right for you.
• Avoid risks. These include harmful substances such as alcohol, cigarettes and illegal drugs. Also, avoid X-rays, hot tubs and saunas.
• Avoid infections. Be sure you are up to date on all of your vaccinations before becoming pregnant. Certain types of infections can be harmful to a developing baby.
• Keep diabetes under control. If you have diabetes, work with your doctor to be sure it's well controlled before and after getting pregnant.

If you have a family history of heart defects or other genetic disorders, consider talking with a genetic counselor before becoming pregnant.