# Patent Ductus Arteriosus

Manage PDA by separating preterm ductal patency from a clinically consequential shunt and from persistent congenital PDA in older patients. Echocardiography establishes anatomy and physiology; treatment is reserved for hemodynamic consequences, with transcatheter closure increasingly favored when definitive intervention is required.

**Clinical question:** How should physicians evaluate hemodynamic significance and select observation, pharmacotherapy, transcatheter closure, or surgery for PDA?

Updated: 2026-09-15T22:53:21.057271+00:00

## What matters in practice
- In preterm infants, identify a clinically consequential PDA by integrating echocardiographic shunt characteristics, pulmonary overcirculation, and systemic hypoperfusion rather than ductal diameter alone. [1][10][13]
- Most premature infants with PDA undergo spontaneous ductal closure regardless of pulmonary disease; routine aggressive closure is therefore not the default strategy. [22]
- When pharmacologic closure is selected for a preterm infant, indomethacin, ibuprofen, and acetaminophen are established options; indomethacin has important renal, gastrointestinal perfusion, platelet, and bleeding-related limitations. [14][24]
- For definitive PDA closure when anatomy and patient size permit, transcatheter closure is increasingly preferred over surgical ligation; surgical closure remains relevant for unsuitable anatomy or concomitant intracardiac pathology. [8][23]
- A persistent adult PDA warrants congenital-heart-disease assessment for left-heart volume overload, arrhythmia, pulmonary hypertension, and Eisenmenger physiology before closure planning. [8]

## Separate transitional preterm PDA from a significant shunt or persistent congenital lesion

The management target is hemodynamic consequence, not ductal patency alone.

In a preterm infant, obtain echocardiography when clinical findings raise concern for a left-to-right ductal shunt with pulmonary overcirculation or systemic hypoperfusion, or when escalating respiratory support prompts a physiology-based assessment. Echocardiography confirms PDA and defines ductal size, shunt direction, and the cardiovascular consequences that determine whether observation or closure-directed therapy is appropriate. [1][12][13]

Do not equate a large ductal diameter with a hemodynamically significant PDA. Size-based thresholds correlate with echo-derived shunt-volume markers but are surrogate measures; the actionable assessment incorporates shunt direction and pattern, indices of pulmonary overcirculation, and markers of systemic hypoperfusion. [1][10]

In term infants, children, and adults, a persistent PDA is a congenital left-to-right shunt lesion rather than a transitional finding. Evaluate for left-heart volume overload, arrhythmia, and pulmonary hypertension; advanced pulmonary vascular disease may progress to Eisenmenger syndrome and materially changes closure candidacy. [8][13]
- Use a preterm physiology pathway when the clinical question is whether the ductus is contributing to cardiorespiratory compromise; do not treat echocardiographic patency in isolation. [1][22]
- Refer suspected structural congenital heart disease identified during targeted neonatal echocardiography for formal cardiology evaluation. [1]
- For adult PDA, plan assessment and closure decisions in an adult congenital heart disease setting because pulmonary vascular disease and shunt physiology determine procedural risk and benefit. [4][8]

*Clinical branch points that determine PDA management. [1][8][10][13][22]*

| Clinical setting | Key discriminator | Next action |
| --- | --- | --- |
| Preterm infant with PDA | Echo shows ductal shunt physiology without compelling pulmonary overcirculation or systemic hypoperfusion | Use conservative observation with serial clinical and echocardiographic reassessment; spontaneous closure is common. [1][22] |
| Preterm infant with suspected hsPDA | Integrated evidence of shunt direction/pattern, pulmonary overcirculation, and systemic hypoperfusion | Consider selective pharmacologic closure or definitive closure according to clinical course, contraindications, and local procedural capability. [1][14][23] |
| Term infant or child | Persistent PDA with anatomy suitable for device treatment | Plan transcatheter closure. [3][8] |
| Adult with PDA | Evaluate left-heart volume load, arrhythmia, and pulmonary vascular disease before closure | Use adult congenital heart disease assessment to determine closure strategy and exclude clinically consequential pulmonary vascular disease. [4][8] |

## Use echocardiography to establish anatomy, shunt direction, and organ-level consequences

A complete study should answer whether the ductus is causing a clinically relevant circulatory state.

For preterm PDA assessment, document ductal size, shunt direction, and shunt pattern; then measure or qualitatively assess left-heart volume loading, pulmonary overcirculation, and systemic hypoperfusion. The IWOA score is one physiology-oriented approach that incorporates these features; higher scores indicate greater hemodynamic significance. [1]

Interpret echocardiographic findings in the context of respiratory and perfusion trajectory. A persistent left-to-right shunt has been associated with bronchopulmonary dysplasia risk, but association does not establish that every detectable shunt requires closure. [2][22]

Ensure image acquisition and Doppler alignment are adequate before making an intervention decision. In a targeted neonatal echocardiography pathway, archived studies underwent offline review to confirm completeness of views, measurement accuracy, and appropriate Doppler alignment; this is particularly relevant when serial studies are used to justify escalation. [1]

Before catheter or surgical intervention, use echocardiography to define ductal anatomy and procedural suitability. Echocardiography confirms the diagnosis and guides catheter-based and surgical intervention planning. [12]
- Report ductal flow direction; a left-to-right pattern supports pulmonary overcirculation and left-heart volume loading, whereas non-left-to-right physiology should prompt reassessment of pulmonary vascular conditions and closure appropriateness. [1][13]
- Avoid using a single diameter measurement as the sole treatment trigger because anatomic size is only a surrogate for shunt burden. [10]
- Repeat echocardiography when clinical respiratory or systemic perfusion status changes, when assessing response to a closure attempt, and when selecting a definitive procedure. [1][12]

## Select closure therapy only for persistent hemodynamic consequences

Observation and selective intervention should be individualized to physiology and clinical trajectory.

Most premature infants with PDA will experience spontaneous closure regardless of pulmonary disease. This natural history supports expectant management for infants without a clearly consequential shunt and avoids exposing all infants with PDA to medical or procedural adverse effects. [22]

When an infant has persistent hemodynamic significance with cardiopulmonary compromise, choose among pharmacologic therapy, transcatheter closure, and surgical ligation after considering renal function, bleeding risk, sepsis, coagulopathy, anatomy, and access to experienced procedural teams. Conservative management, pharmacologic intervention, surgery, and transcatheter closure are all used for hemodynamically significant PDA. [7][14][23]

A targeted neonatal echocardiography screening pathway in infants born before 29 weeks' gestation was associated, in a pre-post observational study, with fewer invasive-ventilation days, lower BPD rates, and no surgical ligations in the post-screening period despite similar medical-treatment rates. Use this evidence to support physiology-guided selection, not to infer that screening itself causally improves outcomes. [1]
- Use pharmacologic closure selectively when the shunt is hemodynamically significant and the infant has no major drug contraindication. [3][14]
- Move to definitive closure when hemodynamic significance persists despite initial pharmacotherapy or when pharmacotherapy is contraindicated. [3][14]
- Do not interpret procedural closure as risk-free: post-ligation cardiac syndrome, post-transcatheter cardiorespiratory syndrome, and chronic pulmonary hypertension are clinically relevant post-procedure concerns. [6]

### Pharmacologic closure

Cyclooxygenase inhibition with indomethacin or ibuprofen can induce PDA closure in premature infants; acetaminophen is another pharmacologic option. Indomethacin is generally ineffective in term infants and older patients, so do not extrapolate preterm drug-closure strategies to persistent congenital PDA outside prematurity. [14]

A cited intravenous indomethacin regimen is three doses of 0.1-0.2 mg/kg at 12- or 24-hour intervals. Monitor urine output and renal status, gastrointestinal perfusion concerns, blood pressure, platelet-related bleeding risk, and clinical evidence of sepsis during selection and treatment. [14][24]

Avoid or defer indomethacin when sepsis, renal insufficiency, or a bleeding disorder is present. Indomethacin can decrease renal and gastrointestinal blood flow and interfere with platelet function; reduced diuresis was reported in premature neonates receiving indomethacin. [14][24]
- If a medication course does not achieve closure, reassess hemodynamic significance by echocardiography rather than automatically repeating therapy. [1][14]
- High-dose oral ibuprofen has been reported to have the highest odds of closure for hemodynamically significant PDA in a cited meta-analysis, but concern regarding necrotizing enterocolitis has influenced clinical selection. [14]
- Use acetaminophen as an alternative pharmacologic strategy when clinically appropriate; comparative efficacy and selection remain variable across studies. [14][24]

*Selective preterm PDA treatment options and practical constraints. [3][14][23][24]*

| Option | When it fits | Major limitation or next step |
| --- | --- | --- |
| Observation with serial assessment | PDA is present but integrated echocardiography and clinical course do not show compelling hemodynamic consequences | Continue clinical and echocardiographic surveillance because spontaneous closure is common. [1][22] |
| Indomethacin | Preterm infant selected for pharmacologic closure without sepsis, renal insufficiency, or bleeding disorder | A cited IV course is 0.1-0.2 mg/kg for three doses at 12- or 24-hour intervals; monitor renal, gastrointestinal, and platelet-related effects. [14] |
| Ibuprofen or acetaminophen | Alternative pharmacologic approaches for selected preterm infants | Reassess closure and hemodynamic status after treatment; evidence and selection practices vary. [14][24] |
| Transcatheter closure | Persistent significant PDA after medical therapy or contraindication to pharmacotherapy when anatomy and expertise permit | Monitor for post-transcatheter cardiorespiratory instability. [3][6][23] |
| Surgical ligation | Definitive closure required but catheter closure is not feasible or anatomy favors surgery | Anticipate postoperative cardiorespiratory instability and surgical complications. [6][8][17] |

## Choose transcatheter closure when feasible; reserve surgery for anatomy or concomitant repair needs

Definitive treatment requires anatomy-based planning and post-closure surveillance.

Transcatheter closure is the preferred approach for most persistent PDA cases when anatomy and patient characteristics allow device deployment. In adults, surgical repair is generally reserved for distinct ductal anatomy or concurrent intracardiac pathology requiring surgery. [8]

In infants, transcatheter closure has become more common relative to surgical ligation. A pediatric administrative-database comparison cited lower mortality and shorter length of stay with transcatheter closure than surgical ligation, but procedure selection remains vulnerable to anatomic and illness-severity confounding. [23]

For very preterm infants, anticipate acute hemodynamic change after either modality. Post-ligation cardiac syndrome and post-transcatheter cardiorespiratory syndrome may occur; assess cardiovascular and respiratory status promptly after closure rather than attributing deterioration solely to lung disease. [6][17]
- Use echocardiography before intervention to confirm anatomy and guide catheter or surgical planning. [12]
- Choose surgical ligation when catheter closure is not feasible or when concomitant intracardiac surgical pathology drives the operative plan. [8]
- After either procedure, perform clinical and echocardiographic reassessment for cardiorespiratory instability, residual ductal flow, and evolving pulmonary hypertension. [6][12]

## Approach PDA in term patients, children, and adults as a congenital shunt lesion

Drug closure is not the strategy for persistent PDA beyond prematurity.

For term infants and children with a small-to-moderate PDA, transcatheter device closure is the usual definitive pathway. For large ducts or symptomatic infants too small for device closure, surgical closure may be required. [3]

In adults, quantify the clinical impact of the persistent shunt before intervention, specifically left-heart volume overload, arrhythmias, and pulmonary hypertension. Untreated PDA can progress to Eisenmenger syndrome; pulmonary vascular disease therefore requires deliberate hemodynamic and congenital-cardiology evaluation before closure. [8][13]

Indomethacin is rarely effective in full-term infants and older patients. Persistent congenital PDA should therefore be referred for device or surgical closure assessment rather than repeated prostaglandin-inhibitor courses. [14]
- Use transcatheter closure as first-line definitive treatment when PDA anatomy is suitable. [8]
- Use surgery when anatomy precludes device closure or another intracardiac lesion requires surgical repair. [8]
- Assess adults in a congenital cardiology program when pulmonary hypertension or potential Eisenmenger physiology is present. [4][8]

## References
1. Early protocol-based echocardiographic assessment and management of patent ductus arteriosus in infants less than 29 weeks’ gestation | BMJ Paediatrics Open — bmjpaedsopen.bmj.com — https://bmjpaedsopen.bmj.com/content/9/1/e004177
2. Cardiac catheterisation for closure of patent ductus arteriosus — www.thelancet.com — https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30088-4/fulltext
3. Patent ductus arteriosus - Symptoms, diagnosis and treatment | BMJ Best Practice US — bestpractice.bmj.com — https://bestpractice.bmj.com/topics/en-gb/766
4. MANAGEMENT DECISIONS FOR THE ADULT PATIENT WITH A ... — www.jacc.org — https://www.jacc.org/doi/10.1016/S0735-1097%2823%2903845-7
5. Outpatient Management of Isolated Left-to-Right Shunt Lesions in ... — www.jacc.org — https://www.jacc.org/doi/full/10.1016/j.jacc.2025.11.020
6. Comparison of neurodevelopmental outcomes of extremely preterm infants undergoing trans-catheter closure of the patent ductus arteriosus compared to surgical ligation | Journal of Perinatology — www.nature.com — https://www.nature.com/articles/s41372-025-02417-8
7. Patent ductus arteriosus treatment trends and associated morbidities in neonates | Scientific Reports — www.nature.com — https://www.nature.com/articles/s41598-021-89868-z
8. Management of Patent Ductus Arteriosus in the... : Cardiology in Review — journals.lww.com — https://journals.lww.com/00045415-990000000-01013
9. Comparing transcatheter and surgical closure of... : Annals of Medicine & Surgery — journals.lww.com — https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/9900/comparing_transcatheter_and_surgical_closure_of.4459.aspx
10. Relationship of Patent Ductus Arteriosus Echocardiographic ... — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/full/10.1002/jum.15528
11. Predictive Echocardiographic Parameters for Persistent ... — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1155/joic/1595586
12. Echocardiography for Patent Ductus Arteriosus Including Closure in ... — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1111/echo.12457
13. Effect of patent ductus arteriosus on pulmonary vascular disease — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1111/chd.12702
14. Ductus Arteriosus Obliteration - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/medicine-and-dentistry/ductus-arteriosus-obliteration
15. Management of patent ductus arteriosus: A comparison of operative V pharmacologic treatment - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S0022346887807303
16. Comparative effectiveness and safety of indomethacin versus ibuprofen for the treatment of patent ductus arteriosus - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S037837821500167X
17. Catheter-based closure of the patent ductus arteriosus in lower weight infants - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0146000518300338
18. Diagnosis and Management of Patent Ductus Arteriosus | NeoReviews — publications.aap.org — https://publications.aap.org/neoreviews/article/19/7/e394/91935/Diagnosis-and-Management-of-Patent-Ductus
19. AAP clinical report updates guidance on managing patent ductus ... — publications.aap.org — https://publications.aap.org/aapnews/news/31956/AAP-clinical-report-updates-guidance-on-managing
20. Patent Ductus Arteriosus in Preterm Infants - AAP Publications — publications.aap.org — https://publications.aap.org/pediatrics/article/155/5/e2025071425/201674/Patent-Ductus-Arteriosus-in-Preterm-Infants
21. Prematurity and Congenital Heart Disease: A Contemporary Review — publications.aap.org — https://publications.aap.org/neoreviews/article/23/7/e472/188384/Prematurity-and-Congenital-Heart-Disease-A
22. Management of premature infants with patent ductus arteriosus ... — www.jtcvs.org — https://www.jtcvs.org/article/S0022-5223(19)40540-0/fulltext
23. Anesthesia for Patients With Patent Ductus Arteriosus - StatPearls - NCBI Bookshelf — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/books/NBK572063
24. Oral pharmacological treatment for patent ductus arteriosus in premature neonates with hemodynamic repercussions — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S1995764517312683

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.