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Expectant Management of Patent Ductus Arteriosus

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Patent ductus arteriosis is a congenital heart disease that affects babies after birth. To learn more about patent ductus arteriosis, read the below article.

Medically reviewed by

Dr. Yash Kathuria

Published At May 25, 2023
Reviewed AtJanuary 12, 2024

Introduction:

Congenital heart diseases affect the structure of a baby's heart. It affects the blood flow and how it flows through the heart and the rest of the body. Congenital heart disease can be classified as severe or mild. Mild is like a small hole in the heart, or severe such as missing or poorly formed parts of the heart. In premature babies and stillborns, this incidence is more. There are three types of congenital heart disease, left-to-right shunt, right-to-left shunt, and obstructive congenital heart disease.

What Are the Basic Structure and Blood Supply of the Heart?

The heart's structure is explained below:

  • Four chambers are present in the heart. The left and right atriums are the upper chambers, and the right and left ventricles are the lower chambers.

  • The septum divides the left and right atria and the left and right ventricles.

  • The aorta is a large vessel that delivers oxygen-rich blood to the body.

  • The pulmonary vessels supply blood from the heart to the lungs. They carry oxygen-poor (deoxygenated) blood. The main pulmonary artery (pulmonary trunk) leaves your right ventricle at the pulmonary valve.

  • It soon splits into your right and left pulmonary arteries, which carry blood to each lung.

What Is Ductus Arteriosis?

Ductus arteriosis is explained below:

  • Shunt means blood from the right or left side of the heart is mixing pathologically. Under certain circumstances, we can see left through right shunt congenital heart disease.

  • Ductus arteriosis is a channel between the pulmonary trunk and the aorta.

  • It affects how blood flows through a baby's lungs. The classic example of left to right shunt is patent ductus arteriosis. The major hemodynamic problem is the left-to-right shunt.

  • During intrafetal life, the lungs do not work. The highly oxygenated atrial side of the blood is mixed with the less oxygenated venous side of the blood. At the bifurcation of the pulmonary artery, ductus arteriosis is located.

  • When the baby is in the uterus, the baby will not breathe. So the lungs do not work because there is no oxygen going to the lungs. Since oxygen is the dilator for the blood vessels, the blood arteries become spastic (closed). The blood flows through the ductus arteriosis to reach the aorta and does not flow through the pulmonary artery. The pulmonary artery supplies the lungs.

  • Hypoxia is a contributing factor for pulmonary arterioles. When the baby is in the uterus, the present pulmonary artery is constricted because there is no oxygen. During intrauterine life, there is no oxygen going through the lungs. The blood from the vena cava moves into the right atrium and to the right ventricle, and the blood then moves through the pulmonary artery; there is very high resistance in the pulmonary artery. During intrafetal life, nature does not want the blood to flow through the pulmonary artery because the placenta oxygenates this blood.

  • During intrafetal life, the blood is not oxygenated by blood, and the placenta oxygenates it. The pulmonary arteries are constricted, and blood flows through the pulmonary artery and into the aorta, which is proximal to the origin of the subclavian artery.

  • There is always a physiological hole between the left and right atrium. After the baby is born, the pulmonary vessels dilate, and the resistance falls into the pulmonary vasculature, so blood will start flowing through pulmonary arteries and eventually to the lungs.

  • So, the blood flow through ductus arteriosis will reduce after birth. Secondly, prostaglandins (PGE2) play an important role in prenatal life because they open the ductus arteriosis.

  • After PGE2 levels go down, the ductus arteriosis closes.

What Is Patent Ductus Arteriosis?

The pathological form of ductus arteriosis is explained below:

  • Normally, in a healthy newborn, ductus arteriosis closes. But in some babies, it remains pathologically open. This pathological opening is called patent ductus arteriosis.

  • Patent ductus arteriosis (PDA) is a heart defect that may develop soon after birth.

  • If someone has patent ductus arteriosis, there is persistent blood flow through the aorta. The blood pressure in the aorta becomes very high. This is a classic example of well-oxygenated blood mixing with deoxygenated blood. This is another example of a functional left-to-right shunt.

  • Patent ductus arteriosis is a vessel that connects the pulmonary artery at its bifurcation to the aorta.

  • Whenever the right ventricle pumps blood into the pulmonary circulation, as lungs are not functional in babies, the blood goes to the right heart, through the pulmonary artery, through ductus arteriosis, and the aorta. Ductus arteriosis opens before birth.

  • Ideally, after birth, the ductus arteriosis has to close. But if it does not close, it causes significant large cardiovascular problems. After it closes, fibrosis takes place. This fibrotic piece is called the ligamentous arteriosum in adults.

What Is the Treatment for Patent Ductus Arteriosis?

The following are the pharmacological treatment for patent ductus arteriosis:

  • Medications help the closure of the patent ductus arteriosus.

  • It is used in premature babies but not older children or adults. Ibuprofen inhibits the prostaglandins for closing the patent ductus arteriosis.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) close the patent ductus arteriosis in premature babies and infants. Since the immature ductus is more sensitive to prostaglandin E2, Ibuprofen is used in preterm babies.

  • Ibuprofen inhibits cyclooxygenase-1 and cyclooxygenase-2.

  • These enzymes convert arachidonic acid to various prostaglandins. It inhibits prostaglandin synthesis.

  • Ibuprofen is a protein-bound drug and the liver mainly metabolizes the drug, and 80 % of the dose is excreted in the urine as hydroxyl and carboxyl metabolites.

  • Adverse events associated with ibuprofen include bleeding, skin irritation, hypoglycemia (decreased glucose level), hypocalcemia (decreased calcium level), adrenal insufficiency, respiratory failure, IVH (intraventricular hemorrhage), and renal insufficiency.

  • The dose for treating PDA with Ibuprofen mainly consists of three doses.

  • The recommended initial dose is 10 milligrams per kilogram intravenously.

  • This is followed by two doses of five milligrams per kg 24 and 48 hours later.

  • If the urine output is less than 0.6 milliliters per kilogram per hour, subsequent doses are held until renal functions are normal.

  • A second dose of ibuprofen is given when the ductus arteriosis fail to close re reopens later.

  • The concentration of Ibuprofen available is lysine is 17.1 milligram per milliliter (equivalent to 10 milligram per milliliter ibuprofen).

  • Each single-use vial contains two milliliters of sterile solution. Vials are stored at room temperature (20 to 25 degrees Celsius) and protected from light.

  • Ibuprofen is used within 30 minutes of preparation. The dose is infused over 15 minutes continuously. It is not administered in the same intravenous line with total parenteral nutrition.

Conclusion:

About one percent of live birth are born with CHDs. Babies with CHD require surgery or other procedures in the initial year of life. Congenital heart diseases are diseases in the heart and great vessels. Approximately every one percent of the child in hundred life births has congenital heart disease. With proper medication and surgery, this disease can be cured.

Frequently Asked Questions

1.

Are Congenital Heart Conditions Grave and Fatal?

Congenital heart disease encompasses a spectrum of inborn disease conditions concerning the heart. It can be structural or functional impairments that interfere with the normal functioning of the heart. However, not all congenital heart diseases are fatal. It depends on the severity and extent of congenital impairment and how it influences the heart’s function. Certain conditions are potentially life-threatening, while some are not.

2.

Is It Possible to Cure and Treat Congenital Heart Diseases?

The possibility for cure and treatment depends primarily on the type and extent of the cardiac impairment. There are certain minor inborn heart conditions that do not demand extensive interventions. For most serious congenital heart diseases, a complete cure cannot be achieved. However, many of the inborn heart conditions can be effectively treated and managed with appropriate treatment interventions. Those treatment strategies aid in enhancing the survival rate and quality of life.

3.

What Is the Most Effective and Promising Preventive Strategy for Congenital Heart Disease?

Since congenital heart diseases are precipitated by birth, prevention should be done during the intrauterine (within the womb) stage. The expectant mothers are advised to keep a check on alcohol intake. Smoking and alcohol intake during pregnancy are identified as two potent factors that enhance the susceptibility to heart complications in the developing baby inside the womb. In addition, certain maternal tablets (medicines) can also impair heart development. Hence, it is strictly advised not to take medicines without medical consultation during conception. 

4.

Can Congestive Heart Disease Be Prevented by Any Means?

Congestive heart conditions like congestive heart failure are potentially life-threatening heart conditions. Those conditions can be effectively tackled by incorporating certain habits into their daily routine. Lifestyle and dietary alterations like regular exercise and checking smoking and alcohol intake can keep the heart healthy and functional. Cutting down the intake of food loaded with saturated fats, which burdens the heart, is another promising preventive strategy. 

5.

What Is the Novel Treatment Intervention for Tackling Heart Failure?

There are several medicines that are available in the market for tackling heart failure. Recently, diuretics class of medicines have been used as the mainstay medicine for heart failure. Dapagliflozin is another novel medication that is endorsed by the Food and Drug Administration to narrow down the susceptibility to heart failure and check the development of other heart-related complications (cardiovascular events).

6.

What Made the Ductus Arteriosus to Remain in Open Condition?

The ductus arteriosus persists in open condition when the baby is inside the mother’s womb. The open conformation of the ductus arteriosus is maintained by a specific bodily substance called prostaglandin E1 (PGE1). The ductus and the placenta are responsible for releasing this substance, which keeps the ductus open. 

7.

What Is Meant by the Medical Term Ductus Arteriosus and What Does Ductus Arteriosus Do?

Ductus arteriosus is the name of a stubby blood vessel present in the fetus (baby in the womb). It bridged two significant blood vessels: the aorta and the pulmonary artery. Ductus arteriosus enables the oxygen-rich blood from the placenta to gain access to the aorta so that the baby gets oxygen-loaded blood throughout the intrauterine life. Once the baby is delivered, the lungs will take on their role and carry out oxygenation of the blood, thus eliminating the need for ductus arteriosus. 

8.

What Is the Most Preferred Therapeutic Intervention for Patent Ductus Arteriosus (PDA)?

Indomethacin is the widely advised first-line approach for babies detected with patent ductus arteriosus. Intravenous (into the vein) is the preferred route for Indomethacin administration, which can trigger the closure of the ductus. Recent studies have concluded that Ibuprofen and Paracetamol also elicit similar effectiveness in comparison with Indomethacin in PDA closure. For patients who fail to elicit favorable results with Indomethacin therapy, surgical closure is advised.

9.

Does PDA Relapse or Reopen Even After Surgical Intervention?

Though the possibility for post-surgical issues like reopening of the ductus arteriosus is quite rare, it does happen at times. It is often encountered in the long run, and hence, it is considered as a long-term complication following surgical correction for PDA. However, the majority of surgically corrected babies lead a quality and safe life without potential complications.

10.

What Is the Estimated Probability for a PDA Surgery to Be Successful?

The success rate for patent ductus arteriosus closure was estimated to be in the range of 80 to 100 percent. Various study reports point to a 100 percent success rate without precipitating obvious complications, either during or after the surgical correction. Not all babies detected with PDA undergo surgical repair. Only those babies who fail to elicit fruitful results with nonsurgical intervention and who are reported with larger PDA are indicated for surgical correction.

11.

What Is the Significance Behind Open Ductus Arteriosus?

Though patent ductus arteriosus is identified to be an inborn cardiac condition, it can be a lifesaver if the baby is simultaneously having certain other heart conditions that hinder the supply of oxygen-rich blood from the lungs. In such babies, medicines are advised to keep the ductus in the open conformation so that it allows some mixing of the oxygen-rich and oxygen-deficit blood. Therefore, it helps such babies to survive until a surgical correction is made to access the oxygen-rich blood from the lungs. 

12.

Does Ductus Arteriosus Bypass Any Other Organ in the Child’s Body?

Yes, lungs are bypassed by ductus arteriosus. Ductus arteriosus establishes communication across the aorta and pulmonary artery. During the intrauterine stage, the lungs are not functional. The placenta supplies the oxygen-rich blood that is essential for the baby’s life. The ductus creates a channel to provide access for the blood from the placenta to reach the baby’s circulation through the aorta. 
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Dr. Yash Kathuria
Dr. Yash Kathuria

Family Physician

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