Cardiovascular System - Patent Ductus Arteriosus

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A personal message from Dr Mark Hill (May 2020)  
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I have decided to take early retirement in September 2020. During the many years online I have received wonderful feedback from many readers, researchers and students interested in human embryology. I especially thank my research collaborators and contributors to the site. The good news is Embryology will remain online and I will continue my association with UNSW Australia. I look forward to updating and including the many exciting new discoveries in Embryology!

LA8B.4 Patent Arterial Duct

LA8B.4 Patent arterial duct
ICD-11 Structural developmental anomalies of the circulatory system (draft) 
ICD-11 Beta Draft - NOT FINAL, updated on a daily basis, It is not approved by WHO, NOT TO BE USED for CODING except for agreed FIELD TRIALS.

20 Developmental Anomalies - Structural Developmental Anomalies

Beta coding and tree structure for "structural developmental anomalies" within this section are shown in the table below.

Structural developmental anomalies of the circulatory system  
  • Structural developmental anomaly of heart and great vessels
    • LB00 Congenital heart or great vessel related acquired abnormality
    • LB01 Congenital anomaly of atrioventricular or ventriculo-arterial connections
      • LB01.1 Transposition of the great arteries
      • LB01.2 Double outlet right ventricle
      • LB01.3 Double outlet left ventricle
      • LB01.4 Common arterial trunk
      • LB01.Y Other specified congenital anomaly of atrioventricular or ventriculo-arterial connections
      • LB01.Z Congenital anomaly of atrioventricular or ventriculo-arterial connections, unspecified
    • LB02 Congenital anomaly of the mediastinal veins Congenital anomaly of atria or atrial septum
    • LB20 Congenital anomaly of atrioventricular valves or septum
    • LB21 Congenital anomaly of ventricles and ventricular septum
      • LB21.1 Congenital right ventricular outflow tract obstruction  
      • LB21.2 Double-chambered right ventricle  
      • LB21.3 Tetralogy of Fallot
      • LB21.4 Congenital left ventricular outflow tract obstruction  
      • LB21.5 Congenital ventricular septal defects 
      • LB21.Y Other specified congenital anomaly of ventricles and ventricular septum
      • LB21.Z Congenital anomaly of ventricles and ventricular septum, unspecified  
    • LB22 Functionally univentricular heart
    • LB23 Congenital anomaly of ventriculo-arterial valves and adjacent regions
    • LB24 Congenital anomaly of great arteries including arterial duct
      • LB.1 Congenital aorto-pulmonary window
      • LB.2 Congenital anomaly of pulmonary arterial tree
      • LB.3 Congenital anomaly of aorta and its branches
      • LB.4 Tracheo-oesophageal compressive syndrome
      • LB.5 Patent arterial duct
      • LB.Y Other specified congenital anomaly of great arteries including arterial duct
      • LB.Z Congenital anomaly of great arteries including arterial duct, unspecified
    • LB25 Anomalous position-orientation of heart
    • LB26 Total mirror imagery
    • LB27 Left isomerism
    • LB28 Congenital anomaly of coronary arteries
    • LB29 Structural developmental anomalies of the pericardium
    • LB2Y Other specified structural developmental anomaly of heart and great vessels
    • LB2Z Structural developmental anomaly of heart and great vessels, unspecified
  • LB30 Structural developmental anomalies of the peripheral vascular system
    • LB30.1 Capillary malformations
    • LB30.2 Lymphatic malformations
      • LB30.21 Macrocystic lymphatic malformation
      • LB30.22 Microcystic lymphatic malformation
      • LB30.23 Cystic hygroma in fetus
      • BD23.1 Primary lymphoedema
          • EK91 Yellow nail syndrome
          • LC5F.26 Noonan syndrome
      • LB30.2Y Other specified lymphatic malformations
      • LB30.2Z Lymphatic malformations, unspecified
    • LB30.3 Peripheral venous malformations
    • LB30.4 Peripheral arteriovenous malformations
    • LB30.5 Peripheral arterial malformations
    • LB30.6 Pulmonary arteriovenous fistula
    • LB30.Y Other specified structural developmental anomalies of the peripheral vascular system
    • LB30.Z Structural developmental anomalies of the peripheral vascular system, unspecified
  • LB3Y Other specified structural developmental anomalies of the circulatory system
  • LB3Z Structural developmental anomalies of the circulatory system, unspecified
CD-11 Beta Draft - NOT FINAL, updated on a daily basis, It is not approved by WHO, NOT TO BE USED for CODING except for agreed FIELD TRIALS.

See also International Classification of Diseases | Abnormalities


Patent Ductus Arteriosus

Patent ductus arteriosus (PDA), or Patent arterial duct (PAD), or common truncus, occurs commonly in preterm infants, and at approximately 1 in 2000 full term infants and more common in females (to male ratio is 2:1). Can also be associated with specific genetic defects, Trisomy 21 and Trisomy 18, and the Rubinstein-Taybi and CHARGE syndromes.

The opening is asymptomatic when the duct is small and can close spontaneously (by day three in 60% of normal term neonates), the remainder are ligated simply and with little risk, with transcatheter closure of the duct generally indicated in older children. The operation is always recommended even in the absence of cardiac failure and can often be deferred until early childhood.

The ductus arteriosus, and its corresponding ligament, historically were described as the ductus Botallo, but should this have really been the ductus Aranzio?[1]

Heart Abnormal: Tutorial Abnormalities | atrial septal defects | double outlet right ventricle | hypoplastic left heart | patent ductus arteriosus‎ | transposition of the great vessels | Tetralogy of Fallot | ventricular septal defects | coarctation of the aorta | Category ASD | Category PDA | Category ToF | Category VSD | ICD10 - Cardiovascular | ICD11

Cardiovascular Links: cardiovascular | Heart Tutorial | Lecture - Early Vascular | Lecture - Heart | Movies | 2016 Cardiac Review | heart | coronary circulation | heart valve | heart rate | Circulation | blood | blood vessel | blood vessel histology | heart histology | Lymphatic | ductus venosus | spleen | Stage 22 | cardiovascular abnormalities | OMIM | 2012 ECHO Meeting | Category:Cardiovascular
Historic Embryology - Cardiovascular 
1902 Vena cava inferior | 1905 Brain Blood Vessels | 1909 Cervical Veins | 1909 Dorsal aorta and umbilical veins | 1912 Heart | 1912 Human Heart | 1914 Earliest Blood-Vessels | 1915 Congenital Cardiac Disease | 1915 Dura Venous Sinuses | 1916 Blood cell origin | 1916 Pars Membranacea Septi | 1919 Lower Limb Arteries | 1921 Human Brain Vascular | 1921 Spleen | 1922 Aortic-Arch System | 1922 Pig Forelimb Arteries | 1922 Chicken Pulmonary | 1923 Head Subcutaneous Plexus | 1923 Ductus Venosus | 1925 Venous Development | 1927 Stage 11 Heart | 1928 Heart Blood Flow | 1935 Aorta | 1935 Venous valves | 1938 Pars Membranacea Septi | 1938 Foramen Ovale | 1939 Atrio-Ventricular Valves | 1940 Vena cava inferior | 1940 Early Hematopoiesis | 1941 Blood Formation | 1942 Truncus and Conus Partitioning | Ziegler Heart Models | 1951 Heart Movie | 1954 Week 9 Heart | 1957 Cranial venous system | 1959 Brain Arterial Anastomoses | Historic Embryology Papers | 2012 ECHO Meeting | 2016 Cardiac Review | Historic Disclaimer

Some Recent Findings

Patent ductus arteriosus analysis method pulse phase difference
  • Comparative effectiveness of drugs used to constrict the patent ductus arteriosus: a secondary analysis of the PDA-TOLERATE trial (NCT01958320)[2] "To evaluate the effectiveness of drugs used to constrict patent ductus arteriosus (PDA) in newborns < 28 weeks. We performed a secondary analysis of the multi-center PDA-TOLERATE trial (NCT01958320). ...Indomethacin was more effective than acetaminophen in producing ductus constriction." (indomethacin a non-steroidal anti-inflammatory drug, NSAIDs)
  • Predictors of Respiratory Improvement 1 Week after Ligation of Patent Ductus Arteriosus in Preterm Infants[3] "To characterize preterm infants that demonstrates respiratory improvement 7 days after ligation of a patent ductus arteriosus (PDA). We performed a 2-phase study of preterm infants (birthweight <1500 g between 2010 and 2016). ...Among infants undergoing PDA ligation, those on HFV were more likely to have respiratory improvement in the first week, possibly because of the prevention of further respiratory deterioration. For infants on conventional ventilation, ligation was associated with higher respiratory support in the immediate postligation period without respiratory benefits at 7 days. As high frequency ventilation (HFV) was used as a rescue mode, our findings suggest that those with worse lung disease may achieve greater short term benefit from PDA ligation."
  • Review - Preterm patent ductus arteriosus[4] "How to manage the preterm patent ductus arteriosus (PDA) remains a conundrum. On the one hand, physiology and statistical association with adverse outcomes suggest that it is pathological. On the other hand, clinical trials of treatment strategies have failed to show any long-term benefit. Ultrasound studies of PDA have suggested that the haemodynamic impact may be much earlier after birth than previously thought (in the first hours); however, we still do not know when to treat PDA."
More recent papers  
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Search term: Patent Ductus Arteriosus

Older papers  
These papers originally appeared in the Some Recent Findings table, but as that list grew in length have now been shuffled down to this collapsible table.

See also the Discussion Page for other references listed by year and References on this current page.

  • Noninvasive technique for the diagnosis of patent ductus arteriosus in premature infants by analyzing pulse wave phases on photoplethysmography signals measured in the right hand and the left foot[5] "To evaluate the impact of patent ductus arteriosus (PDA) on the pulse phase difference (PPD) between the left foot (postductal region) and the right hand (preductal region). PPD was determined from arterial photoplethysmography signals (pulse waves) measured by infrared sensors routinely used for pulse oximetry in 56 premature infants less than 32 weeks gestation. Only infants with significant PDA (sPDA) diagnosed by echocardiography were treated with ibuprofen (for 3 days). ...In this study, PPD was correlated with ductus arteriosus status evaluated by echocardiography, indicating involvement of the ductal shunt in the mechanism of redistribution in systemic vascular territories. PPD can be considered for the diagnosis of hemodynamically significant PDA."
  • Cochrane Database - Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants[6] "Indomethacin is used as standard therapy to close a patent ductus arteriosus (PDA) but is associated with reduced blood flow to several organs. Ibuprofen, another cyclo-oxygenase inhibitor, may be as effective as indomethacin with fewer side effects. Twenty-seven studies are included in this review. ...Ibuprofen is as effective as indomethacin in closing a PDA and reduces the risk of NEC and transient renal insufficiency. Given the reduction in NEC ibuprofen currently appears to be the drug of choice. Oro-gastric administration of ibuprofen appears at least as effective as iv administration. Too few patients have been enrolled in studies assessing the effectiveness of a high dose of ibuprofen versus the standard dose and early versus expectant administration of ibuprofen to make recommendations. Studies are needed to evaluate the effect of ibuprofen compared with indomethacin treatment on longer-term outcomes in infants with PDA."
  • Treatment of patent ductus arteriosus with bidirectional flow in neonates[7] "We identified 20 neonates with bidirectional flow out of 317 cases in which medical closure of patent ductus arteriosus was attempted. There was no significant increase in overall complications due to closure of a bidirectional patent ductus arteriosus [40% (8/20)] versus ones with left to right shunting [38% (111/297) p=0.82]. Death occurred in 15% (3/20) with bidirectional PDA compared to 11% (34/297) in the left to right group, p=0.72."

Diagnostic Images

Cardiovascular Abnormalities

Data shown as a percentage of all major abnormalities based upon published statistics using the same groupings as Congenital Malformations Australia 1981-1992 P. Lancaster and E. Pedisich ISSN 1321-8352.

Heart defects and preterm birth are the most common causes of neonatal and infant death. The long-term development of the heart combined with extensive remodelling and post-natal changes in circulation lead to an abundance of abnormalities associated with this system.

A UK study literature showed that preterm infants have more than twice as many cardiovascular malformations (5.1 / 1000 term infants and 12.5 / 1000 preterm infants) as do infants born at term and that 16% of all infants with cardiovascular malformations are preterm. (0.4% of live births occur at greater than 28 weeks of gestation, 0.9% at 28 to 31 weeks, and 6% at 32 to 36 weeks. Overall, 7.3% of live-born infants are preterm)[8]

"Baltimore-Washington Infant Study data on live-born cases and controls (1981-1989) was reanalyzed for potential environmental and genetic risk-factor associations in complete atrioventricular septal defects AVSD (n = 213), with separate comparisons to the atrial (n = 75) and the ventricular (n = 32) forms of partial AVSD. ...Maternal diabetes constituted a potentially preventable risk factor for the most severe, complete form of AVSD." [9]

In addition, there are in several congenital abnormalities that exist in adults (bicuspid aortic valve, mitral valve prolapse, and partial anomalous pulmonary venous connection) which may not be clinically recognized.

Clinical Classifications

Patent Ductus Arteriosus (PDA) classification system on the basis of angiogram appearance by Krichenko (1989).[10]
  • Type A - conical duct with well defined aortic ampulla and constriction near the pulmonary artery end.
  • Type B - large duct with window like structure which is very short in length.
  • Type C - tubular duct without any constriction.
  • Type D - complex duct with multiple constrictions.
  • Type E - elongated duct with constriction remote from the edge of the trachea (as viewed on lateral angiography).
Patent ductus arteriosus classification cartoon

A recent publication suggests a classification based on angiographic size and haemodynamic sound significance.[11]

Type Size Haemodynamics
Silent PDA usually less than 1.5 mm PDA murmur not present
Very small PDA less than 1.5 mm PDA murmur present
Small PDA 1.5 to 3.0 mm PDA murmur present
Moderate PDA 3 to 5 mm PDA murmur present
Large PDA greater than 5 mm PDA murmur present

The Aristotle Comprehensive Complexity (ACC) score has been suggested as a clinical tool for complexity adjustment in the analysis of outcome after reparative congenital heart surgery.[12][13]

Links: Aristotle Comprehensive Complexity Score

Patent Ductus Arteriosus with Persistent Fifth Aortic Arch

Three-dimensional reconstructed computed tomography image showing left-sided patent ductus arteriosus with double-lumen aortic arch.[14]

The arch had two lumina and the left carotid and subclavian arteries were originating from the upper lumen.

Persistent fifth aortic arch and patent ductus arterioles CT


  1. Fransson SG. (1999). The Botallo mystery. Clin Cardiol , 22, 434-6. PMID: 10376187
  2. Liebowitz M, Kaempf J, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Wolf IS, Kimball A, Sankar M, Leone T, Perez J, Serize A & Clyman RI. (2019). Comparative effectiveness of drugs used to constrict the patent ductus arteriosus: a secondary analysis of the PDA-TOLERATE trial (NCT01958320). J Perinatol , , . PMID: 30850756 DOI.
  3. Hsu KH, Wong P, Subramanyan RK, Evans J & Noori S. (2018). Predictors of Respiratory Improvement 1 Week after Ligation of Patent Ductus Arteriosus in Preterm Infants. J. Pediatr. , , . PMID: 30348438 DOI.
  4. Evans N. (2015). Preterm patent ductus arteriosus: A continuing conundrum for the neonatologist?. Semin Fetal Neonatal Med , 20, 272-7. PMID: 25818393 DOI.
  5. Goudjil S, Imestouren F, Armougon A, Razafimanantsoa L, Mahmoudzadeh M, Wallois F, Leke A & Kongolo G. (2014). Noninvasive technique for the diagnosis of patent ductus arteriosus in premature infants by analyzing pulse wave phases on photoplethysmography signals measured in the right hand and the left foot. PLoS ONE , 9, e98763. PMID: 24892695 DOI.
  6. Ohlsson A, Walia R & Shah SS. (2013). Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev , , CD003481. PMID: 23633310 DOI.
  7. Ethington PN, Smith PB, Katakam L, Goldberg RN & Cotten CM. (2011). Treatment of patent ductus arteriosus with bidirectional flow in neonates. Early Hum. Dev. , 87, 381-4. PMID: 21402454 DOI.
  8. Tanner K, Sabrine N & Wren C. (2005). Cardiovascular malformations among preterm infants. Pediatrics , 116, e833-8. PMID: 16322141 DOI.
  9. Loffredo CA, Hirata J, Wilson PD, Ferencz C & Lurie IW. (2001). Atrioventricular septal defects: possible etiologic differences between complete and partial defects. Teratology , 63, 87-93. PMID: 11241431 <87::AID-TERA1014>3.0.CO;2-5 DOI.
  10. <pubmed>2929450</pubmed>
  11. Fernando R, Koranne K, Loyalka P, Kar B & Gregoric I. (2013). Patent ductus arteriosus closure using an Amplatzer(™) ventricular septal defect closure device. Exp Clin Cardiol , 18, e50-4. PMID: 24294051
  12. Bojan M, Gerelli S, Gioanni S, Pouard P & Vouhé P. (2011). Evaluation of a new tool for morbidity assessment in congenital cardiac surgery. Ann. Thorac. Surg. , 92, 2200-4. PMID: 22115230 DOI.
  13. Chang YH, Lee JY, Kim JE, Kim JY, Youn Y, Lee EJ, Moon S, Lee JY & Sung IK. (2013). The Aristotle score predicts mortality after surgery of patent ductus arteriosus in preterm infants. Ann. Thorac. Surg. , 96, 879-84. PMID: 23895892 DOI.
  14. Warrier D, Shah S, John C & Dayananda L. (2012). A rare association with patent ductus arteriosus. Ann Pediatr Cardiol , 5, 191-3. PMID: 23129912 DOI.


Isayama T, Kusuda S, Reichman B, Lee SK, Lehtonen L, Norman M, Adams M, Bassler D, Helenius K, Hakansson S, Yang J, Jain A & Shah PS. (2020). Neonatal Intensive Care Unit-Level Patent Ductus Arteriosus Treatment Rates and Outcomes in Infants Born Extremely Preterm. J. Pediatr. , , . PMID: 32145968 DOI.

Sasi A & Deorari A. (2011). Patent ductus arteriosus in preterm infants. Indian Pediatr , 48, 301-8. PMID: 21532100


Yun SW. (2011). Congenital heart disease in the newborn requiring early intervention. Korean J Pediatr , 54, 183-91. PMID: 21829408 DOI.

Thébaud B & Lacaze-Mazmonteil T. (2010). Patent ductus arteriosus in premature infants: A never-closing act. Paediatr Child Health , 15, 267-70. PMID: 21532789

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