Background
Isolated patent ductus arteriosus (PDA) is a relatively common defect, accounting for 5% to 10% of congenital heart defects (excluding premature infants).¹ Given the increased use of echocardiography, incidental detection of asymptomatic "silent" PDA is on the rise. Patients with trivial or small PDAs are usually asymptomatic, while moderate and large PDAs may cause tachypnea, tachycardia, poor weight gain, left heart dilation and eventual pulmonary hypertension. Symptomatic patients and those with left heart dilation related to PDA or an audible PDA are referred for closure, most often by transcatheter based approach, but surgical closure is also performed, particularly in premature infants.¹ A recent survey of pediatric cardiologists regarding echocardiographic findings in asymptomatic newborns, including small PDAs, demonstrated a wide variation in timing of follow-up and recommended testing.² There remains a lack of evidence-based guidelines for optimal frequency of follow-up and testing in patients with PDA, either before or following intervention, leading to this wide variation in clinical practice and resource utilization.

Goals and Details of the Algorithm
The goal of the PDA clinical practice algorithm is to provide those caring for patients with congenital heart disease (CHD) a decision support tool that can be used prior to and/or following catheterization-based or surgical interventions for PDA. By providing this tool, cardiologists will hopefully have a standard approach for frequency of follow-up and testing including electrocardiography and echocardiography for patients with isolated PDA, from birth to adulthood. Cardiologists and health care providers may use the algorithm as a reference point when seeing PDA patients in the outpatient setting. However, it is not intended to replace decision-making on individual cases where patients have more complex disease related to extra-cardiac co-morbidities and fall outside of the algorithm.

The algorithm includes sub-algorithms by age-group (PDA <18 Years of Age, PDA >18 Years of Age) and Post-Intervention. Each sub-algorithm starts with the initial standard workup and progresses to follow-up frequency and testing based upon PDA size and hemodynamic significance. In the case of the trivial "silent" PDA, the algorithm recommends discharge from care.^3,4 Frequency of follow-up and testing with echocardiography in the various clinical scenarios is guided by the Appropriate Use Criteria for Multimodality Imaging During the Follow-up Care of Patients with CHD.⁴ It is considered reasonable to follow a small PDA infrequently rather than discharging from care, given in some cases, it may result in left heart dilation over time, which would be an indication for intervention. The algorithm for patients >18 years of age is guided by the existing adult CHD guidelines^5,6 and includes assessment for pulmonary arterial hypertension (PAH), management depending on pulmonary vascular resistance, and follow-up in cases where PDA closure is not advised and PAH therapy is therefore pursued. The Post-Intervention sub-algorithm addresses follow-up based upon residual PDA, left pulmonary artery obstruction, and arch obstruction.^3,7-9 In the case of surgical PDA closure, discharging the patient from cardiology care may be considered if there are no clinical concerns at the post-discharge clinic visit. Following transcatheter PDA closure, annual follow-up for the first 2 years with echocardiogram is recommended, followed by every 3-5 years with echocardiogram.⁴

Methods: Algorithm Development
The algorithm was created by the Quality Working Group of the American College of Cardiology (ACC) Adult Congenital and Pediatric Cardiology (ACPC) member section. This is a multidisciplinary group of experienced pediatric and adult congenital cardiologists from diverse training and practice backgrounds. A subset of this group successfully derived the first algorithm (secundum atrial septal defects [ASD]) of a series of algorithms for mildly complex CHD.¹⁰ The same quality-driven approach used for the secundum ASD algorithm was used for the development of this PDA algorithm to translate current evidence into best practice recommendations. Lesion specific references^7-9,11,12 and existing guidelines^3-6 were used to create the evidence-based algorithm. The attached PDA algorithm was then discussed, and peer reviewed for consensus.

Conclusion
The PDA clinical practice algorithms can be integrated by clinicians as a decision support tool in their practice. Furthermore, centers can use them for quality improvement initiatives and projects that may be used for Maintenance of Certification (MOC) part IV credit. The wide-spread use and implementation of the PDA algorithms could improve resource utilization and standardize care of patients with isolated PDA.

References

1. Allen HD, Penny DJ, Feltes TF, Cetta F. Moss and Adams' Heart Disease in Infants, Children, and Adolescents Including the Fetus and Young Adult. 9th ed. Wolters Kluwer; 2016.
2. Hokanson JS, Ring K, Zhang X. A survey of pediatric cardiologists regarding non-emergent echocardiographic findings in asymptomatic newborns. Pediatr Cardiol 2022;43:837-43.
3. Feltes TF, Bacha E, Beekman RH 3rd, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011;123:2607-52.
4. Sachdeva R, Valente AM, Armstrong AK, et al. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease: a report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol 2020;75:657-703.
5. Baumgartner H, De Backer J, Babu-Narayan SV, et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2021;42:563-645.
6. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:1494-1563.
7. Dimas VV, Takao C, Ing FF, et al. Outcomes of transcatheter occlusion of patent ductus arteriosus in infants weighing ≤ 6 kg. JACC Cardiovasc Interv 2010;3:1295-99.
8. Markush D, Tsing JC, Gupta S, et al. Fate of the left pulmonary artery and thoracic aorta after transcatheter patent ductus arteriosus closure in low birth weight premature infants. Pediatr Cardiol 2021;42:628-36.
9. Tomasulo CE, Gillespie MJ, Munson D, et al. Incidence and fate of device-related left pulmonary artery stenosis and aortic coarctation in small infants undergoing transcatheter patent ductus arteriosus closure. Catheter Cardiovasc Interv 2020;96:889-97.
10. Plummer S, Parthiban A, Sachdeva R, Zaidi A, Statile C. Clinical Practice Algorithm for the Follow-up of Unrepaired and Repaired Secundum Atrial Septal Defects. http://www.acc.org. Mar 08, 2022. Accessed [insert access date]. https://www.acc.org/Latest-in-Cardiology/Articles/2022/03/08/19/34/Clinical-Practice-Algorithm-For-the-Follow-up-of-Unrepaired-and-Repaired-SASD.
11. Weber SC, Weiss K, Bührer C, Hansmann G, Koehne P, Sallmon H. Natural history of patent ductus arteriosus in very low birth weight infants after discharge. J Pediatr 2015;167:1149-51.
12. Zahn EM, Nevin P, Simmons C, Garg R. A novel technique for transcatheter patent ductus arteriosus closure in extremely preterm infants using commercially available technology. Catheter Cardiovasc Interv 2015;85:240-48.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Pulmonary Hypertension, Echocardiography/Ultrasound, Hypertension

Keywords: Ductus Arteriosus, Patent, Aftercare, Follow-Up Studies, Goals, Hypertension, Pulmonary, Consensus, Dilatation, Outpatients, Patient Discharge, Pulmonary Arterial Hypertension, Pulmonary Artery, Quality Improvement, Heart Septal Defects, Atrial, Hemodynamics, Echocardiography, Vascular Resistance, Electrocardiography, Ambulatory Care, Tachycardia, Morbidity, Algorithms, Tachypnea

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