The PIVOTAL Network is a group of healthcare providers, institutions, and researchers working in collaboration to determine the best approach to treat preterm infants diagnosed with patent ductus arteriosus, commonly referred to as a PDA.

A normal heart after the ductus arteriosus blood vessel has closed

Above: Inside a healthy heart 

What is a Patent Ductus Arteriosus?

  • The ductus arteriosus is a blood vessel present in all unborn infants, allowing blood to bypass the lungs while in the womb.
  • The ductus normally closes within a couple of days after birth, after the baby begins to breathe on it’s own.
  • When it does not, it is called a patent ductus arteriosus, and is a congenital heart defect

Patent Ductus Arteriosus (PDA)

Above: Inside a heart with patent ductus arteriosus.

PDA and Prematurity

  • Premature infants are more likely to have a PDA than infants born at term.
  • Younger gestational age increases the likelihood of PDA in premature infants.
  • Natural closure of PDA in premature infants may occur, but this may take much longer than normal.

Risks of PDA in Preterm Infants

A PDA may cause serious problems, especially for preterm infants:

  • Difficulty breathing normally
  • Difficulty eating and gaining weight
  • Development of pulmonary hypertension
  • Changes in size, shape, and function of the heart

Treatment of PDA in Preterm Infants

  • In order to allow time for natural closure, doctors may recommend a “wait and see” approach. This is called conservative management.
  • Doctors may recommend procedures to close PDA in premature infants:
    • Medications to promote closure
    • Catheter-based closure
    • Surgical ligation
Pharmaceutical (Drug) Closure of PDA

Pharmaceutical (Drug) Closure of PDA

  • Premature infants may be given medications to promote closure of the PDA:
    • Indomethacin
    • Ibuprofen
    • Acetaminophen
  • Medications may be tried before any other treatment is recommended


  • Successful in ??% of cases


  • Lower gestational age decreases chances of success
  • Reduced blood flow to intestines (side-effect) may lead to gastrointestinal (gut) complications
Conservative Management of PDA

Conservative Management of PDA

  • During conservative management, the doctors may prescribe
    • Reduced fluid intake
    • Diuretic medications
  • Often attempted before more invasive procedures are recommended


  • No procedural intervention(s)
  • High success in higher gestational age premature infants


  • Longer duration of exposure to PDA and diuretic medications
  • Restricted weight gain
  • May lead to breathing-related complications if prolonged
Catheter-Based Closure of PDA

Catheter-Based Closure of PDA

  • This procedure is performed under general anesthesia.
  • A small incision is made in the groin, and a wire (catheter) is inserted into a blood vessel and run up to and into the heart.
  • Using the catheter, a small device is implanted within the PDA to promote clotting and closure.


  • Complete occlusion (closure) of PDA within 24 hours in successful cases
  • Minimally-invasive procedure


  • Need for blood transfusion due to blood loss during procedure
  • Embolization (implant migrates from PDA to downstream blood vessel)
  • Anesthesia exposure

Catheter-Based Closure for Premature Infants?

  • In January of 2019, the US Food and Drug Administration approved a new device for catheter PDA closure.
  • Unlike previous devices, this new occluder was approved for use in preterm infants of 700 grams body weight, or more.
Surgical Ligation of the PDA

Surgical Ligation of the PDA

  • Surgical ligation is an invasive surgical procedure.
  • An incision is made in the chest, exposing the heart and blood vessels.
  • The PDA is either sewn shut, cut (ligated) and sewn, or a clip (similar to a paperclip) is placed.
  • Often only done when other procedures cannot be used, or fail to close the PDA.


  • Definitive closure of PDA


  • Highly invasive procedure
  • Infection at surgical site
  • Vocal cord paralysis (permanent) due to possible nerve damage
  • Post-surgical instability