The ductus arteriosus is a short blood vessel that connects the pulmonary artery to the aorta in the developing fetus. It is normally open only in a developing fetus. During development, the ductus arteriosus allows for oxygenated blood to bypass the pulmonary circulation (since breathing is not yet possible) and enter directly into the systemic circulation. After birth, the ductus arteriosus closes and becomes the ligamentum arteriosum. However, it is possible for the ductus to remain open after birth in a condition called patent ductus arteriosus. In such a case, the ductus arteriosus is closed either medically or surgically.
During fetal development, the ductus arteriosus serves as a shunt between the pulmonary artery and the aorta. In the fetus, the blood is oxygenated in the placenta before being returned to the body. The lungs are filled with amniotic fluid and therefore cannot be used to oxygenate the blood. Instead, the arterioles in the lungs constrict, which restricts the amount of blood flow that can pass through. Since the blood is already oxygenated after leaving the placenta and entering the body, the ductus arteriosus allows for it to bypass the pulmonary circulation and enter directly into the systemic circulation. The ductus arteriosus is maintained in its open conformation by being exposed to the E series prostaglandins which are in relatively high concentrations before birth. These prostaglandins are produced by the ductus and by the placenta.
Shortly after birth and the first breath, the lungs are filled with oxygen, and the pulmonary arterioles dilate. This change in pulmonary-arteriole resistance allows for a significant increase in pulmonary blood flow. At the around the same time, the placenta is removed from the circulation, and therefore prostaglandin levels drop. The ductus arteriosus responds to these changes by closing and becoming the ligamentum arteriosum. This prevents oxygenated blood from returning to the pulmonary circulation and after passing through the lungs and into the aorta. This closure of the ductus occurs in most individuals within the first 3 months of life. However, there are times when this closure fails to occur. This condition is called patent ductus arteriosus and is discussed in further detail below. In addition, a patent ductus arteriosus can be medically induced in certain situations by administration of prostaglandin E2.
The ductus arteriosus forms from the six aortic arches. During embryonic development, this connection forms between the first portion of the pulmonary artery and the isthmus of the aorta (near the end). This provides a path through which fetal blood can be shunted away from the pulmonary circuit and delivered directly into the systemic circulation.
The ductus arteriosus can be of surgical importance when treating certain congenital heart defects. One such example is when a child is born with a transposition of the great arteries. In this condition, the ascending aorta and the pulmonary trunk are switched in location. This leads to an inability for oxygenated blood to leave the pulmonary circulation and enter the systemic circulation. If left untreated, this condition is incompatible with life. In these cases, a surgery called the arterial switch is the only definitive treatment. However, to buy the surgeons time to prepare for the operation, prostaglandin E2 can be given to maintaining patency of the ductus arteriosus. This allows for blood to mix between the two distinct circulatory circuits.
Another important surgical consideration is in cases where a patent ductus arteriosus is resistant to medical treatment. In these cases, the ductus arteriosus can be closed manually in surgery. There are two different approaches used to accomplish this. One is a more traditional surgical approach which requires the surgeon to open the thoracic cavity and ligate the vessel directly. The other is much less invasive and is done percutaneously. This version of the procedure involves the intravenous delivery of an occlusion device that, from within, plugs up the shunt.
Patent Ductus Arteriosus
Patent ductus arteriosus is a condition in which the ductus arteriosus fails to close after birth. This failure of closure leads to the generation of a left-to-right shunt since the blood pressures in the aorta are much higher than in the pulmonary artery. If allowed to remain patent, the pressure inside the pulmonary circuit will rise, leading to pulmonary hypertension. Pulmonary hypertension can lead to several negative outcomes including arrhythmias and congestive heart failure.
During fetal developments, prostaglandins (such as prostaglandins E1 and E2) are responsible for maintaining the patency of the ductus arteriosus. Prostaglandin E2 has the strongest effect and is produced both by the placenta and the ductus arteriosus itself. A patent ductus arteriosus can also be induced by direct administration of prostaglandin E2. This is often done to maintain circulation in children who are born with life-threatening congenital heart defects. One such example is when a child is born with a transposition of the great vessels (the aorta and pulmonary trunk are switched in location). Ordinarily, this condition would exclude oxygenated blood from entering the systemic circulation. However, a patent ductus arteriosus allows for oxygenated blood to cross over and buys the surgeons time to prepare for surgery.
Patent ductus arteriosus is often treated medically with non-steroidal anti-inflammatory drugs (NSAIDs) such as Indomethacin. These medications work by inhibiting the synthesis of prostaglandins and therefore, decreasing their concentration in the blood. In refractory cases, however, surgery can be done to manually close the shunt.
It should also be noted that NSAIDs taken during pregnancy can increase the risk early closure of the ductus arteriosus. For this reason, it is often advised that pregnant mothers avoid these medications after 30 weeks gestation.
An aortic transection is a condition where the aorta is torn or ruptured due to some trauma. This condition is most often fatal shortly after it’s onset since the aorta is the largest vessel in the body and it supplies blood directly from the heart to the rest of the vessels. The most frequent site of aortic transection is at the location where the ligamentum arteriosum (the remnant of the ductus arteriosus) attaches to the aorta. The ligamentum arteriosum acts as a tether that holds the aorta and pulmonary artery close to each other. When the body experiences a rapid deceleration (such as in a car crash), a large shearing force is applied to these great vessels due to the rigidity of this tether. This sheering force is responsible for the subsequent rupture of the aorta.
|||Agrawal H,Waller BR 3rd,Surendan S,Sathanandam S, New Patent Ductus Arteriosus Closure Devices and Techniques. Interventional cardiology clinics. 2019 Jan [PubMed PMID: 30449419]|
|||Borràs-Novell C,Riverola A,Aldecoa-Bilbao V,Izquierdo M,Domingo M,Iriondo M, Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants. Jornal de pediatria. 2018 Nov 10 [PubMed PMID: 30423323]|
|||Sathanandam S,Balduf K,Chilakala S,Washington K,Allen K,Knott-Craig C,Rush Waller B,Philip R, Role of Transcatheter patent ductus arteriosus closure in extremely low birth weight infants. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography [PubMed PMID: 30269408]|
|||Ashrafi AH,Levy VY, Management strategies for the preemie ductus. Current opinion in cardiology. 2019 Jan [PubMed PMID: 30394907]|
|||Choi GJ,Song J,Kim ES,Lee HL,Huh J,Kang IS, Outcomes of transcatheter closure of ductus arteriosus in infants less than six months of age - A single-center experience. Korean journal of pediatrics. 2018 Sep 19 [PubMed PMID: 30304903]|
|||Hung YC,Yeh JL,Hsu JH, Molecular Mechanisms for Regulating Postnatal Ductus Arteriosus Closure. International journal of molecular sciences. 2018 Jun 25; [PubMed PMID: 29941785]|
|||Yokoyama U, Prostaglandin E-mediated molecular mechanisms driving remodeling of the ductus arteriosus. Pediatrics international : official journal of the Japan Pediatric Society. 2015 Oct; [PubMed PMID: 26228894]|
|||Mitra S,Florez ID,Tamayo ME,Mbuagbaw L,Vanniyasingam T,Veroniki AA,Zea AM,Zhang Y,Sadeghirad B,Thabane L, Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-analysis. JAMA. 2018 Mar 27; [PubMed PMID: 29584842]|
|||Sommer G,Sherifova S,Oberwalder PJ,Dapunt OE,Ursomanno PA,DeAnda A,Griffith BE,Holzapfel GA, Mechanical strength of aneurysmatic and dissected human thoracic aortas at different shear loading modes. Journal of biomechanics. 2016 Aug 16; [PubMed PMID: 26970889]|
|||Villafañe J,Lantin-Hermoso MR,Bhatt AB,Tweddell JS,Geva T,Nathan M,Elliott MJ,Vetter VL,Paridon SM,Kochilas L,Jenkins KJ,Beekman RH 3rd,Wernovsky G,Towbin JA, D-transposition of the great arteries: the current era of the arterial switch operation. Journal of the American College of Cardiology. 2014 Aug 5; [PubMed PMID: 25082585]|
|||Waleh N,Barrette AM,Dagle JM,Momany A,Jin C,Hills NK,Shelton EL,Reese J,Clyman RI, Effects of Advancing Gestation and Non-Caucasian Race on Ductus Arteriosus Gene Expression. The Journal of pediatrics. 2015 Nov; [PubMed PMID: 26265282]|
|||van Wijk SW,Driessen MMP,Meijboom FJ,Takken T,Doevendans PA,Breur JM, Evaluation of Left Ventricular Function Long Term After Arterial Switch Operation for Transposition of the Great Arteries. Pediatric cardiology. 2019 Jan; [PubMed PMID: 30203292]|