By Dr. Sudeep Verma

A few months back, we received a referral call for a 40-day old baby from a peripheral
hospital with very low body weight in critical condition. The child was diagnosed with Patent
Ductus Arteriosus or PDA, a common condition detected in premature babies. Doctors
performed a minimally invasive treatment procedure using a wire mesh device to close the
PDA and successfully treated the infant.

In India, eight out of every 1000 newborn babies suffer from heart defects which accounts for
approximately 1.5 lakh infants born with congenital heart disease per year. About 10% of
the infant mortality rate can be attributed to congenital heart disease alone. These defects
range from simple to complex. Certain problems can be examined by the doctor and
managed with medicines, others require surgery, at times as soon as in the first few hours of
the child’s birth.

Understanding heart defects in newborns
It is critical to know how the heart works to understand congenital heart disease. The heart is
divided into chambers – two upper chambers (atria) and two lower chambers (ventricles).
The right side of the heart transfers blood to the lungs through blood vessels known as
pulmonary arteries. Oxygen-rich blood in the lungs then returns to the left side of the heart.
The left side of the heart then pumps blood to the rest of the body through a blood vessel
known as the aorta. When an individual suffers from congenital heart disease, any of their
heart structure can get affected including valves, chambers, arteries, and the wall of tissue
that separates the upper and lower chambers called the septum.

Congenital heart defects can be broadly classified into three categories viz. one with the
increased flow to the lungs which includes Patent ductus arteriosus (PDA), Atrial septal
defect (ASD), Ventricular septal defect (VSD), and Atrioventricular canal (AVC or AV canal)
Coarctation of the aorta (CoA), pulmonary stenosis and Aortic stenosis (AS).

Congenital heart defects can be detected during pregnancy using an ultrasound (Foetal
echocardiography or anomaly scan). After birth, the defects are diagnosed using
echocardiography on suspicion at a physical examination in the form of abnormal pulses or
abnormal heart sounds. Other clues that point towards the presence of congenital heart
disease are low oxygen levels, recurrent pneumonia, poor weight gain, persistent feeding
and breathing difficulty, or with history of previous sicking affected with heart disease.

PDA occurs commonly in preterm infants, especially in those with respiratory distress
syndrome. In mature full-term neonates incidence of PDA is 1 in 2000 births accounting for 5-
10% of CHD while in premature neonates, the incidence ranges from 20-60%. PDA occurs
when a blood vessel called the ductus arteriosus that connects the pulmonary artery directly
to the aorta (which is supposed to close after birth), remains open. This leads to extra blood
flow from the aorta to the lungs and is often seen in premature infants. Normally PDA gets
closed within 72 hours of birth. But in case PDA persists, it can often result in heart failure,
kidney failure, brain hemorrhage, poor weight gain, or lung congestion that can result in
death, prolonged hospital stay, or dependency on the ventilator or CPAP. In such a scenario,
it is important to close the PDA.

How can this condition be treated?
There are three types of treatment options available for this condition namely, medical
management, surgical management, and non-surgical procedure. Paracetamol, Ibuprofen,
and Indomethacin are three drugs that are widely used in closing the PDA. So, normally
medical treatment is the first choice of treating this condition in newly born babies. If this fails
and the condition of the baby deteriorates, there are two options – surgical and non-surgical.
The surgical repair is performed under general anesthesia and involves closing the open
PDA by surgical incision through the side of the chest using clips or stitches to prevent the
surplus blood from entering the child’s lungs. The third and advanced option to treat this
condition by transcatheter route using wire mesh occluder device closure. This is a minimally
invasive (non-surgical) procedure to close the ductus arteriosus.

Specialized heart doctors called pediatric cardiac interventionists use a minimally invasive
procedure to close the PDA. Medical technology has given way to an advanced pea-sized
device that can help treat even the tiniest of babies as low as 500 grams. This medically
advanced wire mesh device is self-expanding and is inserted through a puncture in the leg
vein and guided through vessels to the heart, where it is placed to seal the opening in the
heart. It is designed to allow the physician to insert it through the aortic or pulmonary artery,
as well as to retrieve and redeploy the device for optimal placement, the release.

Due to the minimally invasive nature of this procedure, many of the premature babies who
are critically ill in the neonatal intensive care unit can be weaned from artificial respiratory
support soon after the procedure with less risk in comparison to surgery.

For years, congenital heart defects were repaired with open-heart surgeries that included
risks like blood transfusion, blood infections, and longer hospital stays. Credit it to advanced
technologies, we now have minimally invasive procedures for selected cardiac conditions to
treat infants with fewer complications and short hospital stays.

Prevention matters
Though technological advancement has given a certain edge in saving a million lives with
CHD, parents or pregnant parents should keep certain things in mind. Young women should
seek early prenatal care, even before they are pregnant. Quitting smoking, reducing stress,
taking folic acid supplementation, maintaining their blood sugars would be key towards
maintaining health and wellness. It is advisable to discuss any medication that you may be
consuming with the doctor. Eating a healthy diet, regular exercise, and working closely with
the doctor to develop a customized plan will help in maintaining a healthy body.

By Dr. Sudeep Verma, Paediatric Cardiologist, KIMS Hospital, Secunderabad – Hyderabad

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