Patent Ductus Arteriosus in Preterm Neonates: A 2025 Synthesis of Evidence‐Based Paradigms and Emerging Clinical Strategies

The American Academy of Pediatrics (AAP) recently published an updated clinical report on the management of patent ductus arteriosus (PDA) in preterm infants authored by Ambalavanan, Aucott, Salavitabar, Levy, and the Committee on Fetus and Newborn and Section on Cardiology and Cardiac Surgery [1]. This comprehensive report addresses the ongoing controversies and uncertainties surrounding PDA management, providing evidence-based guidance for clinicians caring for preterm infants (Table 1). The ductus arteriosus is a fetal blood vessel that typically closes shortly after birth in term infants. However, in preterm infants, especially those born at extreme prematurity, this closure is often delayed. The report highlights that spontaneous closure rates vary significantly by gestational age: whereas the ductus remains open at 4 days in only 10% of infants born at 30–37 weeks, it persists in more than 90% of those born at 24 weeks gestation [1]. This clinical challenge is particularly complex when a PDA becomes “hemodynamically significant” (hsPDA) and requires intervention. The persistence of a PDA can lead to increased pulmonary blood flow and potential “ductal stealing” from systemic circulation, which may contribute to complications, including bronchopulmonary dysplasia, necrotizing enterocolitis, and intraventricular hemorrhage [1]. However, the report emphasized that these associations do not necessarily prove causation, which partly explains the ongoing debate about optimal management strategies. One of the most valuable aspects of the report by Ambalavanan and colleagues are the authors of 2025 clinical report mentioned in [1] is its detailed guidance for assessing the hemodynamic significance of a PDA. The authors acknowledge that there exists no single definition of hsPDA, but they provide a practical framework combining clinical and echocardiographic criteria. Echocardiography remains the cornerstone of PDA assessment, evaluating not only the presence of a PDA but also its hemodynamic impact on pulmonary and systemic circulation. The report details specific measurements, including the left atrial-to-aortic root ratio, PDA diameter, flow patterns, and effects on end-organ perfusion. The authors also discuss the potential role of biomarkers, such as B-type natriuretic peptide (BNP), while noting their limitations. Prophylactic interventions are not recommended. The report clearly states that prophylactic medical interventions (those not guided by PDA status) are not recommended at any age or birth weight as they have no effect on mortality, bronchopulmonary dysplasia (BPD), or neurodevelopmental impairment [1]. Early routine treatment is not beneficial. Very early (< 72 h) or early (< 7–14 days) routine treatment to induce PDA closure, regardless of hemodynamic significance, does not improve outcomes and is not recommended. Conservative management is often appropriate. The report acknowledges the growing trend toward conservative (expectant) management, allowing for spontaneous closure without intervention in many cases. This approach appears safe on the basis of retrospective data and recent randomized trials. Selective treatment may be considered after 2 weeks. For infants with a hemodynamically significant PDA beyond 2 weeks of age, pharmacologic closure may be reasonable, with ibuprofen generally preferred over indomethacin or acetaminophen owing to its safety profile (Table 3). Procedural closure for persistent hsPDA. If the hsPDA persists despite medical therapy (or if medical therapy is contraindicated), transcatheter closure or surgical ligation may be considered. Table 4 provides the comparative assessments of various treatment modalities. The report documents a significant shift in procedural approaches to PDA closure over recent years. Surgical ligation rates have declined substantially, from 8.4% to 2.9% between 2006 and 2015 among very low birth weight infants [1]. Simultaneously, transcatheter closure has gained popularity, with the Amplatzer Piccolo Occluder receiving FDA approval in 2019 for PDA closure in infants weighing ≥ 700 g. The authors provide a balanced assessment of both approaches. While surgical ligation achieves predictable closure, it carries risks, including vocal cord paralysis, pneumothorax, and potential associations, with increased BPD and neurodevelopmental impairment. Transcatheter closure has shown promising results, with high success rates (> 95% in recent studies) and relatively low complication rates, although the authors noted that experience and expertise vary among centers [1]. Despite extensive research, the report identifies significant knowledge gaps that require further investigation. The authors acknowledge that “there is a lack of evidence to guide management, necessitating equipoise regarding treatment options”. They highlight the need for well-designed trials that evaluate not only ductal closure rates but also clinically critical long-term outcomes. The ongoing PDA trial in the NICHD Neonatal Research Network and the PIVOTAL trial (Percutaneous Intervention vs. Observational Trial of Arterial Ductus in Low Birth Weight Infants) are mentioned as studies that may provide critical additional data to guide future recommendations [1]. A more selective approach to PDA management is warranted, with careful assessment of hemodynamic significance before intervention. Conservative management is appropriate for many preterm infants, particularly in the first 2 weeks of life. When intervention is deemed necessary, ibuprofen is generally preferred for medical closure, whereas transcatheter approaches are increasingly favored over surgical ligation for procedural closure. Multidisciplinary collaboration between neonatologists and cardiologists is essential, particularly when considering procedural closure options. This AAP clinical report thoughtfully synthesizes current evidence on PDA management in preterm infants. It acknowledges the complexity of the issue and the limitations of available data while providing practical guidance for clinicians. The shift toward more conservative management for many infants, coupled with selective intervention for those with hemodynamically significant PDAs that persist beyond the early neonatal period, reflects a more nuanced understanding of this common condition. Aditya Hemendra Bhatt: conceptualization, formal analysis, writing – original draft, visualization. Somashekhar Marutirao Nimbalkar: conceptualization, formal analysis, writing – review and editing, supervision, validation. Dipen Vasudev Patel: visualization, writing – review and editing. Reshma Kushal Pujara: validation, writing – review and editing. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. No new data has been generated.