The Ductus Dilemma: To Close or Not to Close in the Fight Against Endocarditis/Endarteritis

Abstract

Highlights: What are the main findings? Infective endocarditis is rare in patients with an audible and non-audible persistent arterial duct. The benefits of ductal closure do not outweigh the drawbacks in cases involving hemodynamically insignificant ducts. What is the implication of the main finding? Hemodynamically insignificant ducts should not be closed. Background: Patent ductus arteriosus (PDA) is a common congenital heart defect. While closure of hemodynamically significant PDAs is well established, closure of small, hemodynamically insignificant PDAs for prevention of infective endocarditis or endarteritis (IEE) remains controversial and is supported only by low-level evidence. Methods: A systematic PubMed search was performed in May 2025 to identify published case reports of PDA-associated IEE. Data on PDA characteristics, audibility, vegetation location, and causative pathogens were extracted. In addition, the annual national number of percutaneous PDA closures in The Netherlands was determined using data from the Dutch Society of Pediatrics. Finally, the literature was searched for the incidence of complications of percutaneous ductal closure. Results: Seventy-two PDA-IEE cases were identified, of which fifty-five reported PDA audibility. Most cases involved audible PDAs with high-velocity turbulent flow and vegetations at sites exposed to shear stress, particularly the main pulmonary artery. Silent PDAs demonstrated similar vegetation locations and flow characteristics, suggesting that they had comparable pathophysiology. National data showed an average of 76.6 percutaneous PDA closures annually, of which 61% were hemodynamically insignificant. Adverse events during percutaneous ductal closure occur in 23.3% of procedures and clinically significant complications are reported in 10.1%. Both audible and silent PDAs appear capable of promoting IEE through similar hemodynamic mechanisms. Conclusions: Given the low incidence of PDA IEE relative to procedural risks, the high number needed to treat and the associated costs, routine closure of non-hemodynamically significant PDAs solely for IEE prevention is not clearly justified, and no distinction should be made between audible and silent PDAs. The current guidelines warrant critical reassessment.