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Asian Cardiovasc Thorac Ann 1999;7:301-304
© 1999 Asia Publishing EXchange Pte Ltd

ORIGINAL CONTRIBUTION

Patent Ductus Arteriosus in a Population-Based Study

Victor Grech, PhD, MRCP

Paediatric Department St. Luke's Hospital Guardamangia, Malta
For reprint information contact: Victor Grech, PhD, MRCP Tel: 356 24 1251 Ext. 1471 Fax: 356 24 0176 email: victor.e.grech{at}magnet.mt Paediatric Department, St. Luke's Hospital, Guardamangia, Malta.

   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
This study was carried out to establish diagnostic and interventional trends in patent ductus arteriosus in a population-based study of births between 1935 and 1994 and to calculate the birth prevalence of this condition. This was done in the setting of a regional hospital catering for diagnosis and follow-up of all cases of congenital heart disease in Malta, under the supervision of visiting consultant pediatric cardiologists from the United Kingdom. Patent ductus arteriosus was diagnosed in 51 cases. Both age at diagnosis and age at surgery declined significantly in the period under study (p < 0.0001). Prior to the mid-1980s, preoperative diagnosis was made clinically with or without catheter confirmation. Subsequently, preoperative diagnosis was made almost exclusively by echocardiography. No mortality was associated with any of the interventions. Birth prevalence for the period 1980 to 1994 was 0.2 per 1000 live births. Rates for this lesion in historical studies vary widely from 0.09 to 2.11 per 1000 live births and this variation was attributed to methodological differences between studies. It was concluded that patent ductus arteriosus in Malta has been diagnosed and treated safely at progressively younger ages and this was attributed to improving medical services over the period studied.


   Introduction
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 Abstract
 Introduction
Methods
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 Discussion
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Congenital heart disease (CHD) constitutes the most common group of congenital malformations. These lesions are very heterogeneous with varying modes and timing of presentation and varying requirements for intervention. This paper studies the epidemiology of persistent patency of the arterial duct in Malta in a population-based study and identifies trends in diagnosis, surgery, and peri-operative mortality of this condition for individuals born between 1935 and 1994.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
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Persistent patency of the arterial duct occurring in association with prematurity, which resolved spontane-ously or required treatment before 3 months of age, was excluded. Diagnosis of patent ductus arteriosus (PDA) was only accepted for inclusion if made by cardiac catheterization, surgery, postmortem, or echocardiography that has been widely available in Malta since 1988.1

The catchment area for this study was the whole of Malta. St. Luke's Hospital is the only regional hospital in Malta and it is responsible for the investigation and follow-up of all patients suspected of having CHD. Data sources for the Maltese Paediatric Cardiology database have already been described.1 In Malta, a high degree of ascertainment for all types of CHD is available for 1990 to 1994, including minor lesions not requiring intervention.2 For lesions requiring intervention, a high degree of ascer-tainment was found from 1980. The period 1980 to 1994 was therefore used for rate calculations of this condition. Due to the historical nature of this study, no upper age limit at diagnosis was used. Official Maltese publications provided total live births from 1980 to 1994, allowing birth prevalences to be calculated.3 Only patients with a diagnosis of isolated PDA or patients with PDA occurring in association with defects that resulted in less hemodynamic disturbance than PDA, were included in this study.

Statistics
Excel (Microsoft Corp., Redmond, WA, USA) and SPSS (SPSS, Inc., Chicago, IL, US) were the graphing and statistical packages used throughout. The quadratic equations of Fleiss were used to derive 95% confidence intervals (CI) for birth prevalence. Pearson correlation was used to analyze trends in diagnosis and surgery. A p value of <= 0.05 was taken to represent a statistically significant result.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
There were 51 patients diagnosed with PDA born between 1935 and 1994 to Maltese residents. Age at diagnosis was unknown in one case. Both age at diagnosis and age at surgery for PDA declined significantly over the period under study (p < 0.0001; Figures 1 and 2GoGo, respectively). Prior to the mid-1980s, preoperative diagnosis of PDA was made clinically with or without catheter confirmation. After this period, preoperative diagnosis was made almost exclusively by echocardiography (Figure 3Go). No patients were diagnosed at postmortem. Type of intervention was exclusively surgical ligation prior to 1990. Between 1990 and 1994, 4 out of 7 PDA corrections were by inter-ventional catheter closure. No mortality was associated with any of the procedures.



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  		Figure 1. Age at diagnosis of patent ductus arteriosus. Calculation based on linear age at diagnosis. Arrow denotes 1988 when echocardiography became widely available in Malta.

 


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  		Figure 2. Age at intervention for patent ductus arteriosus in Malta.

 


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  		Figure 3. Mode of diagnosis of patent ductus arteriosus in Malta.

 
There were 16 cases of PDA between 1980 and 1994, resulting in a birth prevalence of 0.20 per 1000 live births (95% CI, 0.12–0.33) that tallies well with the previously quoted rate of 0.19 per 1000 live births in Malta for the period 1990 to 1994 for patients diagnosed by the age of one year only.2 Rates for PDA in historical studies varied widely from 0.09 to 2.11 per 1000 live births (Table 1Go).4–19 The maximum to minimum ratio was 23.4. The median prevalence was 0.43 per 1000 live births and the mean was 0.52 per 1000 live births (95% CI, 0.25).


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  		Table 1. Review of Birth Prevalence of Patent Ductus Arteriosus
 

   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Prior to the 1980s, local physicians and pediatricians (when sufficient numbers of the latter became available) identified patients likely to have CHD and presented them to visiting consultant cardiologists, and later to the visiting consultant pediatric cardiologists. These consultants (all London hospital based) then undertook decisions as to whether patients needed catheterization and surgery. Since the advent of echocardiography locally, these consultants now review patients with firm diagnoses and continue to undertake the same decisions. Hence, it is reasonable to assume that the trends found locally can be extrapolated to larger countries.

PDA was diagnosed at progressively earlier ages in the period under study. This trend may be attributed to progress in social and medical circumstances in Malta over this period. Such factors include the local availability of increasing numbers of doctors with better training and increasing numbers of pediatricians with awareness of CHD and the evolving possibilities of treatment.20 This led to a higher ascertainment of CHD and the application of new diagnostic and interventional techniques to Maltese patients soon after such techniques were described.21 Diagnostic and follow-up services underwent a quantum leap with the availability of local pediatric echocardio-graphy services since 1988, which led to a further decline in age at diagnosis over the period 1988 to 1994.

The declining trend in age at diagnosis of PDA was paralleled by a decline in the age at surgery that was found for the entire group of operated Maltese patients with CHD.21 PDA closure was the first operation to be carried out on a Maltese patient with CHD and this was performed in 1947 by a local team of doctors, just 8 years after this procedure was first described.21 Similarly, the first interventional cardiac catheter procedure on a Maltese patient with CHD was a duct closure that was performed locally by a visiting consultant cardiologist in 1991, 20 years after this procedure was first described.

Prior to elective surgery for CHD, Maltese patients were evaluated by visiting cardiologists who have always been based in tertiary referral centers in the United Kingdom. For this reason, the trends described in this study may be extrapolated to larger European countries. The wide range in birth prevalence rates reported for this defect is almost certainly due to methodological differences between studies. Earlier studies were hampered by lack of a noninvasive diagnostic technique, resulting in low ascertainment rates. Even more importantly, there is no agreed set of inclusion or exclusion criteria for PDA as part of CHD, with inclusion of PDA in premature babies in some studies, thereby artificially inflating the incidence of the condition. Strict inclusion criteria inevitably result in lower birth prevalence rates for this condition.

It was concluded that in Malta, PDA has been diagnosed and treated safely at progressively younger ages and this is attributed to improving medical services over the period under study.


   Acknowledgments
 
I thank my PhD supervisors, Dr. Chris Wren (Freeman Hospital, Newcastle) and Mr. Martin Elliott (Great Ormond Street Hospital, London); all of my colleagues in the Paediatric Department, especially Dr. H. Lenicker, Dr. M. Bailey, and Dr. V. Mercieca; the Department of Health Information; the Cardiac Laboratory, the Almoner's Office, and Medical Records, St. Luke's Hospital, Malta; the Registry of the Health Division, Valletta, Malta; and the Cardiothoracic Unit, Great Ormond Street Hospital for Sick Children, London, UK.


   References
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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  3. Central Office of Statistics. Demographic review for the Maltese Islands. Malta: Central Office of Statistics (annual publications).

  4. Carlgren L. The incidence of congenital heart disease in children born in Gothenburg 1941–1950. Br Heart J 1959;21:40–50.

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  7. Bound JP, Logan WF. Incidence of congenital heart disease in Blackpool 1957–1971. Br Heart J 1977;39:445–50.[Abstract/Free Full Text]

  8. Hoffman JI, Christianson MA. Congenital heart disease in a cohort of 19,502 births with long-term follow-up. Am J Cardiol 1978;42:641–7.[Medline]

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  11. Dickinson DF, Arnold R, Wilkinson JL. Congenital heart disease among 160480 live-born children in Liverpool 1960–1969. Br Heart J 1981;46:55–62.[Abstract/Free Full Text]

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  14. Samanek M, Slavik Z, Zborilova B, Hrobonova V, Voriskova M, Skovranek J. Prevalence, treatment and outcome of heart disease in live-born children: a prospective analysis of 91,823 live-born children. Pediatr Cardiol 1989;10:205–11.[Medline]

  15. Mayberry JC, Scott WA, Goldberg SJ. Increased birth prevalence of cardiac defects in Yuma, Arizona. J Am Coll Cardiol 1990;16:1696–700.[Abstract]

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  19. Jackson M, Walsh KP, Peart I, Arnold R. Epidemiology of congenital heart disease in Merseyside — 1978–1988. Cardiol Young 1996;6:272–80.

  20. Grech V, Savona-Ventura C. Declining mortality from congenital heart disease related to innovations in diagnosis and treatment — a population based study. Cardiol Young 1999;9:78–80.[Medline]

  21. Grech V, Elliott MJE. The evolution of surgical trends in congenital heart disease: a population based study. Int J Cardiol 1998;66:285–92.[Medline]





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