Case Report: Non-reactive vasoreactivity testing in a patient with patent ductus arteriosus with pulmonary hypertension: is there still a way to turn things around?

Background: Recent guidelines recommend patent ductus arteriosus (PDA) closure in adults based on hemodynamic criteria, such as pulmonary vascular resistance (PVR) and flow ratio (Qp:Qs). However, additional parameters like acute vasoreactivity testing (AVT) and closure testing, though lacking extensive data, may assist in identifying patients eligible for closure. We present the case of an adult patient with PDA and pulmonary hypertension (PH) whosuccessfully underwent transcatheter device closure guided by AVT and closure testing.

Case Presentation: A 35-year-old female presented with a two-year history of shortness of breath, cyanosis, and peripheral edema. She had been diagnosed with PDA at birth but did not undergo ligation due to parental refusal, leading to a 33-year loss of follow-up. Echocardiography revealed a bidirectional shunt through the PDA. Following cardiac catheterization (Qp:Qs 1.38, PVR: 21.5 WU) with AVT, the patient was diagnosed with PDA, PH with low flow, high resistance, and non-reactive to vasoreactivity test. She was prescribed sildenafil and discharged. After one year, the patient reported symptom improvement, with repeat catheterization showing a slight reduction in Qp:Qs (1.25) and PVR (16.38 WU), though values remained above the guideline cut-off for closure. However, the patient was then reactive to AVT, so we decided to perform device closure and observed the patient for 10 min before releasing the device. The patient was stable following the procedure and recovered well. One month later, the patient experienced significant symptom relief and could engage in moderate physical activity without discomfort.

Conclusion: This case highlights the potential AVT, closure testing, and also the treat-and-repair strategy with sildenafil to expand the window of operability in adult PDA patients with PH. Further research especially on long-term outcomes, is recommended.