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**3** 

*Japan* 

*1Waseda University* 

*2Yokohama City University* 

**Recent Advances Concerning the Molecular** 

The ductus arteriosus (DA), a fetal arterial shunt between the main pulmonary artery and the descending aorta, is a normal and essential fetal structure. Normally, the DA begins to close immediately after birth, but in some cases it remains patent after birth. Postnatal patent DA (PDA) is a major cause of morbidity and mortality in premature infants, leading to severe complications including pulmonary hypertension, right ventricular dysfunction, postnatal infections, and respiratory failure (Hermes-DeSantis & Clyman, 2006). The incidence of PDA among full-term newborns has been estimated at one in 500, and in preterm newborns it accounts for the majority of all congenital heart disease cases (Mitchell, 1971). The incidence of PDA exceeds 30% in preterm babies with birth weights <1,500 g (Van Overmeire, 2004). Curiously, patent DA can be essential for patients with complex congenital heart diseases in which the systemic or pulmonary circulation is dependent on the passage of blood through the DA. Therefore, a thorough understanding of the precise molecular mechanism underlying DA

Closure of the human DA occurs in two phases: functional closure of the lumen within the first hours after birth by smooth muscle constriction, and anatomic occlusion of the lumen over the next several days due to extensive neointimal thickening and vascular remodelling. Although this overall process is similar among all mammals, the time course of the two

DA constriction after birth is induced by an increase in arterial oxygen tension, a dramatic decline in circulating prostaglandinE2 (PGE2), and a decrease in blood pressure within the DA lumen (Smith 1998; Clyman 2006). Anatomical closure of the DA is associated with a unique system of differentiation of the vessel wall. The most prominent phenotypic change is intimal thickening, a process characterized by (a) an area of subendothelial deposition of extracellular matrix, (b) the disassembly of the internal elastic lamina and loss of elastic fiber in the medial layer, and (c) the migration of undifferentiated medial smooth muscle cells (SMCs) into the subendothelial space. The DA later undergoes permanent closure through structural remodelling and fibrosis. The resulting fibrous band with no lumen persists in the adult as the ligamentum arteriosum (Fay & Cooke 1972). The cascade of events is thought to orchestrate the activation of subsequent signalling pathways, leading finally to the complete obliteration of the DA. In this chapter, we focus on reviewing the current state of knowledge

regarding the mechanisms by which vascular remodelling of the DA is regulated.

closure is very important in pediatric cardiovascular medicine.

**1. Introduction** 

phases varies among species.

**Mechanism of Patent Ductus Arteriosus** 

Susumu Minamisawa1 and Utako Yokoyama2

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