Ligation of a patent arterial duct in a 7 year old girl with intractable heart failure in 19381 was the first successful “cardiac” operation and may therefore be considered the forerunner of the remarkable developments in surgery for both congenital and acquired heart disease which have occurred since then. It was soon established that ligation of a large arterial duct could not only resolve heart failure by relief of left ventricular volume overload, but also prevent the development of pulmonary vascular obstructive disease and avoid the risk of endarteritis which had been demonstrated in relation to the ductal flow disturbance. Surgical ligation was shown to be both safe and effective. In 936 duct closure operations performed in Great Ormond Street Hospital for Children between 1946 and 1969, only four deaths occurred in patients with no other major congenital abnormality (0.5%), and residual duct patency was found in only four cases (0.4%).2 By the early 1980s, about 40% of patients undergoing surgical closure of a patent arterial duct were symptomatic infants—even when infants born prematurely were excluded—and hospital mortality was approaching zero.3

The success of this surgical approach led to the recommendation that the presence alone of a patent arterial duct was sufficient indication for surgical ligation. However, the issue has become more complicated in recent years. The sensitivity of diagnosis has been vastly increased because of the development of colour flow Doppler techniques. Simultaneously, techniques for percutaneous transcatheter duct occlusion have evolved. These developments have been accompanied by changes in the natural history of the condition.