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Patent Ductus Arteriosus

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Patent ductus arteriosus (PDA) is a heart condition caused by the persistence of the ductus arteriosus.

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Presentation

Patent ductus arteriosus with small caliber may present with minimal signs or no signs at all. However, large caliber PDA may present with the following system wise symptomatology:

  • General appearance: Patients will appear fatigued due to tissue hypoxia. Infants will have difficulty in eating because of breathlessness during swallowing.
  • Integumentary system: Patients will appear cyanotic due to poor oxygen perfusion of the skin.
  • Head and Neck: Dark discoloration around the eyes due to chronic cyanosis.
  • Chest and heart: Machinery like murmur on auscultation due to volume overload through the PDA. Infants will exhibit tachypnea due pulmonary congestion.
  • Abdomen: Ascites may occur with late stage heart failure.
  • Extremities: Fingernail clubbing may be due to nail bed chronic hypoxic state. 
Congestive Heart Failure
  • PDA can place strain on the heart and lead to congestive heart failure.[ucsfbenioffchildrens.org]
  • The patient was diagnosed with congestive heart failure (ejection fraction, 36 %) and PDA (9.7 mm in diameter). TEVAR was successfully performed to exclude the PDA. After TEVAR, the patient's heart failure was well controlled by diuretics.[ncbi.nlm.nih.gov]
  • If the ductus is large in size, symptoms of congestive heart failure may develop. Congestive heart failure can develop at any time but more commonly presents during the first 2 to 3 months of life.[mottchildren.org]
  • This condition, as a constellation of findings , is called congestive heart failure .[en.wikipedia.org]
Asymptomatic
  • We report an adult patient with asymptomatic patent ductus arteriosus and endarteritis involving the main pulmonary artery and secondary infective spondylodiscitis at the L5-S1 intervertebral disc caused by Abiotrophia defectivaA. defectiva, commonly[ncbi.nlm.nih.gov]
  • The clinical presentation is variable, and many patients can be asymptomatic for many years and even throughout their lives. We report the case of a 44-year-old female patient with a history of hemoptysis.[ncbi.nlm.nih.gov]
  • Children with a small PDA are often asymptomatic, but may develop Infective Endocarditis. Surgery may be needed when the ductus is large, but in many cases the ductus can be closed using a spring coil introduced with a heart catheter.[rch.org.au]
  • Patients may be entirely asymptomatic or have signs and symptoms of heart failure and haemodynamic instability. Treatment options vary depending on the age of the patient and the size of the ductus.[bestpractice.bmj.com]
Poor Feeding
  • Symptoms may include failure to thrive, poor feeding, tachycardia, and tachypnea. A continuous murmur at the upper left sternal border is common. Diagnosis is by echocardiography.[merckmanuals.com]
  • feeding Weight loss Failure to thrive Diagnosis and Treatment If a PDA is suspected, an echocardiogram of the heart will typically be performed.[preemies.about.com]
  • Moderate ducts (PDA) Your child may have symptoms of heart failure, such as breathlessness, poor feeding or impaired growth. They may also be more susceptible to chest infections.[jpaget.nhs.uk]
  • The persistence of the vessel is clinically referred to as patent ductus arteriosus that transmits poorly oxygenated blood to the body manifested as failure to thrive, poor feeding, tachycardia, and tachypnea in infants.[symptoma.com]
Fatigue
  • An adult with a large patent ductus arteriosus may present with fatigue, dyspnea or palpitations or in rare presentation with endocarditis.[ncbi.nlm.nih.gov]
  • This keeps blood pressure low and results in many disorders from oxygen starvation, such as fatigue and fainting. The disorder is usually detected in childhood, but in rare cases is not detected until the patient reaches adulthood.[house.wikia.com]
  • In patients who do show signs or experience symptoms, these can include: Cyanosis (a blueish hue to the skin) Fatigue Full, bounding pulses Heart palpitations Shortness of breath Diagnosis UT Southwestern heart doctors might perform several tests to determine[utswmed.org]
  • However, large caliber PDA may present with the following system wise symptomatology: General appearance: Patients will appear fatigued due to tissue hypoxia. Infants will have difficulty in eating because of breathlessness during swallowing.[symptoma.com]
  • Other symptoms in infants include sweating with exertion, poor feeding due to fatigue, and poor weight gain. PDA’s may also predispose to an increased risk of lung infections such as pneumonia.[pediatricheartspecialists.com]
Atrial Septal Defect
  • It may be associated with various intracardiac defects, including atrial septal defects, ventricular septal defects, patent ductus arteriosus or more complicated structural congenital heart defects.[ncbi.nlm.nih.gov]
  • Do you have a child between 30 days and 17 years old who will have elective surgery to close an atrial septal defect? This study tests a tool that allows surgeons to tell the difference between various types of heart tissue and avoid injury.[nhlbi.nih.gov]
  • septal defect ( Q21.1 ) Eisenmenger's defect ( Q21.8 ) patent ductus arteriosus ( Q25.0 ) ventricular septal defect ( Q21.0 ) Aneurysm (anastomotic) (artery) (cirsoid) (diffuse) (false) (fusiform) (multiple) (saccular) I72.9 ICD-10-CM Diagnosis Code[icd10data.com]
Hoarseness
  • Babies with a patent ductus arteriosus will often have a hoarse cry, a cough, pneumonia, heart failure with difficulty breathing, and poor weight gain. They may perspire when they are feeding and have a rapid heart and respiratory rate.[health.state.mn.us]
  • Possible risks of the surgery include hoarseness, bleeding, infection and a paralyzed diaphragm. Catheter procedures. Premature babies are too small for catheter procedures.[mayoclinic.org]
  • If they do happen, they do not last long and may include hoarseness, infection, bleeding, or fluid around the lungs. The baby may need a machine to help with breathing for a short period of time, but this is rare.[nationwidechildrens.org]
Tachypnea
  • Infants will exhibit tachypnea due pulmonary congestion. Abdomen: Ascites may occur with late stage heart failure. Extremities: Fingernail clubbing may be due to nail bed chronic hypoxic state.[symptoma.com]
  • Symptoms may include failure to thrive, poor feeding, tachycardia, and tachypnea. A continuous murmur at the upper left sternal border is common. Diagnosis is by echocardiography.[merckmanuals.com]
  • Three-week to 6-week-old infants can present with tachypnea, diaphoresis, inability or difficulty with feeding, and weight loss or no weight gain.[emedicine.medscape.com]
  • Murmur: systolic at LUSB/Left Infraclavicular, may progress to continuous (machinery) Cardiac: Active Precordium, Widened Pulse Pressure, Bounding Pulses Respiratory Sx: Tachypnea, Apnea 7.[slideshare.net]
Heart Failure
  • Heart failure. A patent ductus arteriosus can eventually cause the heart to enlarge and weaken, leading to heart failure, a chronic condition in which the heart can't pump effectively. Heart infection (endocarditis).[mayoclinic.com]
  • The patient was diagnosed with congestive heart failure (ejection fraction, 36 %) and PDA (9.7 mm in diameter). TEVAR was successfully performed to exclude the PDA. After TEVAR, the patient's heart failure was well controlled by diuretics.[ncbi.nlm.nih.gov]
  • In addition, heart failure, severe pulmonary hypertension, and calcification of the ductus may also exist.[ncbi.nlm.nih.gov]
  • PDA as a cause of heart failure in this patient population is very rare and diagnosis depends on high clinical awareness.[ncbi.nlm.nih.gov]
  • The infantile form is generally presented with severe heart failure, pulmonary hypertension and respiratory distress.[ncbi.nlm.nih.gov]
Heart Murmur
  • A heart murmur may be the only sign that a baby has patent ductus arteriosus (PDA). A heart murmur is an extra or unusual sound heard during the heartbeat. Heart murmurs also have other causes besides PDA, and most murmurs are harmless.[pediatricct.surgery.ucsf.edu]
  • However, if there is enough blood flow to cause a heart murmur (an abnormal noise), the PDA should be closed. A heart murmur can be heard with a stethoscope when the baby has a PDA.[my.clevelandclinic.org]
  • Most children with PDA have a distinctive heart murmur, which can be easily detected by a doctor. Tests may be performed to make a definite diagnosis and rule out other conditions that cause heart murmurs.[ucsfbenioffchildrens.org]
Heart Disease
  • They occur rather rarely in the absence of cyanotic congenital heart disease.[ncbi.nlm.nih.gov]
  • This is the case of a young female who was seen at our adult congenital heart disease and pulmonary hypertension service (Royal Brompton Hospital, London, UK) at the age of 17 years.[ncbi.nlm.nih.gov]
  • Our Adult Congenital Heart Disease Program provides complete diagnostic, treatment, and consultative services for patients age 16 and older with all types of congenital heart disease, including those who are newly diagnosed as adults.[utswmed.org]
  • KEYWORDS: Congenital heart disease; Minimally invasive surgery; Neonate; Patent ductus arteriosus; Premature infants; Surgical ligation; Video-assisted thoracoscopic surgery[ncbi.nlm.nih.gov]
Cyanosis
  • She had features of severe pulmonary hypertension and differential clubbing and cyanosis. A final diagnosis of LEOPARD syndrome with hypertrophic cardiomyopathy and patent ductus arteriosus (PDA) Eisenmenger syndrome was made.[ncbi.nlm.nih.gov]
  • We document a patient with differential cyanosis who improved after corrective surgery of both the lesions. The importance of post-capillary pulmonary artery hypertension in shunt lesions needs to be better appreciated.[ncbi.nlm.nih.gov]
  • At that time, there was differential cyanosis with clubbing and lower oxygen saturations in the toes (82%) compared with her fingers (95%).[ncbi.nlm.nih.gov]
  • On Initial history and examination patient also had primary amenorrhoea, differential cyanosis in lower limbs, differential clubbing, polydactyly, syndactyly, high arched foot, pectus carinatum and scoliosis.[ncbi.nlm.nih.gov]
  • Symptoms Failure to thrive, tachypnea, easy fatigability, tachycardia, and cyanosis may occur. Diagnosis Clinical examination, ECG, echocardiogram and chest X-ray are used to diagnose PDA.[symptoma.com]
Continuous Murmur
  • She presented not only polydipsia, polyphagia, and weight loss but also small elfin face, distended abdomen, enlarged clitoris, hypertrichosis, acanthosis nigricans of the neck, decreased subcutaneous fat and 3/6 continuous murmur radiating to the right[ncbi.nlm.nih.gov]
  • A continuous murmur at the upper left sternal border is common. Diagnosis is by echocardiography.[msdmanuals.com]
  • A patent ductus arteriosus causes a continuous murmur since there is a constant pressure gradient in both systole and diastole forcing blood from the aorta into the pulmonary artery.[healio.com]

Workup

The diagnosis of PDA in infants is initially done by clinical examination by the attending pediatrician. However, additional tests may be recommended to confirm the diagnosis of PDA. The following diagnostic modalities are used in the examination of PDA patients:

  • Electrocardiography (ECG): A left ventricular hypertrophy may be demonstrated by voltage in ECG.
  • Chest X-ray: This radiograph will show a prominent left atria, left ventricle and ascending aorta. There is an increased pulmonary markings in a significant shunt.
  • Echocardiography: A two dimensional imaging of the heart with colored Doppler studies can identify the patent ductus radiographically [3]. A suprasternal view of the aortic side of the PDA in echocardiogram can accurately reveal its diameter [4].
Incomplete Right Bundle Branch Block
  • His chest X-ray showed cardiomegaly and enlargement of the left pulmonary hilum, and an electrocardiogram revealed sinus tachycardia with incomplete right bundle branch block ( Figure 1 A).[elsevier.pt]
Biventricular Hypertrophy
  • A large PDA may be associated with signs of biventricular hypertrophy (BVH) and in those with pulmonary hypertension, right ventricular hypertrophy (RVH) may be present.[patient.info]
  • In the patient with a large ductus arteriosus and elevated pulmonary artery pressure, signs of right atrial enlargement and biventricular hypertrophy are frequently present.[circ.ahajournals.org]
Right Ventricular Hypertrophy
  • A large PDA may be associated with signs of biventricular hypertrophy (BVH) and in those with pulmonary hypertension, right ventricular hypertrophy (RVH) may be present.[patient.info]
  • Findings such as septal flattening, unexplained right ventricular hypertrophy, and high-velocity pulmonary regurgitation should prompt a thorough investigation for a PDA.[circ.ahajournals.org]

Treatment

In premature babies, the PDA may close spontaneously within the first two years of life. This may no longer need any treatment especially when the PDA is small with minimal symptoms. In full term babies, the non-closure after a few weeks from birth may suggest that it may never will. The first line treatment for the closure of PDA in newborns is the use of indomethacin and ibuprofen. Both cyclooxygenase inhibitors are equipotent in PDA closure capabilities [5].

However, excess indomethacin may cause renal toxicity; thus, dose reduction is imperative if warranted [6]. Ibuprofen may be given orally or intravenously with no significant advantage over the other [7]. These regimens are noted to have fewer side effects and may significantly help in the closure if given at an early stage.

An invasive procedure known as trans-catheter device closure may be implored by blocking the PDA with a small metal coil to block the blood flow, this device is introduced through a small cardiac catheter [8]. When conservative medical management fails, a surgical repair of the PDA by ligation may be indicated by doing a chest incision in through the baby’s ribs [9]. Cardiac surgery in infants post no greater risk and threats than those given ibuprofen and indomethacin [10].

Prognosis

Prognosis in patent ductus arteriosus is dependent on ductal size. Smaller sized PDA may convey cardiac symptoms but infants may thrive with some difficulty. Small PDA that occurs even prematurity that appears as a solitary lesion caries a good prognosis.

The patent ductus in premature infants may close spontaneously within the first 3 months of life in 72-75% of cases. The use of prophylactic ibuprofen may lead to a 92% closure rate. However, larger PDA may lead to heart failure, pulmonary hypertension and recurrent infection of the lungs.

Complications

Patients with small PDA may not lead to any complications but larger PDA may complicate into either of these clinical disorders if left untreated:

  • Pulmonary hypertension: The increased blood flow the patent ductus may cause permanent damage to the lungs.
  • Eisenmenger’s syndrome: An irreversible type of pulmonary hypertension that causes a reversal of blood flow.
  • Bacterial endocarditis: The PDA increases the risk of patients to any infection of the myocardial endothelium (inner lining).
  • Heart failure: This is a chronic outcome if the heart muscles over works due to volume overload 
  • Cardiac dysrhythmias: Arrhythmias usually develop with the enlargement of the heart.

Etiology

The congenital heart defect in patent ductus arteriosus is believed to have developed early in the embryology of the heart muscle. The exact mechanism is still unknown to medical science and is continually being researched up to this day. Research scientists believes in the major role of genetics and environmental factors in the development of PDA.

Infants that suffer congenital rubella syndrome whereby the mother had rubella in the first trimester of pregnancy are most prone to PDA. Maternal intake of amphetamine, alcohol and phenytoin may be a causative factor in its development. Premature infants has a very high likelihood of a persistent ductus.

Epidemiology

In the United States, the general incidence of patent ductus arteriosus is 6 to 20 per 100,000 live births. Premature infants less than 28 weeks old has a PDA incidence of 60% while those born more than 32 weeks gestation has an incidence rating of 20% for PDA.

Patent ductus arteriosus as an isolated case represents 5 to 10% of all congenital heart diseases. Females are more prone with a 2:1 ratio as compared with male infants. A great deal of children are usually left undiagnosed until they get older.

Sex distribution
Age distribution

Pathophysiology

The failure of the ductus closure among premature neonates are primarily due to poor prostaglandin metabolism from an immature lung. The failure in prostaglandin metabolism is usually brought about by perinatal asphyxia, hypoxemia, increased pulmonary blood flow, renal failure, and respiratory disorders. It was also postulated that cyclooxygenase-2 (COX-2) induction, an isoform of the COX producing prostaglandin can prevent the duct from closing.

Prevention

There is no definitive cause for PDA; thus, preventive measures in ensuring that PDA doesn’t occur in your baby are hard to determine. This precludes that one must do everything to have a healthy pregnancy to prevent PDA and other congenital diseases of the infant. The following tips are most helpful in having a healthy pregnancy:

Summary

Patent ductus ateriosus or PDA is a clinically characterized as the persistent fetal connection (ductus arteriosus) between the two major vessels from the heart, pulmonary artery and aorta after birth that usually results into the shunting of blood from left-to-right. The ductus arteriosus is a vestigial vessel that shunts the blood from the heart directly to the aorta, this vessel physiologically closes when the lung expands after birth which usually happens within 3 months from birth [1].

The persistence of the vessel is clinically referred to as patent ductus arteriosus that transmits poorly oxygenated blood to the body manifested as failure to thrive, poor feeding, tachycardia, and tachypnea in infants. The symptomatic persistence of the ductus arteriosus may need cardiac surgery or catheter-based correction to achieve normalcy [2].

Patient Information

Definition

Patent ductus arteriosus is a clinical disease characterized by the persistent fetal connection between the pulmonary artery and the aorta.

Cause

Genetics, rubella infection, amphetamine, phenytoin, and alcohol may cause the disorder.

Symptoms

Failure to thrive, tachypnea, easy fatigability, tachycardia, and cyanosis may occur. 

Diagnosis

Clinical examination, ECG, echocardiogram and chest X-ray are used to diagnose PDA.

Treatment and follow-up

Indomethacin and ibuprofen, trans-catheter closure device and surgical repair are the common treatment options.

References

Article

  1. Cassels DE, Bharati S, Lev M. The natural history of the ductus arteriosus in association with other congenital heart defects. Perspect Biol Med. Summer 1975; 18(4):541-72.
  2. Schneider DJ. The patent ductus arteriosus in term infants, children, and adults. Semin Perinatol. 2012; 36(2):146-53 (ISSN: 1558-075X)
  3. Amoozgar H, Soltani M, Cheriki S. Estimation of patent ductus arteriosus diameters by colour Doppler echocardiography in children. Cardiol Young. 2010; 20(6):648-53 (ISSN: 1467-1107)
  4. Zhang XY, Cao TS, Yuan LJ, Liu J, Duan YY. Value of the echocardiographic suprasternal view for diagnosis of patent ductus arteriosus subtypes. J Ultrasound Med. 2012; 31(9):1421-7 (ISSN: 1550-9613)
  5. Ohlsson A, Walia R, Shah S. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. Jan 23 2008; CD003481
  6. Attridge JT, Kaufman DA, Lim DS. B-type natriuretic peptide concentrations to guide treatment of patent ductus arteriosus. Arch Dis Child Fetal Neonatal Ed. May 2009; 94(3):F178-82.
  7. Olukman O, Calkavur S, Ercan G, Atlihan F, Oner T, Tavli V, Kultursay N. Comparison of oral and intravenous Ibuprofen for medical closure of patent ductus arteriosus: which one is better? Congenit Heart Dis. 2012; 7(6):534-43 (ISSN: 1747-0803)
  8. Karagöz T, Akin A, Ertuğrul I, Aykan HH, Alehan D, Ozer S, Ozkutlu S. Closure of the patent ductus arteriosus with the Amplatzer Duct Occluder II: a clinical experience. Acta Cardiol. 2012; 67(6):675-80 (ISSN: 0001-5385)
  9. Kang SL, Samsudin S, Kuruvilla M, Dhelaria A, Kent S, Kelsall WA. Outcome of patent ductus arteriosus ligation in premature infants in the East of England: a prospective cohort study. Cardiol Young. 2013; 23(5):711-6 (ISSN: 1467-1107)
  10. Malviya M, Ohlsson A, Shah S. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. Jan 23 2008; CD003951.

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Last updated: 2019-07-11 20:37