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

  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]

  PDA can place strain on the heart and lead to congestive heart failure. [ucsfbenioffchildrens.org]

  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]

  A large PDA can cause pulmonary hypertension and congestive heart failure if left untreated. [lecturio.com]

• 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]

  We describe 2 cases illustrating the discovery of an asymptomatic PDA on routine physical examination of adult patients. [jabfm.org]

  Ductal closure is indicated in both symptomatic and asymptomatic patients to reduce the risks of endocarditis and pulmonary hypertension. [thoracickey.com]

  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]

• Poor Feeding

  If the PDA is large the pressure in the lungs may be elevated and such larger defects lead to breathlessness, poor feeding and slow weight gain. Most PDAs require closure to avoid complications. [rch.org.au]

  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]

  Symptoms and Tests Babies with a large PDA might have symptoms such as: a bounding (strong and forceful) pulse fast breathing poor feeding habits shortness of breath sweating while feeding tiring very easily poor growth If a PDA is suspected, the doctor [brennerchildrens.org]

  Symptoms and Tests Babies with a large PDA might experience symptoms such as: a bounding (strong and forceful) pulse fast breathing poor feeding habits shortness of breath sweating while feeding tiring very easily poor growth If a PDA is suspected, the [rchsd.org]

  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]

• 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]

  Symptoms may go undetected into adulthood, but others may feel fatigued fast breathing, and low weight gain. Seek medical help if your child is experiencing symptoms. [bonsecours.com]

  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]

• 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]

  The frequency of atrial septal defect/patent foramen ovale was disproportionally higher than those in previous studies4,13, probably because it included many cases of patent foramen ovale in young patients4,14. [nature.com]

  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]

  A ductus arteriosus with a moderate-to-large left-to-right shunt may be associated with a hoarse cry, cough, lower respiratory tract infections, atelectasis, or pneumonia. [emedicine.medscape.com]

• 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]

  Eg: tachypnea, tachycardia, growth retardation. Features of heart failure These symptoms are present in patients with large left to right shunt. Eg: tachypnea, tachycardia, growth retardation. [medicaljoyworks.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]

  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. [msdmanuals.com]

• Exertional Dyspnea

  References:[1] Overview of acyanotic congenital heart defects General clinical features Nonspecific symptoms Normal skin tone Exercise intolerance Exertional dyspnea, tachypnea Recurrent bronchopulmonary infections Failure to thrive Heart failure in larger [amboss.com]

  dyspnea Moderate (5 mm) NR NR, NA No No Recent guidelines from the American Heart Association of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease do not recommend routine subacute bacterial endocarditis prophylaxis for unrepaired [ncbi.nlm.nih.gov]

• Failure to Thrive

  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]

  […] to thrive Diagnosis and Treatment If a PDA is suspected, an echocardiogram of the heart will typically be performed. [preemies.about.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. [msdmanuals.com]

• Heart Failure

  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]

  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]

  PDA can place strain on the heart and lead to congestive heart failure. [ucsfbenioffchildrens.org]

• 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. [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]

• Heart Disease

  They occur rather rarely in the absence of cyanotic congenital heart disease. [ncbi.nlm.nih.gov]

  Congenital heart disease in infancy and childhood. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. Philadelphia: Saunders,2001 : 1505-1591 [Google Scholar] 9. [ajronline.org]

  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]

• Cyanosis

  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]

  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]

  Continuous murmur. S2 is obliterated by the waxing and waning of the murmur. (Reproduced, with permission, from T. Anthony Don Michael, MD. Mastering Auscultation [CD-ROM], 2000.) Play Video B. [accessmedicine.mhmedical.com]

  This produces a continuous murmur. The second heart sound (S2) is often inaudible, because of the murmur. In patients with a large left-to-right shunt, a low-pitched mitral mid-diastolic murmur may be audible at the apex. [medicaljoyworks.com]

  A continuous murmur at the upper left sternal border is common. Diagnosis is by echocardiography. [msdmanuals.com]

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].

• Prominent Aortic Knob

  With greater degrees of shunting, the chest x-ray may reveal a prominent main pulmonary artery, a prominent aortic knob, increased pulmonary vascular markings, and enlargement of the cardiac silhouette. [youtube.com]

• Right Axis Deviation

  It is agreed by most authors writing on the subject that the electrocardiographic findings in patent ductus are usually normal, although prolonged P-R intervals, left axis, and occasionally right axis deviation are also seen (5, 8, 11). [pubs.rsna.org]

• 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

  With a larger degree of shunting, there may be biventricular hypertrophy. [youtube.com]

  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]

  The electrocardiography showed sinus tachycardia and biventricular hypertrophy. The chest X-ray showed a normal cardiac silhouette and pulmonary circulation, and widening of the superior mediastinum (fig. 1). [scielo.br]

  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]

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 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.

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.

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.

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.

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:

• Regular prenatal care with your doctor
• Exercise regularly
• Balanced diet
• Avoid infections
• Avoid smoking, alcohol, X-ray and illegal drugs
• Diabetic mothers should have their glucose controlled

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].

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.

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.