Patent Ductus Arteriosus - Clinicals, Diagnosis, and Management

Cardiology

Clinicals - History

Fact Explanation
None A small PDA is usually asymptomatic. None
A small PDA is usually asymptomatic.
Heart failure A large PDA will result in heart failure similar to that encountered in infants with a large VSD. The children will have decreased exercise tolerance, tachypnea, scalp sweating especially during feeds, poor sucking and failure to thrive. Heart failure
A large PDA will result in heart failure similar to that encountered in infants with a large VSD. The children will have decreased exercise tolerance, tachypnea, scalp sweating especially during feeds, poor sucking and failure to thrive.
pulmonary hypertension Recurrent lower respiratory tract infections. pulmonary hypertension
Recurrent lower respiratory tract infections.
Retardation of physical growth This may be a major manifestation in infants with large shunts. Retardation of physical growth
This may be a major manifestation in infants with large shunts.
Eisenmenger's syndrome This occurs later in life, due to shunting of deoxygenated blood from the pulmonary circulation to the systemic circulation. These patients have cyanosis and clubbing. Eisenmenger's syndrome
This occurs later in life, due to shunting of deoxygenated blood from the pulmonary circulation to the systemic circulation. These patients have cyanosis and clubbing.

Clinicals - Examination

Fact Explanation
Features of heart failure These symptoms are present in patients with large left to right shunt. 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.
Collapsing pulse due to runoff of blood into the pulmonary artery during diastole, there is an increased pressure difference between the systole and the diastole. This increased pulse pressure results in a collapsing pulse. Collapsing pulse
due to runoff of blood into the pulmonary artery during diastole, there is an increased pressure difference between the systole and the diastole. This increased pulse pressure results in a collapsing pulse.
Prominent and laterally displaced apical impulse Due to the left ventricular hypertrophy and dilatation which occurs with large left to right shunts. Prominent and laterally displaced apical impulse
Due to the left ventricular hypertrophy and dilatation which occurs with large left to right shunts.
Heaving apex With cardiac enlargement and hypertrophy an apical heave becomes palpable. Heaving apex
With cardiac enlargement and hypertrophy an apical heave becomes palpable.
A thrill, maximum in the 2nd left inter space. The thrill may radiate toward the left clavicle, down the left sternal border, or toward the apex.
The thrill is also felt with the cardiac enlargement. It is usually systolic but may also be palpated throughout the cardiac cycle.
A thrill, maximum in the 2nd left inter space.
The thrill may radiate toward the left clavicle, down the left sternal border, or toward the apex.
The thrill is also felt with the cardiac enlargement. It is usually systolic but may also be palpated throughout the cardiac cycle.
Classic continuous machinery murmur best heard in the left second inter costal space. Since the pressure in the aorta is greater than the pressure in the pulmonary artery there is a continuous shunt of blood from the aorta to the pulmonary artery through out the cardiac cycle. 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.
This is due to the increased return to the left heart via the pulmonary veins due to the shunt and as a result large volume of blood flows through the mitral valve resulting a mitral flow murmur.
Classic continuous machinery murmur best heard in the left second inter costal space.
Since the pressure in the aorta is greater than the pressure in the pulmonary artery there is a continuous shunt of blood from the aorta to the pulmonary artery through out the cardiac cycle. 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.
This is due to the increased return to the left heart via the pulmonary veins due to the shunt and as a result large volume of blood flows through the mitral valve resulting a mitral flow murmur.
Paradoxical splitting of the second heart sound. (S2) This a result of early closure of the pulmonary valve, and a prolonged period of ejection across the aortic valve. Paradoxical splitting of the second heart sound. (S2)
This a result of early closure of the pulmonary valve, and a prolonged period of ejection across the aortic valve.

Investigations - Diagnosis

Fact Explanation
Chest X Ray usually normal but if the PDA is large and symptomatic the features on chest X-ray are indistinguishable from those seen in a patient with a large VSD.
Normal sized or an enlarged heart with increased pulmonary vasculature and prominant pulmonary arteries will be seen in CXR.
However the cardiac size depends on the degree of left-to-right shunting.
Chest X Ray
usually normal but if the PDA is large and symptomatic the features on chest X-ray are indistinguishable from those seen in a patient with a large VSD.
Normal sized or an enlarged heart with increased pulmonary vasculature and prominant pulmonary arteries will be seen in CXR.
However the cardiac size depends on the degree of left-to-right shunting.
Electrocardiogram. (ECG) Usually normal and as above if the PDA is large and symptomatic the features on ECG are similar to those seen in a patient with a large VSD.
Left ventricular hypertrophy with large left to right shunt.
Right ventricular hypertrophy with the development of pulmonary hypertension.
Often bi ventricular hypertrophy can be observed in the ECG.
Electrocardiogram. (ECG)
Usually normal and as above if the PDA is large and symptomatic the features on ECG are similar to those seen in a patient with a large VSD.
Left ventricular hypertrophy with large left to right shunt.
Right ventricular hypertrophy with the development of pulmonary hypertension.
Often bi ventricular hypertrophy can be observed in the ECG.
2D Echocardiography assisted by Doppler ultrasound This will readily identify the PDA. 2D Echocardiography assisted by Doppler ultrasound
This will readily identify the PDA.
Cardiac catheterization This is not routinely done. Although clinical examination and 2D Echocardiography is adequate for the diagnosis of PDA to be made, for patients with atypical findings Cardiac catheterization helps to establish an accurate diagnosis. Cardiac catheterization
This is not routinely done. Although clinical examination and 2D Echocardiography is adequate for the diagnosis of PDA to be made, for patients with atypical findings Cardiac catheterization helps to establish an accurate diagnosis.

Investigations - Management

Fact Explanation
2D Echocardiogram A post operative repeat 2D Echocardiogram is usually enough to establish the closure of the PDA. Regular followup is not necessary provided there are no other anomalies or co-morbidities. 2D Echocardiogram
A post operative repeat 2D Echocardiogram is usually enough to establish the closure of the PDA. Regular followup is not necessary provided there are no other anomalies or co-morbidities.
Full blood count Hemoglobin levels should be checked and optimized prior to the surgery. This is important because these children tend to have malnutrition due to heart failure and poor feeding. Full blood count
Hemoglobin levels should be checked and optimized prior to the surgery. This is important because these children tend to have malnutrition due to heart failure and poor feeding.
Renal function test Blood urea, serum creatinine, serum electrolytes should be checked prior to the corrective surgery. Renal function test
Blood urea, serum creatinine, serum electrolytes should be checked prior to the corrective surgery.
Chest X Ray (CXR) A CXR should be done to rule out respiratory tract infection, and this will help to detect or to exclude heart failure. Chest X Ray (CXR)
A CXR should be done to rule out respiratory tract infection, and this will help to detect or to exclude heart failure.

Management - Supportive

Fact Explanation
Treatment of Heart failure Once the diagnosis of moderate PDA is made pharmacological treatment should be commenced for heart failure. Treatment of Heart failure
Once the diagnosis of moderate PDA is made pharmacological treatment should be commenced for heart failure.
Treat any respiratory tract infection. Structural heart defects predispose to recurrent respiratory tract infections in children, due to pulmonary congestion. Treat any respiratory tract infection.
Structural heart defects predispose to recurrent respiratory tract infections in children, due to pulmonary congestion.
Screen for other congenital anomalies VACTREL (Vertebral anomalies, Anal atresia, Cardiac defects, Tracheoesophageal fistula and/or Esophageal atresia, Renal anomalies and Limb defects.) anomalies should be looked for. Screen for other congenital anomalies
VACTREL (Vertebral anomalies, Anal atresia, Cardiac defects, Tracheoesophageal fistula and/or Esophageal atresia, Renal anomalies and Limb defects.) anomalies should be looked for.

Management - Specific

Fact Explanation
Closure of the PDA with a coil or an occlusion device In infants with an asymptomatic PDA, closure is recommended to abolish the lifelong risk of bacterial endocarditis. These patients has the least operative mortality when the PDA is considered.
In patients with a small PDA, the rationale for closure is prevention of bacterial endarteritis or other late complications.
In patients with a moderate to large PDA, closure is accomplished to treat heart failure or to prevent the development of pulmonary vascular disease, or both.
Small PDAs are generally closed with intravascular coils. Moderate to large PDAs may be closed with an umbrella-like device or with a catheter-introduced sac which release several coils.
Closure of the PDA with a coil or an occlusion device
In infants with an asymptomatic PDA, closure is recommended to abolish the lifelong risk of bacterial endocarditis. These patients has the least operative mortality when the PDA is considered.
In patients with a small PDA, the rationale for closure is prevention of bacterial endarteritis or other late complications.
In patients with a moderate to large PDA, closure is accomplished to treat heart failure or to prevent the development of pulmonary vascular disease, or both.
Small PDAs are generally closed with intravascular coils. Moderate to large PDAs may be closed with an umbrella-like device or with a catheter-introduced sac which release several coils.
Pharmacological management with intravenous (IV) indomethacin or ibuprofen. This can be done for premature neonates.
These inhibit the enzyme cyclooxygenase (COX) there by the synthesis of prostaglandin, which maintains the patency of the duct. Once the prostaglandin synthesis is inhibited the duct closes.
Pharmacological management with intravenous (IV) indomethacin or ibuprofen.
This can be done for premature neonates.
These inhibit the enzyme cyclooxygenase (COX) there by the synthesis of prostaglandin, which maintains the patency of the duct. Once the prostaglandin synthesis is inhibited the duct closes.

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  1. KLIEGMAN Robert M. , STANTON Bonita F. , ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of pediatrics. . 19th Edition, Elsevier, 2011 Chapter 420.8
  2. KLIEGMAN Robert M. , STANTON Bonita F. , ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of pediatrics. . 19th Edition, Elsevier, 2011 Chapter 420.8
  3. 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.