Patent Ductus Arteriosus

Patent ductus arteriosus (PDA) is a persistent opening between the two major blood vessels leading from the heart. The opening (ductus arteriosus) is a normal part of a baby's circulatory system in the womb that usually closes shortly after birth. If it remains open, it's called a patent ductus arteriosus.
A small patent ductus arteriosus often doesn't cause problems and might never need treatment. However, a large patent ductus arteriosus left untreated can allow poorly oxygenated blood to flow in the wrong direction, weakening the heart muscle and causing heart failure and other complications.
Treatment options for a patent ductus arteriosus include monitoring, medications, and closure by cardiac catheterization or surgery.

1. Patent Ductus Arteriosus
MemoonaArshad
Group 11
ISM –IUK
Presented to: DjunushalievaA.B.

2. Overview
▪Patent ductusarteriosus(PDA) is a persistent opening between the
two major blood vessels leading from the heart. The opening (ductus
arteriosus) is a normal part of a baby's circulatory system in the
womb that usually closes shortly after birth. If it remains open, it's
called a patent ductusarteriosus.
▪A small patent ductusarteriosusoften doesn't cause problems and
might never need treatment. However, a large patent ductus
arteriosusleft untreated can allow poorly oxygenated blood to flow
in the wrong direction, weakening the heart muscle and causing
heart failure and other complications.
▪Treatment options for a patent ductusarteriosusinclude monitoring,
medications, and closure by cardiac catheterization or surgery

3. Patent Ductus Arteriosus
▪Patent ductus arterious, shown
in the heart on the right, is an
abnormal opening between the
aorta and the pulmonary
artery.
▪A normal heart is shown on the
left.

4. Path physiology
▪The ductusarteriosusis a normal
connection between the
pulmonary artery and aorta; it is
necessary for proper fetal
circulation.
▪At birth, the rise in PaO2 and
decline in prostaglandin
concentration cause closure of the
ductusarteriosus, typically
beginning within the first 10 to 15
hours of life.
▪f this normal process does not
occur, the ductusarteriosuswill
remain patent.
Pulmonary blood flow, LA and LV volumes, and
ascending AO volume are increased.
AO=aorta; LA=left atrium; LV=left ventricle;
PA=pulmonary artery.

5. Path physiology (Contd..)
▪Physiologic consequences depend on ductal size.
▪A small ductus rarely causes symptoms.
▪A large ductus causes a large left-to-right shunt.
▪Over time, a large shunt results in left heart enlargement, pulmonary
artery hypertension, and elevated pulmonary vascular resistance,
ultimately leading to Eisenmenger syndrome.

6. Specific Inspection Findings
▪A patent ductus arteriosus (PDA) is variable in its presentation. It
may vary in size from small to large and may not be picked up based
on physical examination at birth.
▪Patients usually appear well and have normal respirations and heart
rates. A widened pulse pressure may be noted when the blood
pressure is obtained. Suprasternal or carotid pulsations may be
prominent.
▪As many as one third of children with patent ductus arteriosus (PDA)
is small for their age. In the presence of significant pulmonary
overcirculation, tachypnea, tachycardia, and a widened pulse
pressure may be found.
▪Cardiac Assessment is used to diagnose the PDA.

7. Specific Inspection Findings(Contd..)
▪Cardiac Assessment
–In neonates, a heart murmur is
discovered within the first few days or
weeks of life. The murmur is usually
recognized as systolic rather than
continuous in the first weeks of life
and can mimic a benign systolic
murmur.

8. Specific Inspection Findings(Contd..)
▪Findings upon cardiac examination include the following:
–If the left-to-right shunt is large, precordial activity is increased, with the
magnitude of increased activity related to the magnitude of left-to-right shunt
–The apical impulse is laterally displaced; a thrill may be present in the
suprasternal notch or in the left infraclavicular region
–The first heart sound (S
1) is typically normal, and the second heart sound (S
2) is
often obscured by the murmur; phonocardiographic data from the past
suggested the occurrence of paradoxical splitting of S
2related to premature
closure of the pulmonary valve and a prolonged ejection period across the aortic
valve
–The murmur may be only a systolic ejection murmur, or it may be a
crescendo/decrescendo systolic murmur that extends into diastole
–Occasionally, auscultation of the patent ductus arteriosus (PDA) reveals
numerous clicks or noises resembling shaking dice or a bag of rocks

9. Palpation, Auscultation, Percurssion
▪Palpation
–We studied the Cardiac Assessment, that how we can perform palpation on the patient of
PDA.
▪Auscultation
–The murmur may be only a systolic ejection murmur, or it may be a
crescendo/decrescendo systolic murmur that extends into diastole.
–Occasionally, auscultation of the patent ductus arteriosus (PDA) reveals numerous clicks
or noises resembling shaking dice or a bag of rocks.
▪Percussion
–Using the percussion technique, we can identify the patent ductus arteriosus sound.
–The murmur of a PDA is described as a medium pitched high-grade continuous murmur
heard best at the pulmonic position, with a harsh machinelike quality that often radiates
to the left clavicle.

10. Complaints
▪Clinical presentation depends on patent ductusarteriosussize and
gestational age at delivery.
▪Infants and children with a small PDA are generally asymptomatic; infants
with a large PDA present with signs of heart failure (eg, failure to thrive,
poor feeding, tachypnea, dyspneawith feeding, tachycardia).
▪Premature infants may present with respiratory distress, apnea, worsening
mechanical ventilation requirements, or other serious complications (eg,
necrotizing enterocolitis).
▪Signs of heart failure occur earlier in premature infants than in full-term
infants and may be more severe.
▪A large ductalshunt in a premature infant often is a major contributor to
the severity of the lung disease of prematurity.

11. Lab Tests
▪If a PDA is suspected, the doctor will use a stethoscope to listen for a
heart murmur, which is often heard in babies with PDAs.
▪Follow-up tests might include:
–a chest X-ray
–an EKG, a test that measures the heart's electrical activity and can show if the
heart is enlarged
–an echocardiogram (ultrasound of the heart). In babies with PDA, an echo shows
how big the opening is and how well the heart is handling it.
–blood tests

12. EKG Changes
The EKG may demonstrate
sinus tachycardia or atrial
fibrillation, left ventricular
hypertrophy, and left atrial
enlargement in patients with
moderate or large ductus
shunts.
In patients with smaller ductal
shunts, the EKG is often
completely normal.
In the patient with a large
ductus arteriosus and
elevated pulmonary artery
pressure, signs of right atrial
enlargement and biventricular
hypertrophy are frequently
present.

13. Treatment
–Supportive medical therapy
–In symptomatic premature infants, cyclo-oxygenase (COX) inhibitor therapy
(eg,indomethacin,ibuprofenlysine)
–Sometimes transcatheter closure or surgical repair
▪Typical medical management of patent ductus arteriosus includes
fluid restriction, a diuretic (usually a thiazide), maintenance of
hematocrit ≥ 35 %, providing a neutral thermal environment, and, for
ventilated patients, use of positive end-expiratory pressure (PEEP) to
improve gas exchange.
▪Treatment differs depending on whether the infant is premature or
full term.

14. Treatment in premature infants
▪Fluid restriction may facilitate ductalclosure.
▪In premature infants without respiratory or other compromise, a patent
ductusarteriosusis typically not treated.
▪In premature infants with a hemodynamicallysignificant PDA and
compromised respiratory status, the PDA can sometimes be closed by
using a COX inhibitor (eitheribuprofenlysine orindomethacin). COX
inhibitors work by blocking the production of prostaglandins. Three doses
ofindomethacinare given IV every 12 to 24 hours based on urine output;
doses are withheld if urine output is < 0.6 mL/kg/hour.
▪An alternative isibuprofenlysine 10 mg/kg orally followed by 2 doses of 5
mg/kg at 24-hour intervals.

15. Indomethacin Dosing Guidelines*
Age at Dose1 Dose1 Dose3 Dose3
<48 hours 0.2 mg/kg IV 0.1 mg/kg IV 0.1 mg/kg IV
2–7 days 0.2 mg/kg IV 0.2 mg/kg IV 0.2 mg/kg IV
>7 days 0.2 mg/kg IV 0.25 mg/kg IV 0.25 mg/kg IV
* Dose intervals are based on urine output.

16. Treatment in full-term infants
▪In full-term infants, COX inhibitors are usually ineffective.
▪Transcatheter closure has become the treatment of choice for PDA in children>1 year, and some
authors consider transcatheter closure to be the preferred route in term neonates and young infants as
well.
▪A variety of catheter-delivered occlusion devices are available (eg, coils, septal duct occluder).
▪In infants<1 year who have ductal anatomy unfavorable for transcatheter closure, surgical division and
ligation may be preferred over the transcatheter approach.
▪For a patent ductus arteriosus with a shunt large enough to cause symptoms of heart failure or
pulmonary hypertension, closure should be done after medical stabilization.
▪For a persistent PDA without heart failure or pulmonary hypertension, closure can be done electively
any time after 1 year.
▪Delaying the procedure minimizes the risk of a vascular complication and allows time for spontaneous
closure.

17. Treatment in full-term infants(Contd..)
Outcomes after PDA closure
are excellent.
Endocarditis prophylaxis is not
needed preoperatively and is
required only for the first 6
months after closure or if
there is a residual defect
adjacent to a transcatheter-
placed device or surgical
material.

18. References
▪Patent Ductus Arteriosus | Circulation (ahajournals.org)
▪Patent Ductus Arteriosus (PDA) -Pediatrics -MSD Manual
Professional Edition (msdmanuals.com)
▪Patent Ductus Arteriosus (PDA) (for Parents) -Nemours KidsHealth
▪Patent Ductus Arteriosus (PDA) | Symptoms, Treatment & Surgery
(cincinnatichildrens.org)
▪Patent Ductus Arteriosus (PDA) Treatment & Management:
Approach Considerations, Conservative Management,
Pharmacologic Management (medscape.com)

19. Thank You 