Patent ductus arteriosus

Patent Ductus Arteroisus, PDA, Cardiology, Paediatrics, Pedicatrics, Critical Care, Emergency medicine, Medicine, Internal Medicine, MBBD, MD, India, CMC Vellore, Christian Medical College

1. Patent Ductus
Arteriosus
Dr. Arun George
Paediatriic Emergency
CMC Vellore

4. Introduction
Communication between the pulmonary
artery and the aorta
Location – distal to left subclavian
F:M = 2:1
Maternal rubella, prematurity

8. History:
Irritable, feed poorly, fail to gain weight
and sweat excessively
Increased respiratory effort and
respiratory rates
prone to develop recurrent upper
respiratory infections and pneumonia

9. Examination
Physical underdevelopment
Wide pulse pressure – bounding
peripheral pulses
Hyperkinetic apex, continuous thrill in 2
nd
lt
ICS
Continous murmur

10. Accentuated first sound and narrowly or
paradoxically split second sound (large
shunts)
Differential cyanosis and clubbing is
pesent in shunt reversal

11. What Physical Exam findings What Physical Exam findings
are consistent with PDA?are consistent with PDA?
Murmur: systolic at
LUSB/Left
Infraclavicular, may
progress to continuous
(machinery)
Cardiac: Active
Precordium, Widened
Pulse Pressure, Bounding
Pulses
Respiratory Sx:
Tachypnea,
Apnea

12. Hemodynamics
Flow during both systole and diastole –
pressure gradient present throughout
(pulm artery pressure normal)
Continuous murmur
Overload of pulm artery  increased
flow through left atrium and ventricle –
accentuated first sound and mitral
delayed diastolic murmur
Delayed closure of aortic valve & late
A2 (S2 may be paradoxically split)

13. Dilatation of the ascending aorta
Aortic ejection click – preceeding the
conti nuous murmur
Aortic ejection systolic murmur – drowned
by the loud continuous murmur

16. ECG

17. CXR

18. Echocardiogram
Gold standard for diagnosing PDA
Taken from Neo Reviews

19. Color and pulsed doppler
Cardiac catheterisation

20. Assessment of severity
Heart size
Third sound and diastolic murmur
Pulse pressure

21. Course and Complications
Ejection systolic murmur at birth (due to
pulmonary hypertension)  continuous
murmur after a few weeks
Development of Pulmonary arterial
hypertension  diastolic component lost
 ejection systolic murmur
Severe PAH  rt to lft shunt 
disappearance of the murmur and
appearance of differential cyanosis

22. Complications:
Cardiac failure
Infective endarteritis
Eisenmenger
Rare complications
-aneurysmal dilatation of the pulmonary
artery or the ductus
-calcification of the ductus
-noninfective thrombosis of the ductus
with embolization
-paradoxical emboli

23. DDX
Aorticopulmonary window defect
Ruptured sinus of valsalva aneurysm
Coronary arteriovenous fistulas
Aberrant left coronary with massive
collaterals from the right
Truncus arteriosus
VSD with aortic insufficiency
Peripheral pulmonic stenosis
Venous hum in TAPVC

24. Treatment
Premature  Indomethacin
0.1mg/kg/dose
12 hourly 3 doses

25. Prophylactic indomethacin has short-term
benefits for preterm infants including a
reduction in the incidence of
symptomatic PDA, PDA surgical ligation,
and severe intraventricular haemorrhage.
However, there is no evidence of effect
on mortality or neurodevelopment.
Cochrane review 2010: Prophylactic
intravenous indomethacin for preventing
mortality and morbidity in preterm infants
Peter W Fowlie et al

26. Ibuprofen is as effective as indomethacin
in closing a PDA and currently appears to
be the drug of choice. Ibuprofen reduces
the risk of NEC and transient renal
insufficiency. 
Ibuprofen for the treatment of patent
ductus arteriosus in preterm or low birth
weight (or both) infants Cochrane reviews
2015- Arne Ohlsson, Rajneesh Walia,
Sachin S Shah

27. Paracetamol appears to be a promising
new alternative to indomethacin and
ibuprofen for the closure of a PDA with
possibly fewer adverse effects.
Paracetamol (acetaminophen) for patent
ductus arteriosus in preterm and low-birth-
weight infants Cochrane review March
2015- Ohlsson A, Shah PS

28. Treatment
All patients with PDA require surgical or
catheter closure.
Rationale:
Small PDA- prevention of bacterial
endarteritis
Moderate to large PDA- to treat heart
failure or prevent the development of
pulmonary vascular disease, or both.

29. Cardiac catheterization –
Trans catheter closure
Small PDAs- closed with intravascular
coils.
Moderate to large – catheter introduced
sacs or umbrella like device

30. Intravascular coils -
gianturco

32. Amplatzer patch

34. Surgery
Left thoracotomy
Thoracoscopic minimally invasive
techniques.

36. Closure of the ductus is indicated even in
asymptomatic patients, preferably before
1 year of age.

37. Reference:
Nelson’s textbook of Paediatrics 20e
Ghai Essential Paediatrics 8e
Uptodate.com
Medscape
Wikipedia
Cochrane reviews