Patent Ductus ArteriosusDr. Arun GeorgePaediatriic EmergencyCMC Vellore

Introduction Communication between the pulmonary

artery and the aorta Location – distal to left subclavian F:M = 2:1 Maternal rubella, prematurity

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

Examination Physical underdevelopment

Wide pulse pressure – bounding peripheral pulses

Hyperkinetic apex, continuous thrill in 2nd lt ICS

Continous murmur

Accentuated first sound and narrowly or paradoxically split second sound (large shunts)

Differential cyanosis and clubbing is pesent in shunt reversal

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

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)

Dilatation of the ascending aorta Aortic ejection click – preceeding the

conti nuous murmur Aortic ejection systolic murmur –

drowned by the loud continuous murmur

ECG

CXR

Echocardiogram Gold standard for diagnosing PDA

Taken from Neo Reviews

Color and pulsed doppler Cardiac catheterisation

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

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

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

DDXAorticopulmonary window defectRuptured sinus of valsalva aneurysmCoronary arteriovenous fistulasAberrant left coronary with massive

collaterals from the rightTruncus arteriosusVSD with aortic insufficiencyPeripheral pulmonic stenosisVenous hum in TAPVC

TreatmentPremature Indomethacin

0.1mg/kg/dose 12 hourly 3 doses

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

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

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

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.

Cardiac catheterization – Trans catheter closure Small PDAs- closed with intravascular

coils.

Moderate to large – catheter introduced sacs or umbrella like device

Intravascular coils - gianturco

Amplatzer patch

Surgery Left thoracotomy

Thoracoscopic minimally invasive techniques.

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

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