Updated: 1/23/2019

Patent Ductus Arteriosus (PDA)

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Snapshot
  • A 7-day-old infant is brought to the pediatrician’s office for poor feeding. She was born to a first time mother without any complications. The mom reports that her infant seems to tire easily when feeding to the point that she is worried about her food intake. On physical exam, the infant has lost more weight than expected. Cardiac exam reveals a grade II/VI continuous machine-like murmur in the left infraclavicular area with a widened pulse pressure. She is sent to receive an echocardiogram for further evaluation.
Introduction
  • Clinical definition
    • a persistent opening between the aorta and pulmonary artery that fails to close in the immediate postpartum period
  • Epidemiology
    • demographics
      • female > male 2:1
      • most commonly in premature infants
    • risk factors
      • maternal rubella infection
      • premature infants
      • in utero alcohol exposure
  • Pathogenesis
    • the ductus arteriosus is normal in utero and typically closes hours after birth
      • patency of PDA is maintained by prostaglandin E2 (PGE2) synthesis and low oxygen tension
    • if unfixed, a large PDA can cause left-to-right shunting in the heart, which increases pulmonary blood flow and causes alterations in the pulmonary vasculature
      • shifting of blood from systemic circulation can cause cyanosis
        • over time, with severe defects, this eventually results in pulmonary hypertension and Eisenmenger syndrome
  • Associated conditions
    • fetal alcohol syndrome
    • congenital rubella
    • neonatal respiratory distress syndrome
      • due to persistently low oxygen tension
    • ventricular septal defect
  • Prognosis
    • typically progresses over time
Presentation
  • Symptoms
    • symptoms usually occur with larger defects
    • respiratory distress
    • poor feeding
    • poor weight gain
    • easy fatigability
  • Physical exam
    • cardiac auscultation
      • continuous “machine-like" or "to-and-fro” murmur
    • wide pulse pressure
    • bounding arterial pulses
    • cyanosis and clubbing of lower extremities
    • signs of respiratory distress
      • tachypnea
      • grunting
      • nasal flaring
      • retractions during breathing
Imaging
  • Radiography
    • indication
      • for all patients
    • views
      • chest
    • findings
      • enlarged pulmonary artery
      • increased pulmonary markings
      • cardiomegaly
  • Echocardiography
    • indication
      • performed as a diagnostic test
      • most specific test
    • findings
      • ductal flow
      • increased left atrium to aortic root
Studies
  • Labs
    • ↑ B-type natriuretic peptide is a biomarker for PDA
  • Electrocardiography
    • indications
      • to assess for arrhythmias
    • findings
      • left ventricular hypertrophy can occur over time
  • Making the diagnosis
    • based on clinical presentation and echocardiogram
Differential
  • Ventricular septal defect
    • distinguishing factor
      • holosystolic murmur
Treatment
  • Management approach
    • many lesions may close spontaneously
    • premature infants often need medical or surgical treatment
  • Medical
    • indomethacin  
      • indications
        • first-line therapy for all patients who do not need the PDA
          • patients with certain congenital cardiac abnormalities that result in the separation of the systemic and pulmonary circulation may require a shunt between the two systems, such as the PDA, to sustain life
        • premature infants with PDA
    • prostaglandin E
      • indication
        • for patients who require PDA to survive
          • e.g., for patients with transposition of the great vessels
  • Operative
    • surgical closure
      • indications
        • failure of PDA to close after medical therapy
        • term infants with large PDAs
      • contraindications
        • severe pulmonary vascular disease (e.g., pulmonary hypertension)
Complications
  • Heart failure
  • Eisenmenger syndrome
  • Infective endocarditis

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Questions (2)
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(M2.CV.17.4679) A 2-day-old boy delivered at 34 weeks gestation is found to have a murmur on routine exam. He is lying supine and is not cyanotic. He has a pulse of 195/min, and respirations of 59/min. He is found to have a nonradiating continuous machine-like murmur at the left upper sternal border. S1 and S2 are normal. The peripheral pulses are bounding. Assuming this patient has no other cardiovascular defects, what is the most appropriate treatment?

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Indomethacin

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Thiazide diuretic

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Aspirin

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Penicillin

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Reassurance

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M 7 B

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