Difference between revisions of "Patent ductus arteriosus"

 
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==Background==
 
==Background==
*Abbreviation: PDA
+
*Ductus arteriosus is a blood vessel connecting main pulmonary artery to proximal descending aorta
*A condition where the ductus arteriosus does not close after birth.  It is the second most common congenital heart disease affecting approximately 1 in 1600 to 5000 live births in the US.<ref>Mitchell, S. C., Korones, S. B., Berendes, H. W. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43: 323-332, 1971.</ref>
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**Shunts blood from right ventricle to bypass fetus's non-functioning lungs in utero
 +
*In PDA, ductus fails to close after birth
 +
*Second most common congenital heart disease
 +
*Approximately 1 in 1600 to 5000 live births in the US.<ref>Mitchell, S. C., Korones, S. B., Berendes, H. W. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43: 323-332, 1971.</ref>
  
 
===Pathophysiology===
 
===Pathophysiology===
*The ductus arteriosus shunts blood from the pulmonary artery to the aorta bypassing the lungs
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[[File:PDA.png|thumb]]
*It closes soon after birth by a complex process that is regulated by oxygen tension and decreases in prostaglandin E2
+
*Ductus arteriosus shunts blood from the pulmonary artery to the aorta bypassing the lungs while in utero
*In a PDA, the vessel fails to close, resulting in transmission of blood between the aorta and the pulmonary artery
+
*Normally closes soon after birth via complex process
*This shunting, or transmission of blood, allows some oxygenated blood from the aorta, which has a higher pressure, to the pulmonary artery, which has the lower pressure.  If the shunt is large enough, the infant may become short of breath due the increase fluid return to the lungs, increased lung pressure, and thus increased energy demands to fill the lungs.
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**Regulated by oxygen tension and decreases in prostaglandin E2
 
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**Becomes ligamentum arteriosum
Some congenital heart defects, such as transposition of the great vessels, are incompatible with life and a PDA may be neccessary in keeping the infant alive by allowing oxygenated and deoxygenated blood to mix. In these cases prostaglandins are used to keep the ductus arteriosus open.
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*In PDA, ductus fails to close
 
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**Results in shunting of blood between aorta and pulmonary artery
[[File:Blausen_0707_PatentDuctusArteriosus.png|thumbnail]]<ref>Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436</ref>
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**Some oxygenated blood from high-pressure aorta shunts to lower pressure pulmonary artery
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**A large shunt can cause increased fluid return to lungs and increased lung pressure, leading to [[pulmonary hypertension]]
 +
*Some congenital heart defects, such as [[transposition of the great arteries]], are incompatible with life ''''without''' a PDA; may be necessary to allow oxygenated and deoxygenated blood to mix
 +
**In these cases [[prostaglandin E1|prostaglandins]] are used to keep the ductus arteriosus '''open'''.
  
 
==Clinical Features==
 
==Clinical Features==
* Continuous machine like heart murmur
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* Continuous machine like heart [[murmur]]
 
* Differential cyanosis (cyanosis of lower extremities and not the upper extremities)
 
* Differential cyanosis (cyanosis of lower extremities and not the upper extremities)
* Dyspnea
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* [[Dyspnea]]
* Tachycardia
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* [[Tachycardia]]
* Widened Pulse Pressure
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* Widened pulse pressure
 
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* [[Congestive heart failure]]
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* [[Failure to thrive (peds)|Failure to thrive]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
* Acute Pericarditis
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* [[Acute pericarditis]]
 
* Aortopulmonary Septal Defect
 
* Aortopulmonary Septal Defect
* Coarctation of the Aorta
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* [[Coarctation of the Aorta]]
* Coronary Artery Fistula
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* [[Anomalous coronary arteries|Coronary artery fistula]]
* Pediatric Acute Respiratory Distress Syndrome
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* Pediatric acute [[respiratory distress syndrome]]
* Pediatric Sinus of Valsalva Aneurysm
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* Sinus of valsalva aneurysm
* Pediatric Tachycardia
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* Pediatric [[tachycardia]]
* Pulmonic Valvular Stenosis
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* Pulmonic valvular stenosis
* Sickle Cell Anemia
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* [[Sickle cell anemia]]
* Tetralogy of Fallot With Absent Pulmonary Valve
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* [[Tetralogy of Fallot]] with absent pulmonary valve
  
 +
{{Congenital heart disease DDX}}
  
 
==Evaluation==
 
==Evaluation==
 +
[[File:PDA Fomani.gif|thumbnail|Echocardiography demonstrating PDA<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
 
* Careful physical examination demonstrating characteristic machine like murmur
 
* Careful physical examination demonstrating characteristic machine like murmur
* Echocardiography
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* [[Echocardiography]]
 
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**MRA and Cardiac CT can also be used as diagnostic tools
Laboratory tests are usually not helpful.  MRA and Cardiac CT can also be used as diagnostic tools
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*Laboratory tests usually not helpful
  
 
==Management==
 
==Management==
Spontaneous closure is usually common but if significant respiratory distress or impaired oxygen delivery is present, therapy is usually required.  
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*Spontaneous closure common
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*If significant [[shortness of breath (peds)|respiratory distress]] or impaired oxygen delivery, therapy usually required   
  
==== Medical Therapy: ====
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=== Medical Therapy ===
IV [[indomethacin]] is usually effective when administered in the first 10-14 days of life.   
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*IV [[indomethacin]]: usually effective when administered in the first 10-14 days of life.   
 +
**<48 hour old: start 0.2mg/kg IV x 1, then 0.1mg/kg q12-24h x 2
 +
**2-7 days old: Start 0.2mg/kg IV x 1, then 0.2mg/kg q12-24h x 2
 +
**> 7 days old: Start 0.2mg/kg IV x 1, then 0.25mg/kg q12-24h x 2
  
==== Surgical Therapy: ====
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=== Surgical Therapy ===
Cardiac catheterization and catheter closure in addition to surgical ligation are also options if medical therapy fails.
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*Offered if medical therapy fails
 +
**Cardiac catheterization and catheter closure
 +
**Surgical ligation
  
 
==Disposition==
 
==Disposition==
 
+
*Stable, asymptomatic patients can be discharged home with cardiology follow-up
 +
*Symptomatic patients and patients requiring treatment should be admitted with cardiology consultation
  
 
==See Also==
 
==See Also==
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[[Category:cardiology]]
 
[[Category:cardiology]]
 +
[[Category:Pediatrics]]

Latest revision as of 15:10, 12 September 2019

Background

  • Ductus arteriosus is a blood vessel connecting main pulmonary artery to proximal descending aorta
    • Shunts blood from right ventricle to bypass fetus's non-functioning lungs in utero
  • In PDA, ductus fails to close after birth
  • Second most common congenital heart disease
  • Approximately 1 in 1600 to 5000 live births in the US.[1]

Pathophysiology

PDA.png
  • Ductus arteriosus shunts blood from the pulmonary artery to the aorta bypassing the lungs while in utero
  • Normally closes soon after birth via complex process
    • Regulated by oxygen tension and decreases in prostaglandin E2
    • Becomes ligamentum arteriosum
  • In PDA, ductus fails to close
    • Results in shunting of blood between aorta and pulmonary artery
    • Some oxygenated blood from high-pressure aorta shunts to lower pressure pulmonary artery
    • A large shunt can cause increased fluid return to lungs and increased lung pressure, leading to pulmonary hypertension
  • Some congenital heart defects, such as transposition of the great arteries, are incompatible with life 'without a PDA; may be necessary to allow oxygenated and deoxygenated blood to mix
    • In these cases prostaglandins are used to keep the ductus arteriosus open.

Clinical Features

Differential Diagnosis

Congenital Heart Disease Types

Evaluation

Echocardiography demonstrating PDA[3]
  • Careful physical examination demonstrating characteristic machine like murmur
  • Echocardiography
    • MRA and Cardiac CT can also be used as diagnostic tools
  • Laboratory tests usually not helpful

Management

  • Spontaneous closure common
  • If significant respiratory distress or impaired oxygen delivery, therapy usually required

Medical Therapy

  • IV indomethacin: usually effective when administered in the first 10-14 days of life.
    • <48 hour old: start 0.2mg/kg IV x 1, then 0.1mg/kg q12-24h x 2
    • 2-7 days old: Start 0.2mg/kg IV x 1, then 0.2mg/kg q12-24h x 2
    • > 7 days old: Start 0.2mg/kg IV x 1, then 0.25mg/kg q12-24h x 2

Surgical Therapy

  • Offered if medical therapy fails
    • Cardiac catheterization and catheter closure
    • Surgical ligation

Disposition

  • Stable, asymptomatic patients can be discharged home with cardiology follow-up
  • Symptomatic patients and patients requiring treatment should be admitted with cardiology consultation

See Also

External Links

References

  1. Mitchell, S. C., Korones, S. B., Berendes, H. W. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43: 323-332, 1971.
  2. Knipe K et al. Cyanotic congenital heart diseases. Radiopaedia. http://radiopaedia.org/articles/cyanotic-congenital-heart-disease
  3. http://www.thepocusatlas.com/pediatrics/