''Patent ductus arteriosus'' (PDA) is a medical condition in which the ''
ductus arteriosus
The ''ductus arteriosus'', also called the ''ductus Botalli'', named after the Italian physiologist Leonardo Botallo, is a blood vessel in the developing fetus connecting the trunk of the pulmonary artery to the proximal descending aorta. It a ...
'' fails to close after
birth
Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the f ...
: this allows a portion of oxygenated
blood from the left
heart
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to t ...
to flow back to the lungs by flowing from the
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes o ...
, which has a higher pressure, to the
pulmonary artery
A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and ...
. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased
work of breathing and
failure to gain weight at a normal rate. With time, an uncorrected PDA usually leads to
pulmonary hypertension followed by right-sided
heart failure.
The ''ductus arteriosus'' is a
fetal blood vessel that normally closes soon after birth. In a PDA, the vessel does not close, but remains ''patent'' (open), resulting in an abnormal transmission of blood from the aorta to the pulmonary artery. PDA is common in newborns with persistent respiratory problems such as
hypoxia, and has a high occurrence in
premature newborns. Premature newborns are more likely to be hypoxic and have PDA due to underdevelopment of the heart and lungs.
If
transposition of the great vessels is present in addition to a PDA, the PDA is not surgically closed since it is the only way that oxygenated blood can mix with deoxygenated blood. In these cases,
prostaglandins are used to keep the PDA open, and NSAIDs are not administered until surgical correction of the two defects is completed.
Signs and symptoms
Common symptoms include:
*
dyspnea
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...
(shortness of breath)
Signs include:
*
tachycardia
Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
(a heart rate exceeding the normal resting rate)
* continuous "machine-like" (also described as "rolling-thunder" and "to-and-fro")
heart murmur
Heart murmurs are unique heart sounds produced when blood flows across a heart valve or blood vessel. This occurs when turbulent blood flow creates a sound loud enough to hear with a stethoscope. Turbulent blood flow is not smooth. The sound di ...
(usually from aorta to pulmonary artery, with higher flow during
systole and lower flow during
diastole)
*
cardiomegaly (enlarged heart, reflecting
ventricular dilation and
volume overload)
* left subclavicular thrill
*
bounding pulse
Bounding may refer to:
* Establishing limits on the behavior of a process or device, see Listing and approval use and compliance
* Bounding overwatch, a variety of military maneuver
* A cyclical type of jumping
Jumping or leaping is a for ...
* widened
pulse pressure
Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Resting blood pressure is normally appro ...
* increased
cardiac output
* increased
systolic pressure
*
poor growth[MedlinePlus - ''Patent ductus arteriosus'']
Update Date: 21 December 2009
* differential
cyanosis, i.e. cyanosis of the lower extremities but not of the upper body.
People with ''patent ductus arteriosus'' typically present in good health, with normal respirations and heart rate. If the PDA is moderate or large, widened
pulse pressure
Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Resting blood pressure is normally appro ...
and bounding peripheral pulses are frequently present, reflecting increased left ventricular
stroke volume and diastolic run-off of blood into the (initially lower-resistance) pulmonary vascular bed.
Eisenmenger physiology is pulmonary hypertension due to a left-to-right shunt. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.
Risk factors
Known
risk factors include:
*
Preterm birth
*
Congenital rubella syndrome
Congenital rubella syndrome (CRS) can occur in a developing fetus of a pregnant woman who has contracted rubella, usually in the first trimester. If infection occurs 0–28 days before conception, the infant has a 43% risk of being affected. If t ...
*
Chromosomal abnormalities (e.g.,
Down syndrome)
*
Genetic conditions such as
Loeys–Dietz syndrome (would also present with other heart defects),
Wiedemann–Steiner syndrome, and
CHARGE syndrome.
*
Fetal Alcohol Spectrum Disorder
Diagnosis
PDA is usually diagnosed using
noninvasive techniques.
Echocardiography (in which
sound waves are used to capture the motion of the heart) and associated
Doppler studies are the primary methods of detecting PDA.
Electrocardiography (ECG), in which
electrodes are used to record the
electrical
Electricity is the set of physical phenomena associated with the presence and motion of matter that has a property of electric charge. Electricity is related to magnetism, both being part of the phenomenon of electromagnetism, as described ...
activity of the heart, is not particularly helpful as no specific rhythms or ECG patterns can be used to detect PDA.
A chest
X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
may be taken, which reveals overall heart size (as a reflection of the combined mass of the cardiac chambers) and the appearance of blood flow to the lungs. A small PDA most often accompanies a normal-sized heart and normal blood flow to the lungs. A large PDA generally accompanies an enlarged
cardiac silhouette and increased blood flow to the lungs.
File:Blausen 0707 PatentDuctusArteriosus.png, Illustration of PDA
Image:Heart patent ductus arteriosus.jpg, PDA
File:Stent tekst.jpg, An echocardiogram of a stented persisting ''ductus arteriosus'': One can see the aortic arch and the stent leaving. The pulmonary artery is not seen.
File:PDA Coil.png, An echocardiogram of a coiled PDA: One can see the aortic arch, the pulmonary artery, and the coil between them.
Prevention
Some evidence suggests that intravenous NSAIDs, such as
indomethacin, administration on the first day of life to all preterm infants reduces the risk of developing a PDA and the complications associated with PDA.
Intravenous Indomethacin treatment in premature infants also may reduce the need for surgical intervention.
Administering ibuprofen probably helps to prevent PDA and reduce the need for surgery but it also likely increases the risk of
kidney complications.
Treatment
Symptomatic PDA can be treated with both
surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
and non-surgical methods.
Conservative
Neonates without adverse symptoms may simply be monitored as
outpatients.
Surgery
Surgically, the DA may be closed by ligation (though support in premature infants is mixed).
This can either be performed manually and be tied shut, or with intravascular coils or plugs that leads to formation of a
thrombus in the DA.
Devices developed by
Franz Freudenthal block the blood vessel with woven structures of
nitinol
Nickel titanium, also known as Nitinol, is a metal alloy of nickel and titanium, where the two elements are present in roughly equal atomic percentages. Different alloys are named according to the weight percentage of nickel; e.g., Nitinol 55 and ...
wire. Newer procedures performed effectively in older, bigger children include catheter PDA occlusion and video-assisted thoracoscopic PDA clipping.
Prostaglandin inhibitors
Because
prostaglandin E2 is responsible for keeping the DA open, NSAIDs (which can inhibit prostaglandin synthesis) such as
indomethacin or a special form of
ibuprofen have been used to initiate PDA closure.
[ Findings from a 2015 systematic review concluded that, for closure of a PDA in preterm and/or low birth weight infants, ibuprofen is as effective as indomethacin. It also causes fewer side effects (such as transient ]acute kidney injury
Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in kidney function that develops within 7 days, as shown by an increase in serum creatinine or a decrease in urine output, or both.
Causes of AKI are c ...
) and reduces the risk of necrotising enterocolitis
Necrotizing enterocolitis (NEC) is a devastating intestinal disease that affects premature or very low birth weight infants.Gephart S.M., Quinn M. A call to action to fight for equity and end necrotizing enterocolitis disparities. ''Adv. Neonata ...
. A review and meta-analysis showed that paracetamol may be effective for closure of a PDA in preterm infants. A 2018 network meta-analysis that compared indomethacin, paracetamol and ibuprofen at different doses and administration schemes among them found that a high dose of oral ibuprofen may offer the highest likelihood of closure in preterm infants. However, a 2020 systematic review found that early (≤7 days of life) or very early (≤72 hours of life) pharmacological treatment of symptomatic PDA does not reduce death or other poor clinical outcomes in preterm infants but instead increases their exposure to NSAIDS. Vasodilator therapy is suitable for people with Eisenmenger physiology. To assess improvement in people with Eisenmenger physiology, close monitory of toe oxygen saturation is required, for there exists a chance of reversal after a successful right-to-left shunt
While indometacin
Indometacin, also known as indomethacin, is a nonsteroidal anti-inflammatory drug (NSAID) commonly used as a prescription medication to reduce fever, pain, stiffness, and swelling from inflammation. It works by inhibiting the production of pros ...
can be used to close a PDA, some neonates require their PDA be kept open. Keeping a ''ductus arteriosus patent'' is indicated in neonates born with concurrent heart malformations, such as transposition of the great vessels. Drugs such as alprostadil, a PGE-1 analog, can be used to keep a PDA open until the primary defect is corrected surgically.
Prognosis
If left untreated, the disease may progress from left-to-right shunt ( acyanotic heart) to right-to-left shunt ( cyanotic heart), called Eisenmenger's syndrome. Pulmonary hypertension is a potential long-term outcome, which may require a heart and/or lung transplant. Another complication of PDA is intraventricular hemorrhage
Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from phys ...
.
History
Robert Edward Gross, MD performed the first successful ligation of a ''patent ductus arteriosus'' on a seven-year-old girl at Children's Hospital Boston
Boston Children's Hospital formerly known as Children's Hospital Boston until 2012 is a nationally ranked, freestanding acute care children's hospital located in Boston, Massachusetts, adjacent both to its teaching affiliate, Harvard Medical Sch ...
in 1938.fa.hms.harvard.edu
Robert E. Gross, Harvard Medical School Office for Faculty Affairs.
Adult
Since PDA is usually identified in infants, it is less common in adults, but it can have serious consequences, and is usually corrected surgically upon diagnosis.
See also
*
George Alexander Gibson
References
External links
Patent Ductus Arteriosus Causes from US Department of Health and Human ServicesPatent ductus arteriosusinformation for parents.
{{DEFAULTSORT:Patent Ductus Arteriosus
Congenital heart defects
Neonatology