Patent ductus arteriosus physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Priyamvada Singh, M.B.B.S. [2], Cafer Zorkun, M.D., Ph.D. [3], Assistant Editor-In-Chief: Kristin Feeney, B.S. [4] Ramyar Ghandriz MD[5]
Overview
Golden standard of PDA diagnosis is continuous machine-like in usually preterm infant. It is more over an acyanotic heart disease which may be cyanotic due to accompanied situations.
Physical Examination
Appearance of the Patient
- PDA is an acyanotic cardiac congenital disease. Some certain comorbidities can cause the infant to get cyanotic.
Vital Signs
Pulse
- Brisk upstroke pulse: Bounding arterial pulses are present due to the continuous runoff of blood from the aorta into the pulmonary artery during diastole.
Blood Pressure
Skin
- Skin examination of patients with patent ductus arteriosus is usually normal.
HEENT
- HEENT examination of patients with patent ductus arteriosus is usually normal.
Neck
- Neck examination of patients with patent ductus arteriosus is usually normal.
Lungs
- Pulmonary examination of patients with patent ductus arteriosus is usually normal.
- At late course of disease elevated pulmonary blood pressure may cause related symptoms.
Heart
Small PDA
- Pulmonary to systemic flow ratio <1.5 to 1.[1]
- Normal precordial activity.
- Murmur may be present. Its nature may be different for neonates and older patient. This is so because of the relative difference in pulmonary and systemic vascular resistance in them.
- In the newborn, the pressure during systole is greater in aorta compared to pulmonary circulation. However, this gradient between aortic and pulmonary circulation is not so prominent in diastole. Due to this, the murmur may only be audible during the systole.
- The pulmonary artery pressure falls after the newborn period. Due to this, the pressure in aorta is higher than the pulmonary artery both in systole and in diastole. This in turn leads to the characteristic continuous, machinery murmur or Gibson's murmur (both during systole and diastole).
- Features of machinery murmur are:[2][3][4]
- Best heard in the left infraclavicular region.
- The murmur maybe 3/6 or less.
- The intensity is maximal immediately before and after the second heart sound (S2).
- Not vary with changing postures.
Moderate PDA
- Pulmonary to systemic flow ratio between 1.5 and 2.2 to 1
- As a result of the runoff from the aorta, there are bounding pulses, and the pulse pressure widens.
- A continuous thrill may be present in the first or second left intercostal space.
- Displaced apex (indicating left ventricular overload)
- Continuous murmur (maybe grade 2,3 and occasionally 4)
- The features of murmur are very similar to that seen with small ducts, however, they are louder than that associated with small PDA.
Large PDA
- Pulmonary to systemic flow ratio >2.2 to 1
- Dynamic left ventricular impulse
- Left ventricular thrill
- S1 is normal, S2 may be split with an accentuated pulmonary component. The continuous machinery murmurs with similar features as seen in moderate and small sized ducts but with louder intensity (4/6 grade) could be heard.
- An apical diastolic rumble due to increased flow across the mitral valve may be present.
- A third heart sound may be present.
- If there is no reduction in the size of the ductus, after age 2, the progressive obstructive disease develops in these patients:
- Signs of heart failure develop
- The JVP may be elevated due to RV failure. Prominent "a wave" due to diminished RV compliance and RVH.
- Signs of pulmonary hypertension associated with right-to-left shunt start appearing.
- As the pulmonary hypertension increases, left to right flow across the duct decreases and there is no audible murmur.
- A murmur of pulmonic insufficiency may be noted (Graham-Steell murmur) due to the dilation of the pulmonic valve ring resulting from pulmonary hypertension.
- Flow into a dilated pulmonary trunk causes a pulmonic ejection sound and pulmonic ejection murmur.
- The second pulmonic heart sound is closely split or not split.
Abdomen
- Abdominal examination of patients with patent ductus arteriosus is usually normal.
Back
- Back examination of patients with patent ductus arteriosus is usually normal.
Genitourinary
- Genitourinary examination of patients with patent ductus arteriosus is usually normal.
Neuromuscular
- Neuromuscular examination of patients with patent ductus arteriosus is usually normal.
Extremities
- Differential cyanosis
- Cyanosis is more pronounced in lower extremities compared to upper, this is so because the ductus originates distal to the left subclavian artery.
- The left subclavian artery mainly supplies the upper extremities which escape the shunting of blood.
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[6]
Diagnostic Recommendations for Patent Ductus Arteriosus
| Class I |
| 1.Measurement of oxygen saturation should be performed in feet and both hands in adults with a PDA to assess for the presence of right-to-left shunting.(Level of Evidence C-EO) |
| Class IIa |
| 1.In addition to the standard diagnostic tools, cardiac catheterization can be useful in patients with PDA and suspected pulmonary hypertension (Level of Evidence: C-EO) |
References
- ↑ Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
- ↑ Ginghină C, Năstase OA, Ghiorghiu I, Egher L (2012). "Continuous murmur--the auscultatory expression of a variety of pathological conditions". J Med Life. 5 (1): 39–46. PMC 3307079. PMID 22574086.
- ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.
- ↑ Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW (2008). "Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease". Neth Heart J. 16 (7–8): 255–9. doi:10.1007/bf03086157. PMC 2516289. PMID 18711613.
- ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.
- ↑ Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.