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'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
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{{Template:Patent ductus arteriosus}}
{{Patent ductus arteriosus}}
{{CMG}}
{{CMG}}; '''Associate Editor-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com], {{CZ}}, '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] {{RG}}
==Overview==
Golden standard of [[Patent ductus arteriosus|PDA]] diagnosis is [[Continuous heart murmur|continuous]] machine-like in usually [[preterm]] infant. It is more over an acyanotic heart disease which may be [[cyanotic]] due to accompanied situations.


'''Associate Editor-In-Chief:'''{{CZ}}; [[User:KeriShafer|Keri Shafer, M.D.]] [mailto:kshafer@bidmc.harvard.edu] [[Priyamvada Singh|Priyamvada Singh, MBBS]] [[mailto:psingh@perfuse.org]]
==Physical Examination==
===Appearance of the Patient===


'''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [[mailto:kfeeney@perfuse.org]]
* [[Patent ductus arteriosus|PDA]] is an acyanotic cardiac [[Congenital disorder|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]].


==Physical rxamination==
====Blood Pressure====
Patients with a '''small PDA''' may have no symptoms. A '''large PDA''' can cause [[heart failure]] similar to a large [[ventricular septal defect]] [[VSD]],  wide [[pulse pressure]], and bounding arterial pulses. An apical heave may be observed, and a thrill may be heard at the second left intercostal space. The characteristic [[continuous murmur]] has been described as a '''machinery'''  or '''to and fro murmur''' heard in both [[systole]] and [[diastole]]. It can be less prominent or not heard at all in diastole in infants or in the patients with increased [[PVR]].<ref>Giuliani et al, Cardiology: Fundamentals and Practice, Second Edition, Mosby Year Book, Boston, 1991, pp. 1653-1663.</ref>
* [[Wide pulse 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===


In adults with a '''large PDA''', '''[[Eisenmenger's Syndrome]]''' may develop with presents as [[cyanosis]] due to a [[right-to-left shunt]]. The inversion of the shunt is produced because of the progressive increase in [[pulmonary vascular resistance]]. Severe [[pulmonary vascular resistance]] results in reversal of flow through the ductus, and unoxygenated blood is shunted to the descending aorta, and the toes, but not the fingers, become [[cyanotic]] and [[clubbed]], a finding termed differential [[cyanosis]].  
====Small PDA====
*[[Pulmonary]] to systemic flow ratio <1.5 to 1.<ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }}</ref>
* Normal [[precordial]] activity.
* [[Murmur]] may be present. Its nature may be different for [[neonate]]s and older patient. This is so because of the relative difference in [[pulmonary vascular resistance|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 murmur|continuous]], [[continuous murmur|machinery murmur]] or [[Gibson's murmur]] (both during [[systole]] and [[diastole]]).
* Features of machinery [[Murmurs|murmur]] are:<ref name="pmid22574086">{{cite journal| author=Ginghină C, Năstase OA, Ghiorghiu I, Egher L| title=Continuous murmur--the auscultatory expression of a variety of pathological conditions. | journal=J Med Life | year= 2012 | volume= 5 | issue= 1 | pages= 39-46 | pmid=22574086 | doi= | pmc=3307079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22574086  }}</ref><ref name="SchneiderMoore2006">{{cite journal|last1=Schneider|first1=Douglas J.|last2=Moore|first2=John W.|title=Patent Ductus Arteriosus|journal=Circulation|volume=114|issue=17|year=2006|pages=1873–1882|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.592063}}</ref><ref name="pmid18711613">{{cite journal| author=Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW| title=Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease. | journal=Neth Heart J | year= 2008 | volume= 16 | issue= 7-8 | pages= 255-9 | pmid=18711613 | doi=10.1007/bf03086157 | pmc=2516289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18711613  }}</ref>
** 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.


===Small PDA===
====Moderate PDA====
Rarely a continuous thrill in the first or second intercostal space. A [[continuous murmur]] is present underneath the left clavicle, soft and high in frequency. At the beginning of systole, the flow into the PA is chiefly from the RV rather than through the duct, through the course of systole the contribution from the ductus increases progressively, and then during diastole the flow is through the ductus alone and vanishes as the gradient decreases. During the neonatal period, the PVR is high, and flow across the ductus is reduced.  
*[[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 [[Patent ductus arteriosus|PDA]].


===Medium-sized PDA===
====Large PDA====
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. The '''continuous murmur''' is louder and more machinery murmur than for the small PDA. Due to increased left sided return, there is a middiastolic flow murmur and sometimes a third heart sound.
*[[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 murmur]]s 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.


===Large PDAs===
===Abdomen===
If there is no reduction in the size of ductus, after age 2, progressive obstructive disease develops in these patients. Usually present in adolescence or adulthood with the physical findings of pulmonary hypertension associated with some right-to-left shunt. There is preferential cyanosis and clubbing of the lower extremities. The fingers of the left hand may be mildly cyanosed and clubbed. The JVP may be elevated due to RV failure. Prominent a wave due to diminished RV compliance and RVH. Loud pulmonic component of the second heart sound. 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's murmur due to 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.  
*[[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 system|Genitourinary]] examination of patients with [[patent ductus arteriosus]] is usually normal.
===Neuromuscular===
*[[Neuromuscular]] examination of patients with [[patent ductus arteriosus]] is usually normal.
===Extremities===
* [[Cyanosis]]<ref name="SchneiderMoore20062">{{cite journal|last1=Schneider|first1=Douglas J.|last2=Moore|first2=John W.|title=Patent Ductus Arteriosus|journal=Circulation|volume=114|issue=17|year=2006|pages=1873–1882|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.592063}}</ref>
* [[Clubbing]]


==Assessment===
* [[Differential cyanosis]]
'''Small and medium-sized PDAs''' must be distinguished from other conditions with continuous murmurs:
**[[Cyanosis]] is more pronounced in lower extremities compared to upper, this is so because the ductus originates distal to the [[left subclavian artery]].
*'''Venous hum''':  frequently heard in children over the base of the neck, usually best on the right side. Louder in diastole and disappears in the supine position or with compression.
**The left [[subclavian artery]] mainly supplies the upper [[extremities]] which escape the [[shunting]] of [[blood]].
*'''Mammary Souffle''': heard during late pregnancy and the early postpartum period in lactating women. It is Thought to be arterial in origin and can be bilateral. Is louder, peaks in systole, vanishes in the upright position, and is  abolished by local compression.
*'''Aorticopulmonary Window''': is a rare congenital opening between the aorta and the pulmonary trunk just above the aortic valve. It is associated with other abnormalities in approximately 1/2 the cases, such as anomalous origin of the coronary arteries from the pulmonary trunk and coarctation of the aorta. The murmur is lower and more medial in location. In adults is presented without a murmur and clinical features of the [[Eisenmenger's syndrome]].
*'''Rupture of the Sinus of Valsalva''': It can rupture into a cardiac chamber. Almost always arise from the right or the noncoronary cusps and rupture into the RV and RA respectively. Occasionally is acquired as a result of endocarditis. Large acute perforations tend to occur between puberty and age 30 causing severe retrosternal chest pain, dyspnea related to the large left to right shunt. The murmur is louder in a lower parasternal position. People with VSDs and sudden development of chest pain have frequently experienced rupture of a coexistent sinus of valsalva aneurysm. A rupture of the sinus of valsalva can distort or compress the coronary arteries and cause an infarction, distort the conduction system, cause AV block, distort the aortic valve, and cause AS or AI. Patients with rupture of the sinus of valsalva, should undergo surgical correction because mortality is high within a year of rupture.
*''Fistulas of the coronary circulation''': Generally a coronary artery that arises normally will communicate with the RV. Occasionally drain into the pulmonary trunk. The artery that forms the fistula is generally dilated, elongated, and tortuous. The left to right shunt is small. It may not be recognized radiographically. Patients with small fistula are generally asymptomatic. Therefore, no justification to repair it. On the other hand, if the shunt is extremely large, then failure may develop in the 4th, 5th or 6th decade of life. It can be treated with ligation.
*'''Anomalous Origin of the Coronary Artery From the Pulmonary Trunk''': Usually refers to the origin of the left coronary artery from the pulmonary trunk. Approximately, 80 to 90% of the patients die in their first year of life due to ischemia. Blood from the high pressure RCA flows to the low pressure left coronary artery and the pulmonary artery. Anomalous origin of the RCA from the PA is much rarer, but these patients stand a better chance of surviving into adulthood because it is less likely to cause ischemia early in life.
*'''Pulmonary Arteriovenous Fistulas'': Instead of being localized to the precordium, these murmurs are localized to the lung fields. Cyanosis is presented with a normal heart size. Seen in Rendu-Osler-Weber syndrome. A fistula causing cyanosis could be treated with lobectomy if it is confined to a single lobe.


== 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<ref name="pmid30121240">{{cite journal| author=Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2019 | volume= 73 | issue= 12 | pages= 1494-1563 | pmid=30121240 | doi=10.1016/j.jacc.2018.08.1028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30121240  }}</ref> ==
=== Diagnostic Recommendations for Patent Ductus Arteriosus ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''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="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''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==
==References==
{{reflist}}
{{reflist|2}}
 
{{WH}}
{{WS}}


[[Category:Cardiovascular system]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Congenital heart disease]]
[[Category:Congenital heart disease]]
[[Category:Pediatrics]]
[[Category:Pediatrics]]
 
[[Category:Needs overview]]
{{WH}}
{{WS}}

Latest revision as of 12:26, 14 December 2022

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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

Vital Signs

Pulse

Blood Pressure

Skin

HEENT

Neck

Lungs

Heart

Small PDA

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

Abdomen

Back

Genitourinary

Neuromuscular

Extremities

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

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.
  4. ↑ 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.
  5. ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.
  6. ↑ 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.

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