Patent ductus arteriosus differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:Cafer Zorkun, M.D., Ph.D. [2]; Keri Shafer, M.D. [3] Priyamvada Singh, MBBS[4] Ramyar Ghandriz MD[5]

Overview

Patent ductus arteriosus is very famouse due to its continuous machine-like murmur. There are some certain conditions that may make continuous murmur.

Differentiating Patent Ductus Arteriosus from other Diseases

  • Patent ductus arteriosus should be differentiated from other conditions producing machine-like continuous murmur.

Differentiating Patent ductus arteriosus from other acyanotic congenital heart diseases:

[1] [2] [3] [4] [5] [6] [4]

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Imaging
Exertional dyspnea Failure to thrive Recurrent respiratory infections Murmur on auscultation Peripheral edema Clubbing Echocardiography Chest x-ray Cardiac CT
Patent ductus arteriosus
  • Not at beginning
  • May be produced during the course of disease
  • Depends on the size
-
  • Continuous machine-like murmur
-
  • May be present by progressing
  • In color-Doppler visualization of flow through the patent duct which has a high velocity
  • Non-specific
  • Used for determining Krichenko classification based on PDA size and anatomical features.
  • Echocardiogram
  • Krichenko criteria for classification is a very important factor for treatment
Atrial septal defect +/− +/− +/−
  • Systolic flow murmur in the upper left sternal border
  • Wide, fixed splitting of S2
  • Diastolic flow rumble across the tricuspid valve
+/− +/−
  • Hypermobile interatrial septum
  • Abrupt septal irregularity
  • Right atrial and ventricular volume overload
  • Pulmonary artery dilatation
  • Cardiomegaly
  • Pulmonary artery enlargement/increased pulmonary vascularity
  • Enlargement of the right atrium and ventricle
  • Echocardiogram
  • Atrial septal defect is classified into 5 types including ostium primum defect, ostium secundum defect, superior sinus venosus defect, inferior sinus venosus defect, and coronary sinus defect
Ventricular septal defect -/+ -/+ After Eisenmenger syndrome
  • Holosystolic murmur
  • May mimic aortic stenosis(mid/end dyastolic murmur due to increased pulmonary circulation)
-/+ -/+
  • Defect localization
  • septal dropout in the area adjacent to the tricuspid septal leaflet and below the right border of the aortic annulus
  • Direction of jet: Left to right / right to left
  • Direct visualisation of murmur
  • Echocardiogram
-
Diseases Exertional dyspnea Failure to thrive Recurrent respiratory infections Murmur on auscultation Peripheral edema Clubbing Echocardiography Chest x-ray Cardiac CT Gold standard Additional findings
Coarctation of the aorta +/− +/−
  • Systolic murmur over the upper sternal border with radiation to the back
  • Murmur of mitral regurgitation (holosystolic murmur best heard at the apex)
- -
  • Narrowing of the aortic arch at the level of the isthmus
  • Left ventricular hypertrophy
  • Notching of the posterior fourth to eighth ribs due to dilated intercostal arteries
  • Indentation of the aorta at the site of coarctation with pre- and post-stenotic dilation of the aorta (classic "3 sign")
  • Dilation of the intercostal arteries
  • Echocardiogram
  • Patients present with arm-leg blood pressure gradient of >20mmHg
Patent foramen ovale
  • Appearance of at least 3 micro-bubbles in the left atrium within three cardiac cycles after the complete opacification of the right atrium
Non specific
  • Echocardiogram
  • It is associated with migraine headache and decompression sickness in divers
Aortic stenosis + + +
  • Crescendo-decrescendo mid-systolic (or ejection systolic) murmur
+/-
  • Depending on severity
  • Used for finding the location of stenosis
  • Finding severity
  • Evaluating the flow jet with color-Doppler ultrasound technique
  • Non-specific at the beginning
  • At progressed stage calcification of the valve and cardiomegally
  • MRI
  • MRI provides a more detailed structural and dynamic assessment of the aortic valve and left ventricle, in particular
Pulmonary stenosis
  • Depending on severity
- -/+
  • Continuous systolic murmur
- -/+
  • Right atrial hypertrophy
  • Non-specific
  • Direct visualization of stenosis
  • Echocardiogram
-

Differential diagnosis of patent ductus arteriosus from other continuous machine-like murmur:[7][8][9]


Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Imaging
Exercise intolerance Respiratory distress Failure to thrive Cardiac auscultation Cyanosis Wide pulse pressure Chest X-ray Doppler Echocardiography CT-scan
Patent Ductus Arteriosus In medium to large size In large size In large size Continuous Machine-like murmur + + Left sided cardiomegaly Left to right shunt krichenco criteria Charachtristic murmur Increased QT-intrerval maybe seen
Venus Hum - - - Continuous murmur - - Normal Normal Normal
Mammary Souffle - - Does not apply Continuous murmur - -/+ Normal Normal Normal Pregnancy related
Diseases Exercise intolerance Respiratory distress Failure to thrive Machine-like murmur Cyanosis Wide pulse pressure Chest X-ray Doppler Echocardiography CT-scan Gold standard Additional findings
Aortopulmonary Window + + + Continuous murmur + + Cardiomegaly Left to right shunt, Eisenmenger's syndrome Aortic aneurysm
Rupture of the Sinus of Valsalva + + Does not apply Continuous murmur - + No change Turbulent flow Saccular aneurysm Emergent surgery needed, more over after MI
Fistulas of the Coronary Circulation + + Does not apply Continuous murmur - + Unremarkable / Cardiomegaly Not applied Suggestive markers Coronary artery Angiography


Differentiating Patent Ductus Arteriosus from other Diseases

Venous Hum

  • Frequently heard in children over the base of the neck, usually best on the right side.
  • Changes with position. Disappears in the supine position or with compression.
  • Louder in diastole

Mammary Souffle

  • Heard during late pregnancy and the early postpartum period in lactating women.
  • Thought to be arterial in origin
  • Can be bilateral
  • Is louder, peaks in systole
  • Vanishes in the upright position
  • Abolishes by local compression

Aortopulmonary Window

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 Fistula

VSD and AR

Coarctation(Rarely)

References

  1. Morgan-Hughes, Gareth J.; Marshall, Andrew J.; Roobottom, Carl (2003). "Morphologic Assessment of Patent Ductus Arteriosus in Adults Using Retrospectively ECG-Gated Multidetector CT". American Journal of Roentgenology. 181 (3): 749–754. doi:10.2214/ajr.181.3.1810749. ISSN 0361-803X.
  2. Edwards, DK; Higgins, CB; Merritt, TA; DiSessa, TG; Friedman, WF (1978). "Radiographic and echocardiographic evaluation of newborns treated with indomethacin for patent ductus arteriosus". American Journal of Roentgenology. 131 (6): 1009–1013. doi:10.2214/ajr.131.6.1009. ISSN 0361-803X.
  3. Goitein, Orly; Fuhrman, Carl R.; Lacomis, Joan M. (2005). "Incidental Finding on MDCT of Patent Ductus Arteriosus: Use of CT and MRI to Assess Clinical Importance". American Journal of Roentgenology. 184 (6): 1924–1931. doi:10.2214/ajr.184.6.01841924. ISSN 0361-803X.
  4. 4.0 4.1 Kellenberger, Christian J.; Yoo, Shi-Joon; Büchel, Emanuela R. Valsangiacomo (2007). "Cardiovascular MR Imaging in Neonates and Infants with Congenital Heart Disease". RadioGraphics. 27 (1): 5–18. doi:10.1148/rg.271065027. ISSN 0271-5333.
  5. Wang, Zhen J.; Reddy, Gautham P.; Gotway, Michael B.; Yeh, Benjamin M.; Higgins, Charles B. (2003). "Cardiovascular Shunts: MR Imaging Evaluation". RadioGraphics. 23 (suppl_1): S181–S194. doi:10.1148/rg.23si035503. ISSN 0271-5333.
  6. Gotway, Michael B.; Nagai, Brian K.; Reddy, Gautham P.; Patel, Rita A.; Higgins, Charles B.; Webb, W. Richard (2001). "Incidentally Detected Cardiovascular Abnormalities on Helical CT Pulmonary Angiography". American Journal of Roentgenology. 176 (2): 421–427. doi:10.2214/ajr.176.2.1760421. ISSN 0361-803X.
  7. Groom, Dale (1955). "VENOUS HUM IN CARDIAC AUSCULTATION". Journal of the American Medical Association. 159 (7): 639. doi:10.1001/jama.1955.02960240005002. ISSN 0002-9955.
  8. Scott, James T.; Murphy, Edmond A. (1958). "Mammary Souffle of Pregnancy". Circulation. 18 (5): 1038–1043. doi:10.1161/01.CIR.18.5.1038. ISSN 0009-7322.
  9. Ghaderian, Mehdi (2012). "Aortopulmonary window in infants". Heart Views. 13 (3): 103. doi:10.4103/1995-705X.102153. ISSN 1995-705X.

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