Your SlideShare is downloading. ×
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.


Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply



Published on

Published in: Health & Medicine

  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Patent DuctusArteriousus
  • 2. History
    In 1593 GiambattistaCarcano described ductusarteriosus in book “great cardiac vessels of the fetus”
    Leo bottani falsely associated with “ ductus”
  • 3.
  • 4. Anatomy
    Normal fetal vascular channel between aorta and pulmonary artery.
    The pulmonary end is located to left of bifurcation of pulmonary trunk
    Aortic end is just beyond the origin of left subclavian artery
    With a right aortic arch, the ductusarteriosus may be on the right, joining the right pulmonary artery and the right aortic arch just distal to the right subclavian artery
  • 5. Introduction
  • 6.
  • 7. microscopic structure of the ductusarteriosus differs
    the media of the ductusarteriosus consist largely of layers of smooth muscle arranged spirally in both leftward and rightward directions
    The intimal layer of the ductusarteriosus is thicker than that of the adjoining arteries and contains an increased amount of mucoid substance
  • 8. Embryology
  • 9. Physiology
    Role in the Fetus
    6 weeks of gestation, the ductusarteriosus is developed sufficiently to carry most of the right ventricular output
    The right ventricle ejects about two thirds of combined ventricular output
    ductusarteriosus permits flow to be diverted away from the high-resistance pulmonary circulation
  • 10. Normal Postnatal Closure
    closure of the ductusarteriosus is effected in two phases
    Immediately after birth, contraction and cellular migration of the medial smooth muscle in the wall of the ductus
    resulting in functional closure
    commonly occurs within 12 hours after birth
  • 11. Normal Postnatal Closure
    The second stage usually is completed by 2 to 3 weeks
    produced by infolding of the endothelium, disruption and fragmentation of the internal elastic lamina
    replacement of muscle fibers with fibrosis
    permanent sealing of the lumen to produce the ligamentumarteriosum
  • 12. mechanisms responsible for the initial postnatal closure of the ductusarteriosus are not fully understood
    increase in pO2, as occurs with ventilation after birth, constricts the ductusarteriosus
    prostaglandins play an active role in maintaining the ductusarteriosus in a dilated state
    PGE1, PGE2, and PGI2 dilate isolated ductusarteriosus strips or rings from term fetal lambs
  • 13. At birth, the placental source is removed, and the marked increase in pulmonary blood flow allows effective removal of circulating PGE2
    increased dramatically over the last two decades
    improved survival rate of premature infants
    incidence is approximately 0.02 to 0.04 percent among term infants born at sea level
    slight female predominance
    incidence is as high as 60 percent in infants born before 28 weeks gestation
  • 15. Clinical History
    The diagnosis of PDA canot be made at birth
    The murmur emerges after few days as the pulmonary vascular resistance falls
    History of prematurity is very important.
    Premature babies with respiratory distress tend to have large shunts
    PDA is moe common in females with a ratio of 2:1
  • 16. Family history is important , as it tends to recur in siblings
    Rubella infection to mother during the first trimester is a common cause
    maternal coxsackie virus infection is another cause
    Low birth weight is common, even in small shunts
    More common in children born in October to January
  • 17.
  • 18.
  • 19.
  • 20. Another interesting point is the relation to the altitude the patient was born
  • 21. Small DuctusArteriosus
    the resistance to flow across the ductusarteriosus is high
    only a small left-to-right shunt develops
    Pulmonary blood flow is increased only minimally
    left ventricular failure does not occur
    Most of the infants are asymptomatic
    Murmur is detected on routine physical examination.
  • 22. Moderate DuctusArteriosus
    In infants a moderate shunt produces symptoms of heart failure
    Poor feeding, irritability, and tachypnea are present
    symptoms ordinarily increase until about the second to third month
  • 23. Large DuctusArteriosus
    Infants with a large PDA are invariably symptomatic
    They are irritable, feed poorly, fail to gain weight and sweat excessively
    They have increased respiratory effort and respiratory rates
    prone to develop recurrent upper respiratory infections and pneumonia
    symptoms indicative of severe left ventricular failure with pulmonary edema may occur early in infancy
  • 24. Patients with reversed shunt
    Small number of cases
    High pulmonary vascular resistance, from infancy
    Effort dyspnea is the most common symptom
    Symptoms of left ventricular failure are absent
    Hoaseness of voice may be present.
    Cyanosis may be overlooked.
    There is marked leg fatigue and absence of dyspnea
    Rarely patients may have swelling and pain in lower limbs.
  • 25. Physical apperance
    Physical underdevelopment due to a large shunt
    Maternal rubella syndrome: cataract, deafness and mental retardation
    Rocker bottom feet and loose skin is present in trisomy 13
    In this syndrome assosiated VSD is usually present
  • 26. Examination
    Differential cyanosis and clubbing is pesent in shunt reversal
    It can be brought out by exersise or a warm water bath
    Useful to have patient sit with hands and feet together.
  • 27.
  • 28. Arterial pulse
    A wide pulse pressure is present
    Pulse has a brisk rise, single peak and rapid collapse
    Diastolic pressure is low, systolic is high
    The peripheral pulses are bounding
    If the shunt is small or if there is pulmonary hypertension the bounding pulse is absent
  • 29. JVP
    JVP is normal in small shunts
    In patients of cardiac failure the jvp is elevated and prominent A and V waves are present
    Prominent A waves are present in high pulmonary resistance
  • 30. Auscultation
    The classic murmur of uncomplicated PDA rises to peak in latter systole
    Continues without interruption through the second heart sound
    Declines in intensity in diastole
    a silent interval may be present towards the end of diastole
  • 31. Continious murmur
    A small duct results in a soft , high frequency continuous murmur
    A larger duct causes a loud noisy machinery murmur
    Loud murmur becomes soft if there is narrowing of the duct.
    The murmur is dependent on the pressure difference between aorta and pulmonary artery
  • 32. Progression of murmur
    As the diastolic pressure of pulmonary artery increases the patient is left with a holosystolic murmur
    As pulmonary hypertension progresses further the systolic component also disappears
    Right to left flow across PDA does not have a murmur
    With increasing PH Gibson murmur is abolished
    Findings of pulmonary hypertension are present
  • 33. Newborn
    In newborns the classic murmur is absent
    Only a soft systolic murmur may be present
    this is due to high pulmoary pressures
    However the signs of cardiac failure are present
  • 34. Second heart sound
    Paradoxical spitting is present in patients of large left to right shunts
    due to Prolonged LV ejection and short RV ejection
    Difficult to detect on auscultation
    With shunt reversal the second heart sound is closely split with loud pulmonary component
  • 35. ECG
    Small ductus ECG may be normal
    Variation in ecg depend on the volume overload of LV and pressure overload of RV
    Usually have sinus rhythm
    P waves are notched, bifid and prolonged
    s/o left atrial enlargement
    With development of pulmonary hypertension signs of biatrial enlargement are present
  • 36. PR interval is prolonged in 10 to 20 percent of patients
    QRS axis is normal
    Volume overload of left ventricle results in deep s waves in v1, tall r waves I v5 to v6, deep q waves and tall t waves
    A large shunt with pulmonary hypertension results in features of biventricular hypertrophy
    Large equidiphasic complexes are present from v1 to v6
  • 37. ECG in right to left shunt
    In PDA with right to left shunt peaked narrow right atrial P waves appear in 2,3,and v1
    QRS axis shows right axis deviation
    Right ventricular hypertrophy
    R waves in v5, v6 remain tall bur the q waves and the tall t waves disappear
  • 38. X ray chest
    Variation in XRAY depend on size, duration and direction and pulmonary pressures
    The ductus may be seen as a convexity between aorta and pulmonary artery
    In older patients calcium may be depoisted
  • 39.
  • 40. Left to right shunt causes increase in pulmoary plethora
    Pulmonary trunk and main branches are dilated
    Ascending aorta is enlarged in adults
    LA and LV are enlarged
    RA and RV dilatation occurs when pulmonary hypertension is present
  • 41. Right to left shunt
    RV is hypertrophied
    Pulmonary trunk and main branches are dilated
    Peripheral vasculature is reduced
    Ascending aorta is normal sized
    Patients who have shunt reversal have larger hearts
    Both RV and LV enlargement is seen
  • 42. Echocardiography
    A complete echocardiographic evaluation of the PDA includes
    two-dimensional imaging of the ductus,
    evaluation of the degree of shunting at the ductus, and
    evaluation of pulmonary artery pressure using Doppler echocardiography
  • 43. Anatomic assessment
    Most commonly, the ductus is imaged in the parasternal and suprasternal notch views
    In the high parasternal short axis view, with the transducer oriented leftward toward the pulmonary artery bifurcation, the ductus can be imaged coursing between the pulmonary artery and the descending aorta
    Absolute quantification of its diameter is the best way to determine its presence or absence
  • 44.
  • 45. In the suprasternal notch window, the ductus arises from the descending aorta at the level of the left subclavian artery, and courses anteriorly to join the pulmonary artery
  • 46.
  • 47.
  • 48. Color flow mapping is particularly helpful in the setting of a small PDA,
    Determination of the origin of the retrograde flow into the pulmonary artery using two-dimensional imaging as well as color flow mapping is crucial to avoid confusion of the patent ductus with other aortopulmonary shunts
  • 49.
  • 50. The Size of the Left Atrium
    Left atrial (LA) enlargement signifies increased pulmonary venous return because of left-to-right ductal shunting
  • 51.
  • 52. Left Ventricular Size
    This will enlarge as cardiac output increases with both increased pulmonary venous return and with increased diastolic run-off
    Descending Aortic Flow in Diastole
    The presence of a significant ductal shunt results in diastolic run-off to the pulmonary circulation
  • 53.
  • 54. Left Pulmonary Artery Diastolic Flow Velocity
    This is higher with large left-to-right shunts.  Values less than 15cm/sec are seen when the duct is closed
  • 55.
  • 56.
  • 57. Hemodynamic assessment
    The pulmonary to systemic flow ratio (Qp:Qs) can be determined echocardiographically
    When the pulmonary artery pressure is lower than systemic arterial pressure, there is continuous left-to-right shunting demonstrated.
    The velocity of flow across the ductus, measured by either pulsed or continuous wave Doppler,
    can be translated into the gradient between the aorta and the pulmonary artery
  • 58.
  • 59. When the pulmonary artery pressure is equal to systemic pressure, pulsed Doppler within the ductus demonstrates systolic right-to-left shunting, with diastolic left-to-right flow within the vessel
  • 60. Cardiac Catheterization
    Color Doppler flow mapping is generally as sensitive as cardiac catheterization for detecting even a small PDA
    In children with pulmonary hypertension, determining the exact location of the shunt can be difficult
    Right heart catheterization alone usually suffices to confirm the diagnosis
    an additional lesion such as ventricular septal defect is suspected
  • 61. An increase of pulmonary arterial blood oxygen content of >0.5 mL/dL or a saturation increase of >4% to 5% from that in right ventricular blood indicates a significant left-to-right shunt at the pulmonary arterial level
    An increase in oxygen saturation in pulmonary arterial blood is not diagnostic of a PDA, but may be present in lesions such as aortopulmonary window or a high ventricular septal defect
  • 62.
  • 63. a small communication, pulmonary arterial blood pressures are normal, but systemic arterial pulse pressure may be slightly widened
    a moderate-sized defect,
    1. pulmonary arterial systolic, diastolic, and mean blood pressures may be slightly elevated.
    2. Systemic arterial diastolic blood pressure falls,
    3. whereas systemic arterial pulse pressure increases
  • 64. large shunt hemodynamics
    pulmonary and systemic arterial pressures are equal,
    left atrial mean pressure may be increased substantially,
    and a prominent V wave is seen.
    Left ventricular end-diastolic pressure may be elevated,
    a diastolic pressure gradient between the left atrium and left ventricle is demonstrated.
    A small systolic pressure difference between the left ventricle and aorta is also encountered
  • 65. Angiography
    it is the most effective test for defining the anatomy of the PDA
    Contrast medium is injected into a catheter passed through the PDA into the aorta from the pulmonary artery or into the aorta retrogradely from the femoral artery
    PDA usually is widely dilated, and the ductus narrows down at the pulmonary arterial end
  • 66. the lateral projection, or occasionally the left anterior oblique projection, demonstrates the anatomy most clearly
    The AP camera can be positioned in the right anterior oblique caudal position to demonstrate the PDA
    selective descending aortography is essential in patients of VSD or ASD to demonstrate PDA
  • 67.
  • 68. Magnetic Resonance Imaging
    simpler techniques such as two-dimensional echocardiography Doppler evaluation accurately define the anatomy
    These studies can be of use in adolescents or adults with poor echo windows
    Velocity-encoded cine MRI imaging for estimation of left-to-right shunting may have additional clinical utility
  • 69.
  • 70. Percutaneous closure
    A variety of devices have been used for percutaneous closure of a PDA
    It is the standard of care in most patients
    Exception in premature and small infants with large shunts
    Have been available for last 20 years
  • 71. Coils
    Stainless steel Gianturcocoils
    Earlier used for AV malformations
    For duct closure the PDA should be less than 2 mm in diameter, long to accommodate loops and should have sufficient aortic ductaldiverticulum
    The coils are deployed in a retrograde fashion from the aorta
    Coil embolisation is a dangerous complication
    Modified coils with release mechanism are available
  • 72.
  • 73.
  • 74. Multiple coils are used for large PDA
    PDA closure rate are around 95 to 100% at 2 years
    Residual shunt causes haemolysis
    Modifications available are
    Giantruco-grifika vascular occlusion device
    Nit occlud PDA occluder
  • 75. Duct occluder device
    AMPLATZ duct occluder is only device which is FDA approved
    Cone shaped device
    Antegrade venous approach
    Delivery cable- release notch
    98% closure at 6 months in large PDA
    Complications are left pulmonary artery stenosis, aortic coarctation
    Small ducts are avoided
  • 76.
  • 77.
  • 78.
  • 79. Follow up
    Anticoagulation for 6 months
    Follow up 2d echo after 6 months
  • 80. Thank you