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Patent ductus arteriosus

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Patent Ductus Arteroisus, PDA, Cardiology, Paediatrics, Pedicatrics, Critical Care, Emergency medicine, Medicine, Internal Medicine, MBBD, MD, India, CMC Vellore, Christian Medical College

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Patent ductus arteriosus

  1. 1. Patent Ductus Arteriosus Dr. Arun George Paediatriic Emergency CMC Vellore
  2. 2. Introduction  Communication between the pulmonary artery and the aorta  Location – distal to left subclavian  F:M = 2:1  Maternal rubella, prematurity
  3. 3. History:  Irritable, feed poorly, fail to gain weight and sweat excessively  Increased respiratory effort and respiratory rates  prone to develop recurrent upper respiratory infections and pneumonia
  4. 4. Examination  Physical underdevelopment  Wide pulse pressure – bounding peripheral pulses  Hyperkinetic apex, continuous thrill in 2nd lt ICS  Continous murmur
  5. 5.  Accentuated first sound and narrowly or paradoxically split second sound (large shunts)  Differential cyanosis and clubbing is pesent in shunt reversal
  6. 6. What Physical Exam findingsWhat Physical Exam findings are consistent with PDA?are consistent with PDA? Murmur: systolic at LUSB/Left Infraclavicular, may progress to continuous (machinery) Cardiac: Active Precordium, Widened Pulse Pressure, Bounding Pulses Respiratory Sx: Tachypnea, Apnea
  7. 7. Hemodynamics  Flow during both systole and diastole – pressure gradient present throughout (pulm artery pressure normal)  Continuous murmur  Overload of pulm artery  increased flow through left atrium and ventricle – accentuated first sound and mitral delayed diastolic murmur  Delayed closure of aortic valve & late A2 (S2 may be paradoxically split)
  8. 8.  Dilatation of the ascending aorta  Aortic ejection click – preceeding the conti nuous murmur  Aortic ejection systolic murmur – drowned by the loud continuous murmur
  9. 9. ECG
  10. 10. CXR
  11. 11. Echocardiogram  Gold standard for diagnosing PDA Taken from Neo Reviews
  12. 12.  Color and pulsed doppler  Cardiac catheterisation
  13. 13. Assessment of severity  Heart size  Third sound and diastolic murmur  Pulse pressure
  14. 14. Course and Complications  Ejection systolic murmur at birth (due to pulmonary hypertension)  continuous murmur after a few weeks  Development of Pulmonary arterial hypertension  diastolic component lost  ejection systolic murmur  Severe PAH  rt to lft shunt  disappearance of the murmur and appearance of differential cyanosis
  15. 15. Complications:  Cardiac failure  Infective endarteritis  Eisenmenger  Rare complications -aneurysmal dilatation of the pulmonary artery or the ductus -calcification of the ductus -noninfective thrombosis of the ductus with embolization -paradoxical emboli
  16. 16. DDX Aorticopulmonary window defect Ruptured sinus of valsalva aneurysm Coronary arteriovenous fistulas Aberrant left coronary with massive collaterals from the right Truncus arteriosus VSD with aortic insufficiency Peripheral pulmonic stenosis Venous hum in TAPVC
  17. 17. Treatment Premature  Indomethacin 0.1mg/kg/dose 12 hourly 3 doses
  18. 18.  Prophylactic indomethacin has short-term benefits for preterm infants including a reduction in the incidence of symptomatic PDA, PDA surgical ligation, and severe intraventricular haemorrhage. However, there is no evidence of effect on mortality or neurodevelopment. Cochrane review 2010: Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants Peter W Fowlie et al
  19. 19.  Ibuprofen is as effective as indomethacin in closing a PDA and currently appears to be the drug of choice. Ibuprofen reduces the risk of NEC and transient renal insufficiency.  Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight (or both) infants Cochrane reviews 2015- Arne Ohlsson, Rajneesh Walia, Sachin S Shah
  20. 20.  Paracetamol appears to be a promising new alternative to indomethacin and ibuprofen for the closure of a PDA with possibly fewer adverse effects. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm and low-birth- weight infants Cochrane review March 2015- Ohlsson A, Shah PS
  21. 21. Treatment  All patients with PDA require surgical or catheter closure.  Rationale: Small PDA- prevention of bacterial endarteritis Moderate to large PDA- to treat heart failure or prevent the development of pulmonary vascular disease, or both.
  22. 22. Cardiac catheterization – Trans catheter closure  Small PDAs- closed with intravascular coils.  Moderate to large – catheter introduced sacs or umbrella like device
  23. 23. Intravascular coils - gianturco
  24. 24. Amplatzer patch
  25. 25. Surgery  Left thoracotomy  Thoracoscopic minimally invasive techniques.
  26. 26.  Closure of the ductus is indicated even in asymptomatic patients, preferably before 1 year of age.
  27. 27. Reference:  Nelson’s textbook of Paediatrics 20e  Ghai Essential Paediatrics 8e  Uptodate.com  Medscape  Wikipedia  Cochrane reviews

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