PDA - Dr. D. Gunasekaran

1. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
ACYANOTIC CONGENITAL HEART DISEASE

2. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA

3. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Blood is flowing from
Aorta to PA through
ductus
Ductus

4. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Ductus in foetus
Normal structure or not?
Why is it important in the foetal life?
To maintain foetal circulation
Connects which structures?
Aorta and PA
What keeps the ductus open in the foetus?
Low Pa O2 & High Prostaglandin E

5. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Fate of ductus after birth
Functional closure?
12 hours
(PaO2 increases & Prostaglandin E falls)
Anatomical closure?
2 weeks

6. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
PDA Preterms & Terms
Common in preterms:
Usually they have hypoxia (O2 is potent vasoconstrictor)
The actions of Prostaglandin E is more in them
Smooth muscles in the ductus is immature
Prostaglandin analogues may be tried to close PDA
Can PDA occur in terms?
Yes; less common;
Poor mucoid endothelial layer and poor muscle media
So, they require surgery for their closure.

7. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Hemodynamic changes:
RARVPALungsPVLAMV LVAVAorta
Other parts of the body
What organic murmur? Why?
What flow murmurs? Why?
Which chamber gets enlarged? Position of AI? Type of AI?
Why recurrent RTI?

8. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Classification of PDA
Size:
Small, Moderate or Large
(0.5cm2, 0.5-1cm2, >1 cm)

9. Patent Ductus Arteriosus
Symptoms may or may not
present at birth
Look for Dysmorphic features
Rubella History essential
Gestational age at delivery
essential

10. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Symptoms in PDA
Small PDA:
Asymptomatic; growth is normal;
Murmur - routine clinical examination.
Moderate to Large PDA:
 Breathlessness on exertion
 Exercise intolerance
 Feeding difficulties
 Failure to thrive
 Frequent RTI
 Forehead sweating
Chest pain, palpitation, syncope ???

11. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Vitals in PDA
Pulse: Volume? Rate? Character? Rhythm?
Blood pressure?
If there is CCF:

12. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
General examination
Undernourished, pallor & vitamin def may be +
Pedal edema or Pre sacral edema if CCF +
Look for signs of I.E

13. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Examination of heart
Inspection:
Precordial bulge (Cardiomegaly – Pliable chest)
Harrison sulcus +/-
Respiratory distress (CCF, LRTI)

14. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Examination of heart
Palpation:
Position of apical impulse:
Shifted down & out (LV enlargement)
Type of apical impulse:
Hyper dynamic
Palpate in the left upper para-sternal area:
Continuous thrill in the upper left sternal order
Palpate in the PA for the presence of PHT:
Palpable P2

15. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Examination of heart
Auscultation:
Heart sounds:
Usually, no changes
Murmurs:
Continuous – left upper parasternal area - grade 4, 5 or 6
(heard throughout the systole & diastole, as the pressure in the Aorta > PA)
Other possible murmurs: Flow murmurs:
MDM at MA – often drowned by the loud continuous murmur
ESM at AA-often drowned by the loud continuous murmur

16. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Complications
Congestive Cardiac Failure
Pulmonary Hypertension
Recurrent LRTI
Failure to thrive
Eisenmengers syndrome
Infective Endocarditis

17. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Complications
Congestive Cardiac Failure:
Symptoms:
Gen Exam:
Vitals: Pulse:
BP:
Auscultation of Heart:
RS:
Abdomen examination:

18. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Complications
Congestive Cardiac Failure:
Symptoms: Breathlessness, PND or Orthopnoea, cough
Gen Exam: Pedal edema
Vitals: Pulse:
BP:
Auscultation of Heart: Gallop
RS: Basal creps
Abdomen examination: Tender hepatomegaly

19. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Complications
Pulmonary Hypertension:
Palpable P2
P2 loud
Ejection systolic murmur
Continuous murmur  systolic murmur (In severe PHT,
pressure in Aorta = pressure in PA in diastole; so, PDA
murmur is heard only in systole)

20. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Blood is flowing from
Aorta to PA through
ductus
When this can
happen?
What is its name?

21. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Complications
Eisenmengers syndrome:
Shunt reversal in severe PHT; Cyanosis
Can occur in all LR (VSD, ASD & PDA)
Non-restrictive lesions, in late teens age
If it occurs in PDA:
P2 becomes loud
Instead of continuous murmur, only systolic murmur +

22. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Differential diagnosis (of continuous murmur)
Venous hum:
Murmur is heard above the clavicle, best between the sternomastoid heads;
Well heard if head is turned to the R side
Disappears if the head is turned to the same side or when the pt. lies down
Aorto-Pulmonary window:
Very difficult to differentiate; ECHO is necessary
Rupture of Sinus of Valsalva:
Diastolic component is accentuated; heard little lower down (3rd LICS)
Coarctation of Aorta with Collaterals:
Murmur is heard in the inter-scapular area

23. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Natural History
Spontaneous closure :
Possible in Preterms ; but, not in terms (abnormal smooth
muscle of ductus).
In smaller PDAs, the risk of IE is more
In larger PDAs:
Risk of CCF is more; (8 weeks of age)
Risk of PHT is more

24. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection
ECG: Chamber enlargement
ECHO:

25. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Normal heart & cardiomegaly

26. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Management
Medical:
Dental Hygiene
Infective Endocarditis Prophylaxis
Diet: high calorie and high protein
Frequent short breast feeding
Anemia correction, vitamin supplements

27. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Management
Medical: Drug used?
Indomethacin
Dose: 0.2 mg/kg /dose ; 3 doses; 12 hourly
Best before 3 days; at least by 10 days
Indication: only in Preterms
Contra indications: NEC, Renal impairment, thrombocytopenia
In renal impairment: Ibuprofen can be tried

28. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Management
Medical: Transcatheter closure
Indications: Term baby, PDA with cardiac failure
Devices used: Rashkind umbrella occluder
Spring coils
Amplatzer mush room occluder

29. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Blood is flowing from
Aorta to PA through
ductus
When this can
happen?
What is its name?

30. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Blood is flowing from
Aorta to PA through
ductus
When this can
happen?
What is its name?

31. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Management - Surgical
Closure: Ligation and division – left lateral thorcotomy
No need for cardiopulmonary bypass
Decision for surgery:
Always operate, irrespective of the size
Best between 6 months to 2 years (before PHT develops)
Until surgery, IE prophylaxis

32. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
6
Blood is flowing from
Aorta to PA through
ductus
Tie at both ends and
then cut in between

33. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Management - Surgical
Contraindications for surgery:
Severe PHT
(PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion
> 12 wood units / m2 BSA)

34. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
Syndromes associated with PDA
1. Chromosomal anomalies: Trisomy 18 (Edward synd)
Trisomy 13 (Patau synd)
Cri-du-chat syndrome
Fragile X syndrome
2. Syndromes: CHARGE, VATER
3. Maternal conditions: Rubella, Phenytoin, Diabetes

35. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA
PDA is a must to sustain life in
Aortic atresia
Pulmonary atresia
TGA with intact atrial and ventricular septum
To keep it open:
infuse Prostaglandin continuously

36. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - PDA