This document discusses the case of a 2 year old male child presenting with recurrent lower respiratory tract infections. On examination, a systolic murmur was heard. Echocardiogram showed a patent ductus arteriosus (PDA) of size 8mm with left to right shunting. Cardiac catheterization found a Qp/Qs ratio of 1.83, confirming a left to right shunt. Post oxygen, the Qp/Qs ratio increased to 2.94, and PVR decreased, indicating reactivity. The document then discusses two other cases and provides information on indications for catheterization in PDA, angiographic views, classifications of PDA, and factors affecting shunting through a PDA

1. CATH MEET
Dr.NAGULA PRAVEEN

2. Case
• 2 year old male child.
• h/o recurrent LRTIs at presentation.
• Patient had h/o breathing difficulty, feeding difficulty and poor
weight gain at the age of 3 months. Symptoms decreased with
medications,was diagnosed to have a heart disease at this
admission.
• No H/o cyanotic spells, pedal edema .
• No F/o consanguinity, no other member in the family having a
Heart disease.

3. On examination:
Physical Examination:
• weight-8kg, height-81 cm,
• No anemia,no cyanosis,no jaundice,no clubbing,no
lymphadenopathy,no pedal edema.
Vitals :
• Pulse - 106/min,regular,high volume & no special character
no Radio radial or radiofemoral delay.
• B.P-110/50mmhg,
• RR-25/min,
• Afebrile.

4. CardioVascular System
• JVP : normal mean column height with normal wave pattern.
Inspection & Palpation :
• Apex is in 6th ICS,LV type at Anterior Axillary line, hyperdynamic.
• Grade 2/3 parasternal pulsations felt,
• Palpable P2,
• Systolic thrill in 1st & 2nd Lt ICS.
Auscultation:
• S1-Normal
• S2- Narrow split ; P2 >A2 in Pulmonary Area
• no additional sounds
• A 4/6 long systolic murmur most prominent in 1st & 2ndLt ICS, high
pitched,increases with inspiration,
• no other murmur.

5. ECG

6. ECHO
• Situs solitus,levocardia, 2atria,2ventricles, AV –VA concordance ,
NRGA , normal systemic and pulmonary venous drainage.
• PDA of size 8mm - shunt is Left to right shunt with Pressure
Gradient of 25 mm hg in systole and 10mm in diastole.
• PA Systolic pressure of 80 mm hg.
• LA, LV are dilated .
• Mild MR,no PR,TR.
• Normal biventricular function
• No associated VSD,COA, ASD.
• Left sided aortic arch.

7.  2 year old,Height - 81 cm, weight - 8.5 kg, BMI- 12.95 Kg/m²,
 Hb-10.1gm/dl, O2 con-175 ml/min/mt², BSA- 0.48 m²
 Catheter course:
RT FV---IVC---RA--- RV--- PA---PCW
RT FA---Ao---LV PDA ---DES.AORTA.
CATHETERISATION
PRESSURE DATA in mm Hg
FA--- 110/50 (67)
RA--- 4
RV--- 80/0-6
PA--- 80/40(54)
PCWP--- 5
LV--- 106/0-8
SATURATION DATA in %
SVC--- 64.6
IVC--- 68.6
MVO2--- 65.07
RA--- 63.4
RV--- 67.5
PA--- 83.4
FA--- 94.9
PV - 98.0

8. • Qp = 175/13.6 × 10.1×(0.98 -0.83) = 8.73 L/min.
• Qs = 175/13.6 × 10.1 ×(0.95 -0.67) = 4.77 L/min.
• Qp/Qs = 8.73/4.77 = 1.83
• PVR = 54-5 / 8.73 = 5.612 wood units
• SVR = 67-4 / 4.77 = 13.2 wood units
• PVRI/SVRI = 5.612/13.2 = 0.425
CATHETERISATION

9. CATHETERISATION
POST O2
Pressure Data in mm Hg
FA--- 120/74 (90)
RA--- 3
RV--- 70/0-4
PA--- 70/40(50)
PCWP--- 15
LV--- 115/0-6
Saturation data in %
SVC--- 82.1
IVC--- 87.5
MVO2--- 83.45
PA--- 98.7 (pO2=161mmhg)
FA--- 99.9 (pO2 =417mmhg)

10. • Qp = 175/(13.6×10.1×0.99+13.34) – (13.6×10.1×0.987 + 5.15) =
17.78L/min.
• Qs = 175/(13.6 ×10.1×0.99+13.34)-(13.6×10.1×0.834+1.8) =
6.04L/min.
• Qp/Qs= 17.78/6.04 = 2.94
• PVR= 50-15/17.78 = 1.96 wood unit
• SVR= 90-3= 14.40 wood unit
• PVRI/SVRI =1.96/14.40 = 0.136
CATHETERISATION
POST O2

11. Case 2
• 3 yr old F
• Wt 13.6 kgs
• Child had been very active,without evident dyspnea or cyanosis.
• A murmur was first reported at 1 ½ yrs.
• Her development was normal for her age.
• Mild pallor
• JVP normal,BP – 104/38mmHg
• Systolic at left 2nd and 3rd Left ICS.
• P2 masked by murmurs.
• Very loud,continuous,machinery type systolic and diastolic
murmurs,left 2nd 3rd ICS.
• ECG- normal ,normal axis,LVH

12. Cath data
Pressure data (mm Hg)
• RA – 5
• RV – 31/4 (13)
• PA – 30/13(19)
• LA – 8
• LV – 90/40 (65)
Saturation data
• IVC – 65
• SVC – 62
• MV02 – 62.75
• RA – 61
• RV - 65
• MPA – 65
• LPA – 80
• AORTA – 95
PDA without pulmonary hypertension
Qs – 2.38 l/min
Qp – 4.98 l min
Qp/Qs – 2.09:1

13. Case3
• 8yrs old F
• Weight 18.4 kg
• 2 episodes of pneumonia and frequent bronchitis.
• Less active than other children.easy fatiguability and dyspnea on climbing more
than one flight of stairs.
• No h/o suggestive of rheumatic fever.
• Fragile,under developed child.
• No cyanosis.
• Examination: slight precordial bulge to left of sternum.
• JVP normal
• Systolic thrill at left 2nd ICS.
• S1 loud,P2 accentuated.
• Long loud coarse systolic
• Coarse early to mid diastolic left 2nd ICS.
• High pitch Systolic murmur LLSB.
• MDM at apex
• ECG- notching of P wave,biventricular hypertrophy

14. Cath data
• Saturation data:
• SVC – 60
• IVC – 65
• MVO2 – 61.25
• RA – 60
• RV – 72
• PA – 88
• PV - 98
• Aorta -98
Pressure data:
RA – 5
RV - 64/6(25)
PA – 64/23(39)
LV – 104/10
Aorta – 107/46(73)
LA – 8
Qp = 9.50 lit/min
Qs = 3.10 lit/min
L-R shunt ventricular – 0.90 lit/min
Aorta to pulmonary – 5.5 lit/min
PDA with VSD with pulmonary hypertension

15. PATENT DUCTUS ARTERIOSUS

16. Indications for catheterization
• Usually does not require.
• Color doppler is as sensitive as cardiac catheterization for
detecting even a small PDA.
• 1.Clinical findings – symptomatology discreprancy.
• 2.Severity of pulmonary hypertension.
• 3.Reactivity to pulmonary vasodilators.
• 4.If closure is indicated in a particular case scenario.
• 5.Detection of assosciated lesions.

17. • Right heart catheterization – suffices to confirm diagnosis.
• Venous catheter from MPA – PDA – descending aorta.
• Retrograde – if interatrial spetum is intact, LV cannot be
entered prograde.
• Catheters used.
• Multipurpose catheter
• Pigtail

18. Angiographic views
• Defining the anatomy of the PDA.
• Left Lateral projection. – for sizing of device
• LAO 60 - profile of PDA
• RAO caudal
• RAO 30 – ampulla at pulmonary end

19. Isolated PDA type A
DuctusinTricuspidatresia
Ductusarisingmoreproximally
Ductusarisingmoreproximally,elongated
Ductusarisingveryproximallyundersideofarchtypicallyseenin
TOF-PA
DuctusarisingfromsubclavianarteryinTOFPAwithrightsided
aorticarch

20. Significant shunt at great arteries
• An increase of pulmonary arterial blood oxygen content of
>0.5mL/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.

21. Imp points
Feature Implication
Increase in O2 saturation just below the
pulmonary valve
Pulmonary Regurgiation
A sample from either one of the pulmonary
artery branches does not reflect mixed
pulmonary arterial blood oxygen saturation
preferential streaming of oxygenated blood
from the PDA into one or another
pulmonary branch.
Accurate pulmonary blood flow from blood
oxygen data
difficult
Accurate calculation of true magnitude of
left to right shunting
impossible
Reduced PVO2 LV failure with pulmonary edema
Increased O2 saturation in RA blood PFO with L-R shunt
Presence of large ASD Masks the significant shunt at great artery
level
O2 saturation of blood in the descending
aorta less than that obtained in the
ascending aorta
Significant Pulmonary hypertension,R-L
shunting

22. • Increase in oxygen saturation in pulmonary arterial blood is
not diagnostic of a PDA,
But may be present in lesions such as
• Aortopulmonary window,
• Supracristal VSD,
 streaming may direct the highly saturated blood into the pulmonary
artery.
• Calculation of pulmonary blood flow is inaccurate,the calculation
of pulmonary vascular resistance is also inaccurate.

23. Shunt depends upon
3 major factors
• Diameter and the length of the ductus arteriosus
• Pressures between the aorta and the pulmonary artery
• Systemic and pulmonary vascular resistances

24. Pulmonary arterial
blood pressure
Systemic arterial
pressures
Pulse pressure
SBP/DBP/MP SBP/DBP/MP
Small PDA normal Low diastolic pressure widened
Moderate sized PDA Slightly elevated,less
than Systemic
Pressures
Low DBP
Mean pressure elevated
widened
Large PDA with
pulmonary
hypertension
Equal to Systemic
pressures
Increased LVEDP
Diastolic gradient between
LA and LV
LA mean pressure may be
increased
Prominent V wave
Small systolic difference
between LV and aorta
decreased

25. Classifications
• Krichenko’s classification
• Sri Chitra Tirunal classification
• Size of the ductus
• Staging of PDA

26. Krichenko classification
Type A : CONICAL ductus
Well defined aortic ampulla
Constriction near pulmonary artery end
Type B : WINDOW ductus
Very short length
Type C : TUBULAR ductus
No constrictions
Type D: COMPLEX ductus
multiple constrictions
Type E: ELONGATED ductus
Constriction remote from the anterior edge of trachea

27. Krichenko et al .Am J Cardiol.1989;63:877-79

28. Sri Chitra Tirunal Classification of PDA,
ProfJaganMohanA.Tharakanetal.(2003)
• Angiographic appearance of PDA
• Retrograde analysis of the appearance of PDA on angiography
selected for device closure.
Magnification factor = catheter size measured on the screen
/ Actual catheter size.
• Measurement of anatomical components of ductus
Ex:
Ampulla size = ampulla measured on screen / magnification
factor.
Lateral view
167 pts

29. Patentductusarteriosus
Saucer shaped
Length of the ductus < 6 mm
Narrowing at PA end by > 50% of the
width of the ampulla
Cylindrical
(tubular ductus)
Length of ductus > 6mm
Narrowing at PA end by < 50 % the
width of ampulla
Conical
(cup shaped)
Length of ductus > 6mm
Narrowing at PA end >50% of the width of ampulla
Length of this narrow portion (stem of the ductus ) <
1/3 of the total length of the ductus
Funnel shaped
Similar to conical
Longer stem >1/3 of the total length
of ductus
Hour glass shaped Ampulla at both PA end and the
aortic end

30. Patent Ductus Arteriosus
Length of ductus
< 6mm
PA end narrowing
> 50% of width
of ampulla
Saucer
shaped
> 6mm
PA end narrowing
> 50% width of ampulla
Length of narrow
portion
< 1/3
of length of ductus
Conical
(cup shaped)
Longer
stem
Funnel shaped
< 50 % of
width of ampulla
Cylindrical
Ampulla
Usually at
aortic end
At both ends
Hourglass type

31. Saucer shaped ductus
Shallow depth of ductus
Hardly any narrowing at the pulmonary end

33. Based on size of ductus

34. Staging of PDA
• Clinical
• C1 – Asymptomatic
• C2 – Mild
• C3 – Moderate
• C4 – severe
• Echocardiography
• E1 – no evidence of flow on 2D or doppler interrogation
• E2 - small non significant ductus
• E3 – moderate HSDA
• E4 - Large HSDA

35. Staging of PDA

36. Treatment of preterm infantsMedical :
Oral /IV indomethacin
• Effects are apparent when administered < 10 days of age, less mature infants.
• Infants <1000g before manifestation (<72 hrs of age).
• C/I : Renal dysfunction, necrotizing enterocolitis,overt bleeding, shock, ECG
evidence of myocardial ischemia.
• Serum creatinine >1.6mg/dl, BUN >20 mg/dl.
• Dose – 0.2mg/kg NG or IV.
• A total of three doses,12-24 hrs apart, based on urinary output.
• If urine flow decreases – increase the time period or less doses.
• Second course if clinical signs reappear.
• True prophylactic therapy on the first day after birth - no advantage.
• Refractory patients – L NMMA and indomethacin.
Ibuprofen (less side effects,increased pulmonary hypertension).
Oral paracetamol
< 48 hrs Subsequent two doses are 0.10mg/kg IV
2-7 days 0.20mg/kg
>7 days 0.25mg/kg

37. Surgical
• Unsuccessful /not possible medical treatment.
• <10 days of age -  duration of ventilatory support,hospital
stay,lowers morbidity.
• Ligation rather than division of ductus arteriosus.
• Thoracoscopic surgery
• Both are safe,0% mortality,100% complete closure.
• Less morbidity with thoracoscopic surgery.

38. Complications
• Bleeding
• Pneumothorax
• Infection
• Injury to recurrent laryngeal nerve
• Ligation of the left pulmonary artery or aorta

39. Percutaneous in pre term infants
• 4F catheters,outer diameter <1.3mm.
• Reports of closure in infants <1.5kg.
• Antegrade apporach –femoral vein.
• Late femoral vein thrombosis.
• Device embolization.

40. Prophylactic closure
• Not advised in preterm infants,even extremely low birth weight ones.

41. Term infants,children,adults
• 9 months of age – asymptomatic infants.
• Catheter coil/device closure
• Surgery
• Indomethacin – ineffective

42. Catheter coil/device closure
• Outpatient procedure.
• Sheaths 4-8 Fr.(1.3 to 2.5 mm outer diameter)
• Single coil loop on the pulmonary artery side and the remaining three
to four loops – aortic ductal ampulla.
• Size of the device atleast 2 mm more than the narrow diameter of the
duct.
• >97% success procedural rate.
• >98% closure rate at 6 months.
< 2.5 mm Occluding coils
Platinum, stainless steel
Few mm to < 12 mm ADO,
PFM duct occlud coil
> 12 mm AGA septal occluder,
AGA VSD device,
NMT cardio SEAL device.
Covered stents

44. Complications
• Embolization
• Usually can be retreived
• Disturbance in the proximal left pulmonary artery or
descending aorta from a protruding device
• Hemolysis from high velocity residual shunting.
• Femoral artery or vein thrombosis
• Infection.

45. Surgery
• Surgical ligation --- left 4th ICS lateral thoracotomy
• Surgical division
• Midline thoracotomy with cardiopulmonary bypass – complex
cases
• Post device embolization
• Calcified PDA
• VATS
• Transaxillary muscle sparing thoracotomy

46. Surgery
• Indications : PDA too large for catheter closure.
• Minimal mortlaity and morbidity.
• Return to activity in <3 weeks.
• Video Assisted Thoracoscopic Surgical (VATS) closure.
• Advantages over conventional
• Tearing and hemorrhage with large PDAs in adults (calcified)
• Higher rate of laryngeal nerve injury

47. PDA with Pulmonary hypertension
 Response to test occlusion with a balloon catheter,O2,NO.
 Good response – closure advised.
 Device closure > surgical.
 Equivocal response –
 Home oxygen
 Sildenafil
 Bosentan
 Inhaled iloprost
 Repeat catheterization 4-9 months later
 Post procedure – pulmonary vasodilators.
 Only C/I to closure – severe pulmonary hypertension with
irreversible pulmonary vascular disease and baseline right to left
ductal shunting despite maximal medical pulmonary vasodilation.

48. Take home message
• PDA is congenital malformation with a left to right shunt at
great artery level.
• Clinical implications vary depending on the age,anatomy of the
ductus and the underlying cardiovascular status of the patient.
• Echocardiographic diagnosis is enough in most of the
case,reserving the catheterization in complex cases,Pulmonary
hypertension for feasibility.
• Surgery was definitive treatment for PDA previously.
• Transcatheter replacing the surgery over the past 3 decades in
most of the patients.
• Complications can be avoided by appropriate diagnosis and
management.

49. Questions asked
• 1.what are the lesions to be suspected along with PDA?
• 2.what are ductal dependent lesions ?
• 3.what will be the gradients between the aorta and pulmonary
artery in restrictive,moderately restrictive,unrestricted PDA?
• 4.what is the importance of the ampulla?
• 5.how you will assess the size of device for PDA?
• 6.describe the procedure of PDA device closure?
• 7.how do you suspect based on the catheter course whether PDA
or AP window?
• 8.significant step up at the great artery level ?
• 9.what is the criteria for adequate response of reversibility?
• 10.what is the use of covered stent in PDA?
• 11.in what cases PDA will be kept patent?