website:
www.drsarma.in
• 1888 – Munro – Cadaver Dissection – Ligation
• 1940 – 50 years later surgical Rx. PDA closure
• 1971 – Cather based closure Rx. Options
Structures in close proximity to ductus
• Recurrent Laryngeal nerve
• Thoracic duct
• Phrenic nerve
• Pulmonary Vascular Resistance (PVR)
• Associated Congenital Anomalies
• Direction of shunt – L
R or R
L
PVR =
( Mean pulmonary artery pressure – mean
pulmonary capillary wedge pressure ) 
cardiac output =
1.7~2.0 mmHgL-1min or 144 dyne.sec.cm-5
• PGE2 Production by the ductus
• PGE2 high levels from placenta
• No clearance of PGE2 by fetal lungs
• Difference in oxygen tensions
• At birth – Placental supply of PGE2 is cut off
• Metabolism by lungs removes PGE2
•  levels of PGE2 stimulate closure of Ductus
• Functional Closure
– Occurs with in 15 hours after birth
• Anatomical Closure
– Takes place with in 6 to 8 weeks
• Spontaneous closure after birth
– Can occur up to 2 years
• Best time for surgical closure
– 3 years of age
Patent ductus arteriosus (PDA) is a congenital
heart disease that is usually noted in the first few
weeks or months after birth. It is characterized
by a connection between the aorta and the
pulmonary artery, which allows oxygen-rich
blood intended for systemic circulation to
reenter the lungs
•
•
•
•
•
•
•
•
•
Prematurity < 32 weeks – 20%; < 28 weeks 60%
Low birth weight
Maternal Rubella
Fetal Alcoholic Syndrome (FAS)
Asphyxia around term and delivery
Familial or Genetics
5 to 10% of all C.H.Ds
Approximate incidence – 0.02% to 0.0006%
Gender: Male v/s Female – is 1:2
Location of PDA
• Usually left side
• Occasionally right side
• From the bifurcation of
PA to
• The descending part of
Aortic Arch
• Distal to the origin of
the Lt. subclavian A
• Embryologically it is
from 6th aortic arch
• http://www.indiana.edu/~anat550/cvanim/f
etcirc/fetcirc.html
A Conical
B Window
C Tubular
D Complex
E Elongated
20% by 20
years of age
45% by 45
years of age
60% by 70
years of age
•
•
•
•
•
•
•
•
•
Effort intolerance
Pulmonary congestion
CHF in adults
Arrhythmias in adults
Wide pulse pressure
Collapsing pulse
Hyper dynamic apex
Displaced apex – LVH
Differential cyanosis
•
•
•
•
•
•
•
•
•
S1 and S2 muffled
Paradoxical split of S2
Precordial thrill
SS notch, 2nd Lt. space
Continuous murmur
Machinery murmur
Train in tunnel murmur
Gibson’s murmur
Respiratory variation
Congenital, Developmental Disorders
•
Patent ductus arteriosus
•
Coronary arteriovenous fistula
•
Anomalous origin coronary artery/sinus
•
Aortic septal defect / window
Anatomic, Foreign Body, Structural Disorders
•
Sinus of Valsalva ruptured aneurysm
•
Pulmonary arteriovenous fistula
Functional, Physiologic Variant Disorders
•
Cervical venous hum, Mammary soufflé
Right to Left
Left to Right
Direction of shunt depends on pressures
1.
2.
3.
4.
5.
Effort intolerance
Signs of PHT and Right heart overload
Differential cyanosis
Clubbing
Disappearance of diastolic component
of the continuous murmur
6. Pulse no more collapsing
7. Syncope is not a feature of PDA
•
•
•
•
•
May be normal ECG
LVH may be seen
Pulmonary hypertension
ST-T changes due to LV strain
RVH, RAE may be seen
Available in boxes of 5 vials/ampules
Cost per vial Rs. 2500 – 3200
500 mcg drug in one ml vial – dilute with 49 cc D5
Standard concentration 10 mcg/ml
(NEOFAX) or (PROSTIN) 0.05-0.2 mcg/kg/min IV
1. Spontaneous closure (with in 2 years)
2. If symptomatic treatment is prudent
a)  systemic O2 delivery
b) Respiratory distress
3. Medical management
a)
b)
c)
d)
IV Indomethacin (Indocin) 0.2mg/kg x 3 -12 hourly
IV Ibuprofen (NeoProfen) 10 mg/kg – 5mg/kg
Bacterial Endocarditis prophylaxis, Antibiotics
Diuretics/ Digoxin – BNP guided Rx.
4. Catheter based closure of PDA
a) Gainturco – Spring Occluding Coils
b) Amplatzer Duct Occluder – ADO I & ADO II
c) Rashkind Duct Occluding Device – RDOD
5. Surgical closure
a) Ligation and Division – L&D – Open surgery
b) Video Assisted Thoracoscopic Surgery (VATS)
•Ideal age for surgical / device closure – 3 yrs.
•Contraindication – Any disease of pulm. valve
• Age more than 3 years
• Children less than who are symptomatic
• Significant left-to-right shunt suggested by
– Symptomatic – effort intolerance, recurrent LRI,
– e/o left-sided volume overload, LVH, LAE
– Reversible pulmonary arterial hypertension (PAH)
• Irreversible pulmonary vascular disease
(Eisenmenger syndrome) – e/o shunt reversal
• Other associated congenital heart diseases
1. Echocardiography of PDA
2. Devise closure of PDA
3. Surgical closure of PDA
Click on the enclosed video files in the folder