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patent ductus arteriosus

Congenital anomaly resulting from failure of the ductus arteriosus to close after birth. Etiology: - maternal rubella - premature delivery * also see Eisenmenger's syndrome Pathology: 1) arteriovenous fistula 2) small ductus compatible with normal life span 3) ductus may calcify in adult life 4) large patent ductus arteriosus may cause significant left-to-right shunt, with left sided cardiac chamber enlargement & result heart failure 5) may produce elevated pulmonary pressure - patent ductus arteriosus with severe pulmonary hypertension is Eisenmenger's syndrome* * Eisenmenger's syndrome is severe pulmonary hypertension associated with left-to-right shunt (patent ductus arteriosus, ventricular septal defect or atrial septal defect) Clinical manifestations: 1) may be asymptomatic 2) retarded growth 3) exertional dyspnea 4) heart murmur spanning the entire cardiac cycle a) machinery-like (machine-like) in quality b) late systolic accentuation c) loudest in the 2nd intercostal space beneath left clavicle d) S2 may be inaudible 5) collapsing pulse (large shunt) 6) high pulse pressure (large shunt) 7) adults may present with: a) cyanosis & clubbing of feet > hands b) heart failure [3] Special laboratory: - electrocardiogram - normal with small PDA - left atrial enlargement, left ventricular hypertrophy - right ventricular hypertrophy with pulmonary hypertension - angiography determines morphology & feasibility of percutaneous surgical closure [3] Radiology: - chest X-ray - normal with small PDA - with large PDA - cardiomegaly, increased pulmonary vasculature - calcified PDA - with pulmonary hypertension - prominent central pulmonary arteries - reduced peripheral pulmonary vascular markings - pulmonary artery opacification on aortogram - echocardiogram Complications: - endocarditis [3] - right heart failure, pulmonary hypertension, Eisenmenger's syndome with large PDA Management: 1) size determines management: a tiny PDA requires not intervention [3] 2) surgery is curative - indications - left atrial enlargement or left ventricular enlargement - absence of pulmonary hypertension &/or left-to-right shunt - systolic pulmonary artery pressure < 50% of systolic blood pressure [3] - surgical closure may result in clinical deterioration [3] 3) medical therapy for pulmonary hypertension if patient is not a candidate for surgery 4) endocarditis prophylaxis not needed after surgery

Related

ductus arteriosus (Botallo's duct)

General

congenital heart disease; congenital cyanotic heart disease

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 46
  2. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 880
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022.
  4. Silversides CK, Dore A, Poirier N et al Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: shunt lesions. Can J Cardiol. 2010 Mar;26(3):e70-9. PMID: 20352137