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Patent ductus arteriosus (PDA) is a congenital disorder in the heart wherein a neonate's ductus arteriosus fails to close after birth. Early symptoms are uncommon, but in the first year of life include increased work of breathing and poor weight gain. With age, the PDA may lead to congestive heart failure if left uncorrected. The ductus arteriosus is a normal fetal blood vessel that closes soon after birth. In a patent ductus arteriosus (PDA) the vessel does not close and remains "patent" (open) resulting in irregular transmission of blood between two of the most important arteries close to the heart, the aorta and the pulmonary artery. PDA is common in neonates with persistent respiratory problems such as hypoxia, and has a high occurrence in premature children. In hypoxic newborns, too little oxygen reaches the lungs to produce sufficient levels of bradykinin and subsequent closing of the DA. Premature children are more likely to be hypoxic and thus have PDA because of their underdeveloped heart and lungs. A patent ductus arteriosus allows a portion of the oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta (which has higher pressure) to the pulmonary artery. If this shunt is substantial, the neonate becomes short of breath: the additional fluid returning to the lungs increases lung pressure to the point that the neonate has greater difficulty inflating the lungs. This uses more calories than normal and often interferes with feeding in infancy. This condition, as a constellation of findings, is called congestive heart failure. In some cases, such as in transposition of the great vessels (the pulmonary artery and the aorta), a PDA may need to remain open. In this cardiovascular condition, the PDA is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the patent ductus arteriosus open
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Patent Ductus Arteriosus
Ramachandra
The bottle neck of large PDA:Occasional missed large PDAs with or without Eisenmenger syndrome by even renowned cardiologist.
Time line1939:Surgical ligation by Gross and Hubbard1980:Maturation stages of ductus by
Gittenberger-De Groot AC et.al1989: Krichenko A, Benson LN, Burrows P, et al:
classification1967:First transcatheter closure by Portsmann
and coworkers1979:doubleumbrella device by Rashkind2003:Amplatzer device
Define
If ductus remains patent beyond 3 months of
life in full-term infants and beyond 1 year in premature infants, it is termed persistent PDA
Signature of PDA
• Most of them small• Seesaw murmur• TTE is enough for Dx and Rx• PDA with noise needs closure• Percutaneus closure is Rx-98% success• No IE prophylaxis
Foetal Life
PDA is life thread in normal developing heart like
part of series connection in electrical circuit shunting 60-70% oxygenated umbilical venous return to aorta
Post natal
After birth the duct closes functionally in 12 to 18 hours and anatomically in 2 to 3 weeks.
Embryology day 29 6th aortic /pulmonary arch develops 8th week of gestation, the ventral portions of the RT
and LT 6th AA form the proximal part of the RPA and the proximal part of LT MPA ,respectively. The dorsal portion of the right sixth arch is obliterated along with the right dorsal aorta. Sometimes the dorsal portion of the left 6th arch persists as a vascular conduit called PDA arising from the roof of the junction between the main and LPA and joining the left dorsal aorta just distal to the LSCA in normal left-sided aorta
Anatomy
• Usually LPDA• PDA and DTA angle at junction is 30 degree• Angiographic class: A to E (90 degree LL) by
Krichenko & colleagues®• 80% of PDA : A or B, Rx=Percutaneus closure• Siblings: Reverse , Rt AA,aneurysm•
Krichencko et.al:1989• Angiography • Dead left lateral• Left angiograms• Types– A:conical– B:window(L< 2 to 3 mm)– C:Tubular(both ends narrowing)– D:complex(multiple narrowing)– E :Elongated=a beaklike constriction at the
pulmonary end
Hemodynamic classification
• Small PDA :QP:QS <1.5 to 1• moderate PDA: QP:QS :1.5 and 2.2 to 1• large PDA:QP:QS >2.2 to 1.43• silent PDA :shunt is minimal/no murmur
detected on echocardiography
Reverse PDA
• Pulmonary atresia• Tricuspid atresia• Inferior angle near 90 degree OK but if <60
deree ,needs ductal stenting
Ductal aneurysm
90% spontaneous closure except large size causing pressure effect
Up to 8% reported of all PDA
Phenotypes Rt-sided PDA X RPA to the RT DTALPDA X RT Brachiocephalic A. LSCA X LPA Dual PDALPDA from LSCAVascular ring: SCA from RT DTA and runs behind
the trachea and esophagus, forming a around them by the right aortic arch anteriorly, and to the RT,the LSCA at the back and the PDA to the left.
Histology
• Mature:SMC are arranged longitudinally and circularly helping close by spasm
Physiology in foetus
• Life thread• Tunnels 70% saturate blood into DA• Only 7% of volume enters unexpanded lungs• Patency:Immature duct,low O2 ,high O2/PGE-2
from placenta• Functional closure:15th day• Anatomical closure:21st day=placenta turn off,
high O2 stops Ik ,intracellular ca2+ increase add to spasm in mature duct
Incidence
1/2000 births5% to 10% of CHDWith silent PDA ,Incidence is 1:500F>M(2:1)
Etiologic factors
• Sporadic• Multifocal(genetic+environmental+ low
O2(Asphyxia),rubella(First 4 weeks)/chemicals
Genetics
Chromosomal aberrations:Trisomy 21Single-gene mutations:Holt-Oram syndrome/
Char syndrome(TFAP2B mutations )X-linked mutations
Pathophysiology Small PDA :asymptomatic throughout life.Accidental detection by ECHO
for murmur Moderate PDA:compensate well throughout childhood and may remain completely asymptomatic in early adulthood but will eventually
present with exercise intolerance and symptoms related to left ventricular failure, usually starting in the third decade. Moderate to large:Large volume of blood leads to the very early
development of pulmonary congestion,decreased lung compliance, and failure of the left ventricle, often presenting within weeks after birth with failure to thrive, recurrent pulmonary infections, and even death. Pulmonary overcirculation remains uncorrected,the arteriolar medial hypertrophy, intimal proliferation,and eventual obliteration of pulmonary arterioles and capillaries will lead to an irreversible marked increase in pulmonary arterial pressure. When pulmonary vascular resistance exceeds the systemic vascular resistance, ductal shunting is reversed and becomes right to left (Eisenmenger syndrome)
Natural History
• Spontaneous closure may be delayed until 3 months of life, after which the closure rate is less than 0.6%/Yr
• Silent PDA remain undetected for life• premature :Closure could be delayed up to
1 year and more PDA• Sibling :1% and 5%• Parents:3%
Physical Examination
• Small PDA:Gr-II/III continuous murmur engulfing and peaking around S2
• Thrill :moderate to large PDA• S1 normal,S2 usual split with P2 accentuated• S3 and diastolic rumble : moderate/ large PDA• Eisenmenger syndrome:P2 loud/PSL/Graham
Still’s murmur• wide pulse :large shunt• Cyanosis/clubbing: Eisenmenger
ECG
• LAE• LVH• RVH
Chest Radiograph
• Small PDA: normal• moderate to large: increased pulmonary
vascular markings with prominent ascending aorta, and enlarged cardiac silhouette with prominence of the left atrium, left Ventricle and peripheral pruning
• Calcification
ECHO
• TTE allows the assessment of ductal size,geometry, the degree of shunt, and pulmonary artery pressures
• A left atrium/aorta ratio greater than 1.3/1 is considered to be a reliable marker of a hemodynamically significant ductal shunt
• Shunt ratio: continuity equation
Catheterization
• PDA closure• Hypertensive PDA
Management
• Ignore• Follow• Transcathetor closure• Surgical closure• IE prophylaxis
Class I closure
Evidence of volume overload on the left atrium or left ventricle (LAE/LVH)
Development of PAH but the pressure and the resistance still remain less than two-thirds of the systemic levels
Endarteritis
Class IIa closure
Small PDAs with normal PA pressures andnormal heart size with a shunt ratio less than1.5/1 or followed with repeat evaluationsevery 3 to 5 year
Class III closure
Silent PDAPDA with net right-to-left shunting
Closure method
• Cox inhibitors has no role in grown up• Percutaneus Methods: Coil and device• Surgical
Transcathetor
• Coils :<3 mm• Device:3-12mm
Post closure follow up
Six months with IE prophylaxis
The basic of transcathetor technique
• Coils :Retrograde aortic • Device :Antegrade veno-arterial• 7Fr venous and 6Fr arterial sheath• Pigtail angio in dead left lateral to decide• Device size is 2mm more than PA end• Cross with multipurpose and Terumo• Confirm with repeat angio• 6month F/U SBE prophylaxis
Success story of TCC
• ADO is 99% • immediate closure at the time of
implantation of 76%• day 1 of 89%• 6 to 12 months of 99% by echocardiography.
Complication
• Mortality in 1 / 439 cases• major events 2.3%• Device embolisation 2%
Surgicalvery large PDA unusual ductal anatomyDuctal aneurysmSignificant endarteritisAbscess• Methods: lateral thoracotomy,median
sternotomy, or VAT ligation• 100% success• Morbidity:long hospital stay,laryngial palsy
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