PDA - Dr. D. Gunasekaran

ACYANOTIC CONGENITAL HEART DISEASE

ACYANOTIC CONGENITAL HEART DISEASE

Dr. D. Gunsekaran Consultant Paediatrician

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

Patent Ductus Arteriosus


Blood is flowing from Aorta to PA through ductus Ductus


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


Fate of ductus after birth

Functional closure? 12 hours (PaO2 increases & Prostaglandin E falls)

Anatomical closure? 2 weeks


PDA Preterms & TermsCommon in preterms:Usually they have hypoxia (O2 is potent vasoconstrictor)The actions of Prostaglandin E is more in themSmooth muscles in the ductus is immatureProstaglandin 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.


Hemodynamic changes:

RARVPALungsPVLAMV LVAVAorta 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?


Classification of PDA

Size:

Small, Moderate or Large (0.5cm2, 0.5-1cm2, >1 cm)


Patent Ductus ArteriosusSymptoms may or may not present at birth

Look for Dysmorphic features

Rubella History essential

Gestational age at deliveryessential

Symptoms in PDASmall PDA: Asymptomatic; growth is normal; Murmur - routine clinical examination.Moderate to Large PDA: Breathlessness on exertionExercise intoleranceFeeding difficultiesFailure to thriveFrequent RTIForehead sweatingChest pain, palpitation, syncope ???


Vitals in PDA

Pulse: Volume? Rate? Character? Rhythm?Blood pressure?

If there is CCF:


General examination

Undernourished, pallor & vitamin def may be +

Pedal edema or Pre sacral edema if CCF +

Look for signs of I.E


Examination of heart Inspection: Precordial bulge (Cardiomegaly Pliable chest)

Harrison sulcus +/-

Respiratory distress (CCF, LRTI)


Examination of heartPalpation: 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


Examination of heartAuscultation: 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


Complications

Congestive Cardiac FailurePulmonary HypertensionRecurrent LRTIFailure to thriveEisenmengers syndromeInfective Endocarditis


Complications Congestive Cardiac Failure:

Symptoms: Gen Exam: Vitals: Pulse: BP:Auscultation of Heart: RS: Abdomen examination:


Complications Congestive Cardiac Failure:

Symptoms: Breathlessness, PND or Orthopnoea, cough Gen Exam: Pedal edemaVitals: Pulse: BP:Auscultation of Heart: GallopRS: Basal crepsAbdomen examination: Tender hepatomegaly


ComplicationsPulmonary 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)


Blood is flowing from Aorta to PA through ductusWhen this can happen?What is its name?


ComplicationsEisenmengers syndrome:Shunt reversal in severe PHT; Cyanosis Can occur in all LR (VSD, ASD & PDA)Non-restrictive lesions, in late teens age

If it occurs in PDA: P2 becomes loudInstead of continuous murmur, only systolic murmur +


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 sideDisappears if the head is turned to the same side or when the pt. lies downAorto-Pulmonary window: Very difficult to differentiate; ECHO is necessaryRupture 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


Natural HistorySpontaneous 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


Investigations

Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection

ECG: Chamber enlargement

ECHO:


Normal heart & cardiomegaly


ManagementMedical: Dental Hygiene Infective Endocarditis Prophylaxis Diet: high calorie and high protein Frequent short breast feeding Anemia correction, vitamin supplements


ManagementMedical: Drug used?Indomethacin Dose: 0.2 mg/kg /dose ; 3 doses; 12 hourlyBest before 3 days; at least by 10 daysIndication: only in PretermsContra indications: NEC, Renal impairment, thrombocytopenia

In renal impairment: Ibuprofen can be tried


Management

Medical: Transcatheter closure

Indications: Term baby, PDA with cardiac failure

Devices used: Rashkind umbrella occluder Spring coils Amplatzer mush room occluder






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


6

Blood is flowing from Aorta to PA through ductusTie at both ends and then cut in between


Management - Surgical

Contraindications for surgery:

Severe PHT (PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion > 12 wood units / m2 BSA)


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


PDA is a must to sustain life in

Aortic atresiaPulmonary atresiaTGA with intact atrial and ventricular septum

To keep it open: infuse Prostaglandin continuously


Bye-Bye


Healthcare

PDA - Dr. D. Gunasekaran