Patent ductus arteriosus: Difference between revisions
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==Background== | ==Background== | ||
*Ductus arteriosus is a blood vessel connecting main pulmonary artery to proximal descending aorta | |||
**Shunts blood from right ventricle to bypass fetus's non-functioning lungs in utero | |||
*In PDA, ductus fails to close after birth | |||
*Second most common congenital heart disease | |||
*Approximately 1 in 1600 to 5000 live births in the US.<ref>Mitchell, S. C., Korones, S. B., Berendes, H. W. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43: 323-332, 1971.</ref> | |||
===Pathophysiology=== | |||
[[File:PDA.png|thumb]] | |||
*Ductus arteriosus shunts blood from the pulmonary artery to the aorta bypassing the lungs while in utero | |||
*Normally closes soon after birth via complex process | |||
**Regulated by oxygen tension and decreases in prostaglandin E2 | |||
**Becomes ligamentum arteriosum | |||
*In PDA, ductus fails to close | |||
**Results in shunting of blood between aorta and pulmonary artery | |||
**Some oxygenated blood from high-pressure aorta shunts to lower pressure pulmonary artery | |||
**A large shunt can cause increased fluid return to lungs and increased lung pressure, leading to [[pulmonary hypertension]] | |||
*Some congenital heart defects, such as [[transposition of the great arteries]], are incompatible with life ''''without''' a PDA; may be necessary to allow oxygenated and deoxygenated blood to mix | |||
**In these cases [[prostaglandin E1|prostaglandins]] are used to keep the ductus arteriosus '''open'''. | |||
==Clinical Features== | ==Clinical Features== | ||
* Continuous machine like heart [[murmur]] | |||
* Differential cyanosis (cyanosis of lower extremities and not the upper extremities) | |||
* [[Dyspnea]] | |||
* [[Tachycardia]] | |||
* Widened pulse pressure | |||
* [[Congestive heart failure]] | |||
* [[Failure to thrive (peds)|Failure to thrive]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* [[Acute pericarditis]] | |||
* Aortopulmonary Septal Defect | |||
* [[Coarctation of the Aorta]] | |||
* [[Anomalous coronary arteries|Coronary artery fistula]] | |||
* Pediatric acute [[respiratory distress syndrome]] | |||
* Sinus of valsalva aneurysm | |||
* Pediatric [[tachycardia]] | |||
* Pulmonic valvular stenosis | |||
* [[Sickle cell anemia]] | |||
* [[Tetralogy of Fallot]] with absent pulmonary valve | |||
{{Congenital heart disease DDX}} | |||
==Evaluation== | ==Evaluation== | ||
[[File:PDA Fomani.gif|thumbnail|Echocardiography demonstrating PDA<ref>http://www.thepocusatlas.com/pediatrics/</ref>]] | |||
* Careful physical examination demonstrating characteristic machine like murmur | |||
* [[Echocardiography]] | |||
**MRA and Cardiac CT can also be used as diagnostic tools | |||
*Laboratory tests usually not helpful | |||
==Management== | |||
*Spontaneous closure common | |||
*If significant [[shortness of breath (peds)|respiratory distress]] or impaired oxygen delivery, therapy usually required | |||
== | === Medical Therapy === | ||
*IV [[indomethacin]]: usually effective when administered in the first 10-14 days of life. | |||
**<48 hour old: start 0.2mg/kg IV x 1, then 0.1mg/kg q12-24h x 2 | |||
**2-7 days old: Start 0.2mg/kg IV x 1, then 0.2mg/kg q12-24h x 2 | |||
**> 7 days old: Start 0.2mg/kg IV x 1, then 0.25mg/kg q12-24h x 2 | |||
=== Surgical Therapy === | |||
*Offered if medical therapy fails | |||
**Cardiac catheterization and catheter closure | |||
**Surgical ligation | |||
==Disposition== | ==Disposition== | ||
*Stable, asymptomatic patients can be discharged home with cardiology follow-up | |||
*Symptomatic patients and patients requiring treatment should be admitted with cardiology consultation | |||
==See Also== | ==See Also== | ||
*[[Congenital Heart Disease]] | |||
==External Links== | ==External Links== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:cardiology]] | [[Category:cardiology]] | ||
[[Category:Pediatrics]] |
Latest revision as of 15:10, 12 September 2019
Background
- Ductus arteriosus is a blood vessel connecting main pulmonary artery to proximal descending aorta
- Shunts blood from right ventricle to bypass fetus's non-functioning lungs in utero
- In PDA, ductus fails to close after birth
- Second most common congenital heart disease
- Approximately 1 in 1600 to 5000 live births in the US.[1]
Pathophysiology
- Ductus arteriosus shunts blood from the pulmonary artery to the aorta bypassing the lungs while in utero
- Normally closes soon after birth via complex process
- Regulated by oxygen tension and decreases in prostaglandin E2
- Becomes ligamentum arteriosum
- In PDA, ductus fails to close
- Results in shunting of blood between aorta and pulmonary artery
- Some oxygenated blood from high-pressure aorta shunts to lower pressure pulmonary artery
- A large shunt can cause increased fluid return to lungs and increased lung pressure, leading to pulmonary hypertension
- Some congenital heart defects, such as transposition of the great arteries, are incompatible with life 'without a PDA; may be necessary to allow oxygenated and deoxygenated blood to mix
- In these cases prostaglandins are used to keep the ductus arteriosus open.
Clinical Features
- Continuous machine like heart murmur
- Differential cyanosis (cyanosis of lower extremities and not the upper extremities)
- Dyspnea
- Tachycardia
- Widened pulse pressure
- Congestive heart failure
- Failure to thrive
Differential Diagnosis
- Acute pericarditis
- Aortopulmonary Septal Defect
- Coarctation of the Aorta
- Coronary artery fistula
- Pediatric acute respiratory distress syndrome
- Sinus of valsalva aneurysm
- Pediatric tachycardia
- Pulmonic valvular stenosis
- Sickle cell anemia
- Tetralogy of Fallot with absent pulmonary valve
Congenital Heart Disease Types
- Cyanotic
- Acyanotic
- AV canal defect
- Atrial septal defect (ASD)
- Ventricular septal defect (VSD)
- Cor triatriatum
- Patent ductus arteriosus (PDA)
- Pulmonary/aortic stenosis
- Coarctation of the aorta
- Differentiation by pulmonary vascularity on CXR[2]
- Increased pulmonary vascularity
- Decreased pulmonary vascularity
- Tetralogy of fallot
- Rare heart diseases with pulmonic stenosis
Evaluation
- Careful physical examination demonstrating characteristic machine like murmur
- Echocardiography
- MRA and Cardiac CT can also be used as diagnostic tools
- Laboratory tests usually not helpful
Management
- Spontaneous closure common
- If significant respiratory distress or impaired oxygen delivery, therapy usually required
Medical Therapy
- IV indomethacin: usually effective when administered in the first 10-14 days of life.
- <48 hour old: start 0.2mg/kg IV x 1, then 0.1mg/kg q12-24h x 2
- 2-7 days old: Start 0.2mg/kg IV x 1, then 0.2mg/kg q12-24h x 2
- > 7 days old: Start 0.2mg/kg IV x 1, then 0.25mg/kg q12-24h x 2
Surgical Therapy
- Offered if medical therapy fails
- Cardiac catheterization and catheter closure
- Surgical ligation
Disposition
- Stable, asymptomatic patients can be discharged home with cardiology follow-up
- Symptomatic patients and patients requiring treatment should be admitted with cardiology consultation
See Also
External Links
References
- ↑ Mitchell, S. C., Korones, S. B., Berendes, H. W. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43: 323-332, 1971.
- ↑ Knipe K et al. Cyanotic congenital heart diseases. Radiopaedia. http://radiopaedia.org/articles/cyanotic-congenital-heart-disease
- ↑ http://www.thepocusatlas.com/pediatrics/