eMedicine Specialties > Emergency Medicine > Cardiovascular

Patent Ductus Arteriosus: Differential Diagnoses & Workup

Author: Girish Sethuraman, MD, MPH, Clinical Assistant Instructor, Staff Physician, Department of Emergency Medicine, Kings County Hospital, Downstate Medical Center
Coauthor(s): Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Apr 14, 2008

Differential Diagnoses

Anemia, Acute
Pediatrics, Respiratory Distress Syndrome
Anemia, Sickle Cell
Pediatrics, Tachycardia
Aortic Regurgitation
Pericarditis and Cardiac Tamponade
Cardiomyopathy, Dilated
Pulmonic Valvular Stenosis
Mitral Regurgitation
Shock, Cardiogenic
Pediatrics, Bacteremia and Sepsis
Tetralogy of Fallot

Other Problems to Be Considered

Cervical venous hum (usually present on the right side of the neck and more prominent in the sitting position, varying with respiration)
Coronary artery fistula
Ruptured sinus of Valsalva
Tetralogy of Fallot with pulmonary atresia and collateral circulation
Coarctation of the aorta
Pulmonary arteriovenous fistula
Systemic arteriovenous fistula (cerebrovascular or hepatic arteriovenous malformations)
Ventricular septal defect (VSD) with aortic regurgitation
Absence of the pulmonary valve
Tetralogy of Fallot with absent pulmonary valve
Persistent truncus arteriosus
Aortopulmonary septal defect
Peripheral pulmonary artery stenosis
Total anomalous pulmonary venous return

Workup

Laboratory Studies

  • Pulse oximetry/arterial blood gas analysis
    • Usually demonstrates normal saturation because of pulmonary overcirculation
    • A large ductus arteriosus could cause hypercarbia and hypoxemia from CHF and air space disease (atelectasis or intra-alveolar fluid/pulmonary edema).
    • In the event of persistent pulmonary artery hypertension (persistent fetal circulation); right-to-left intracardiac shunting of blood, diminished pulmonary blood flow with resultant hypoxemia, cyanosis, and acidemia may be present.

Imaging Studies

  • Chest radiography
    • Findings range from normal to consistent with CHF
    • Cardiomegaly with or without CHF
    • Prominence of the main pulmonary artery segment is an early sign of increased pulmonary artery pressure and flow.
  • Echocardiography/Doppler imaging - Procedure of choice to confirm a diagnosis of PDA
  • Contrast echocardiography
  • Cardiac catheterization
  • Computed tomography
  • Magnetic resonance imaging (MRI)

Other Tests

  • Electrocardiography
    • Results are usually normal in infants or those with smaller ductal shunts.
    • Sinus tachycardia or atrial fibrillation may be present in moderate-to-large shunts.
    • It may also reveal left ventricular and left atrial hypertrophy in children and adults or in those with larger shunts.
  • Further progression of disease is dependent on volume and pressure relationships.
    • Volume = pressure/resistance
    • High volume yields increasing pulmonary artery pressures eventually producing endothelial and muscular changes in the vessel wall.
    • These changes may eventually lead to pulmonary vascular obstructive disease (PVOD), a condition of resistance to pulmonary blood flow that may be irreversible and will preclude definitive repair.

Procedures

  • Cardiac catheterization and angiography is not indicated for the uncomplicated PDA. It may be used as a therapeutic procedure for coil embolization.
    • Demonstrates the shunt
    • Determines the amount of shunt
    • Determines pulmonary pressure
    • Determines other coexisting cardiac abnormalities

More on Patent Ductus Arteriosus

Overview: Patent Ductus Arteriosus
Differential Diagnoses & Workup: Patent Ductus Arteriosus
Treatment & Medication: Patent Ductus Arteriosus
Follow-up: Patent Ductus Arteriosus
Multimedia: Patent Ductus Arteriosus
References
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References

  1. [Best Evidence] Ohlsson A, Walia R, Shah S. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. Jan 23 2008;CD003481. [Medline].

  2. [Best Evidence] Malviya M, Ohlsson A, Shah S. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. 2008;(1):CD003951. [Medline].

  3. Benders MJ, van de Bor M, van Bel F. Doppler sonographic study of the effect of indomethacin on cardiac and pulmonary hemodynamics of the preterm infant. Eur J Ultrasound. May 1999;9(2):107-16. [Medline].

  4. Bensky AS, Raines KH, Hines MH. Late follow-up after thoracoscopic ductal ligation. Am J Cardiol. Aug 1 2000;86(3):360-1. [Medline].

  5. Brook MM, Heymann MA. Patent ductus arteriosus. In: Heart Disease in Infants, Children and Adolescents. Vol I Section III, Part A. 1995:746-64/chap 54.

  6. Burke RP, Jacobs JP, Cheng W, et al. Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants. Pediatrics. Aug 1999;104(2 Pt 1):227-30. [Medline].

  7. Castaneda AR, Jonas RA, Meyer JE. Surgery for infants with congenital heart disease. In: Kirklin JW, Barrett-Boyes BG, eds. Cardiac Surgery. 1993:841-61.

  8. Fyler DC. Patent ductus arteriosus. In: Nadas Pediatric Cardiology. 1992:525-34.

  9. McConnell ME, Adkins SB 3rd, Hannon DW. Heart murmurs in pediatric patients: when do you refer?. Am Fam Physician. Aug 1999;60(2):558-65. [Medline].

  10. Park MK. Specific congenital heart defects: patent ductus arteriosus. In: Pediatric Cardiology for Practitioners. 1988:134-7.

  11. Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation. Oct 24 2006;114(17):1873-82. [Medline].

  12. Silverman NH. Patent ductus arteriosus. In: Pediatric Echocardiography. 1993:167-77.

  13. Snider AR, Serwer GA. Abnormal vascular connections and structures: patent ductus arteriosus. In: Echocardiography in Pediatric Heart Disease. 1990:264-71. [Medline].

  14. Wyllie J. Treatment of patent ductus arteriosus. Semin Neonatol. Dec 2003;8(6):425-32. [Medline].

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Further Reading

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Keywords

PDA, patent ductus arteriosus, ductal closure, bacterial endocarditis, late congestive heart failure, CHF, development of pulmonary vascular obstructive disease, circulatory abnormalities, ventilatory abnormalities, congenital heart diseases

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Contributor Information and Disclosures

Author

Girish Sethuraman, MD, MPH, Clinical Assistant Instructor, Staff Physician, Department of Emergency Medicine, Kings County Hospital, Downstate Medical Center
Girish Sethuraman, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Charles V Pollack, Jr, MD, MA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: sanofi-aventis Honoraria Consulting; sanofi-aventis Honoraria Speaking and teaching; Schering-Polugh Honoraria Consulting; Schering-Plough Honoraria Speaking and teaching; The Medicines Company Honoraria Consulting; GlaxoSmithKline Grant/research funds Other

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