Patent Ductus Arteriosus (PDA) Clinical Presentation
- Author: Luke K Kim, MD; Chief Editor: Stuart Berger, MD more...
As discussed in Pathophysiology, the ductus arteriosus is always patent in the fetus if the cardiovascular system is otherwise normal. Normally, the ductus arteriosus closes functionally in the first 10-18 hours of life. Prematurity, perinatal distress, and hypoxia delay closure of the ductus arteriosus; however, most children who are found to have a ductus arteriosus have no history of precedent risk factors.
Depending on the size of the patent ductus arteriosus (PDA), the gestational age of the neonate, and the pulmonary vascular resistance (PVR), a premature neonate may develop life-threatening pulmonary overcirculation in the first few days of life. Conversely, an adult with a small patent ductus arteriosus (PDA) may present with a newly discovered murmur well after adolescence.
Patients can present at any age. The typical child with a patent ductus arteriosus (PDA) is asymptomatic. At times, the patient may report decreased exercise tolerance or pulmonary congestion in conjunction with a murmur.
Three-week to 6-week-old infants can present with tachypnea, diaphoresis, inability or difficulty with feeding, and weight loss or no weight gain.
A ductus arteriosus with a moderate-to-large left-to-right shunt may be associated with a hoarse cry, cough, lower respiratory tract infections, atelectasis, or pneumonia. With large defects, the patient may have a history of feeding difficulties and poor growth during infancy, described as failure to thrive (FTT). However, frank symptoms of congestive heart failure (CHF) are rare.
Adults whose patent ductus arteriosus (PDA) has gone undiagnosed may present with signs and symptoms of heart failure, atrial arrhythmia, or even differential cyanosis limited to the lower extremities, indicating shunting of unoxygenated blood from the pulmonary to systemic circulation.
A patent ductus arteriosus (PDA) is variable in its presentation. It may vary in size from small to large and may not be picked up based on physical examination at birth.
Patients usually appear well and have normal respirations and heart rates. A widened pulse pressure may be noted when the blood pressure is obtained. Suprasternal or carotid pulsations may be prominent.
As many as one third of children with patent ductus arteriosus (PDA) is small for their age. In the presence of significant pulmonary overcirculation, tachypnea, tachycardia, and a widened pulse pressure may be found.
In neonates, a heart murmur is discovered within the first few days or weeks of life. The murmur is usually recognized as systolic rather than continuous in the first weeks of life and can mimic a benign systolic murmur.
Findings upon cardiac examination include the following:
If the left-to-right shunt is large, precordial activity is increased, with the magnitude of increased activity related to the magnitude of left-to-right shunt
The apical impulse is laterally displaced; a thrill may be present in the suprasternal notch or in the left infraclavicular region
The first heart sound (S 1) is typically normal, and the second heart sound (S 2) is often obscured by the murmur; phonocardiographic data from the past suggested the occurrence of paradoxical splitting of S 2 related to premature closure of the pulmonary valve and a prolonged ejection period across the aortic valve
The murmur may be only a systolic ejection murmur, or it may be a crescendo/decrescendo systolic murmur that extends into diastole
Occasionally, auscultation of the patent ductus arteriosus (PDA) reveals numerous clicks or noises resembling shaking dice or a bag of rocks
In 1898, Gibson described the classic murmur. Subsequently, the hallmark physical finding of patent ductus arteriosus (PDA) has been referred to as a machinery murmur, which is continuous. The murmur may be accentuated in systole. Typically, the murmur is loudest at the left upper chest. If the pulmonary-to-systemic blood ratio approaches or exceeds 2:1, an apical flow rumble, caused by high flow into the left ventricle, is frequently present. Also, because flow through the left ventricle into the aorta is increased, an aortic ejection murmur may be present. If the patent ductus arteriosus (PDA) is small, the amplitude of the murmur may increase with inspiration as pulmonary impedance drops.
The peripheral pulses are often referred to as bounding. This is related to the high left ventricular stroke volume, which may cause systolic hypertension. The phenomenon of bounding pulses also is caused by the low diastolic pressure in the systemic circulation as blood runs off from the aorta into the pulmonary circulation.
Low birth weight premature infant
In the low birth weight premature infant, diagnosing a patent ductus arteriosus (PDA) on auscultation may be difficult. Babies that have a more severe clinical course of hyaline membrane disease (HMD) may have a higher prevalence of patent ductus arteriosus (PDA). The exact reason for this is unclear.
In the low birth weight premature infant, the classic signs of a patent ductus arteriosus (PDA) are usually absent. The classic continuous murmur is rarely heard. A rough systolic murmur may be present along the left sternal border, but a small baby with a large patent ductus arteriosus (PDA) and significant pulmonary overcirculation may have no murmur. In that case, typically, precordial activity is increased and peripheral pulses are bounding. The increased precordial activity is caused by the large left ventricular stroke volume. Bounding pulses are caused by the relatively low systemic arterial blood pressure due to the continuous runoff of blood from the aorta into the pulmonary artery.
Kaemmerer H, Meisner H, Hess J, Perloff JK. Surgical treatment of patent ductus arteriosus: a new historical perspective. Am J Cardiol. 2004 Nov 1. 94(9):1153-4. [Medline].
Cassels DE, Bharati S, Lev M. The natural history of the ductus arteriosus in association with other congenital heart defects. Perspect Biol Med. 1975 Summer. 18(4):541-72. [Medline].
Condo M, Evans N, Bellu R, Kluckow M. Echocardiographic assessment of ductal significance: retrospective comparison of two methods. Arch Dis Child Fetal Neonatal Ed. 2012 Jan. 97(1):F35-8. [Medline].
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].
Vanhaesebrouck S, Zonnenberg I, Vandervoort P, et al. Conservative treatment for patent ductus arteriosus in the preterm. Arch Dis Child Fetal Neonatal Ed. 2007 Jul. 92(4):F244-7. [Medline]. [Full Text].
Attridge JT, Kaufman DA, Lim DS. B-type natriuretic peptide concentrations to guide treatment of patent ductus arteriosus. Arch Dis Child Fetal Neonatal Ed. 2009 May. 94(3):F178-82. [Medline].
Nuntnarumit P, Chongkongkiat P, Khositseth A. N-terminal-pro-brain natriuretic peptide: a guide for early targeted indomethacin therapy for patent ductus arteriosus in preterm Infants. Acta Paediatr. 2011 Sep. 100(9):1217-21. [Medline].
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. 2008 Jan 23. CD003481. [Medline].
Sekar KC, Corff KE. Treatment of patent ductus arteriosus: indomethacin or ibuprofen?. J Perinatol. 2008 May. 28 Suppl 1:S60-2. [Medline].
Takami T, Yoda H, Kawakami T, et al. Usefulness of indomethacin for patent ductus arteriosus in full-term infants. Pediatr Cardiol. 2007 Jan-Feb. 28(1):46-50. [Medline].
McCarthy JS, Zies LG, Gelband H. Age-dependent closure of the patent ductus arteriosus by indomethacin. Pediatrics. 1978 Nov. 62(5):706-12. [Medline].
Watanabe K, Tomita H, Ono Y, Yamada O, Kurosaki K, Echigo S. Intravenous indomethacin therapy in infants with a patent ductus arteriosus complicating other congenital heart defects. Circ J. 2003 Sep. 67(9):750-2. [Medline].
Shah SS, Ohlsson A. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2006 Jan 25. CD004213. [Medline].
Richards J, Johnson A, Fox G, Campbell M. A second course of ibuprofen is effective in the closure of a clinically significant PDA in ELBW infants. Pediatrics. 2009 Aug. 124(2):e287-93. [Medline].
Ohlsson A, Walia R, Shah SS. Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2010 Apr 14. 4:CD003481. [Medline].
Jones LJ, Craven PD, Attia J, Thakkinstian A, Wright I. Network meta-analysis of indomethacin versus ibuprofen versus placebo for PDA in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2011 Jan. 96(1):F45-52. [Medline].
Brion LP, Soll RF. Diuretics for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2008 Jan 23. CD001454. [Medline].
Lin CC, Hsieh KS, Huang TC, Weng KP. Closure of large patent ductus arteriosus in infants. Am J Cardiol. 2009 Mar 15. 103(6):857-61. [Medline].
Rapacciuolo A, Losi MA, Borgia F, et al. Transcatheter closure of patent ductus arteriosus reverses left ventricular dysfunction in a septuagenarian. J Cardiovasc Med (Hagerstown). 2009 Apr. 10(4):344-8. [Medline].
Chen Z, Chen L, Wu L. Transcatheter amplatzer occlusion and surgical closure of patent ductus arteriosus: comparison of effectiveness and costs in a low-income country. Pediatr Cardiol. 2009 Aug. 30(6):781-5. [Medline].
Tomita H, Uemura S, Haneda N, et al. Coil occlusion of PDA in patients younger than 1 year: risk factors for adverse events. J Cardiol. 2009 Apr. 53(2):208-13. [Medline].
Hoellering AB, Cooke L. The management of patent ductus arteriosus in Australia and New Zealand. J Paediatr Child Health. 2009 Apr. 45(4):204-9. [Medline].
Agnetti A, Carano N, Tchana B, et al. Transcatheter closure of patent ductus arteriosus: experience with a new device. Clin Cardiol. 2009 Nov. 32(11):E71-4. [Medline].
Vida VL, Lago P, Salvatori S, et al. Is there an optimal timing for surgical ligation of patent ductus arteriosus in preterm infants?. Ann Thorac Surg. 2009 May. 87(5):1509-15; discussion 1515-6. [Medline].
Laidman J. Efficacy and risk for PDA ligation uncertain in meta-analysis. Medscape Medical News. Available at http://www.medscape.com/viewarticle/822106. 2014 Mar 17; Accessed: March 23, 2014.
Weisz DE, More K, McNamara PJ, et al. PDA ligation and health outcomes: a meta-analysis. Pediatrics. 2014 Apr. 133(4):e1024-46. [Medline].
Heuchan AM, Hunter L, Young D. Outcomes following the surgical ligation of the patent ductus arteriosus in premature infants in Scotland. Arch Dis Child Fetal Neonatal Ed. 2012 Jan. 97(1):F39-44. [Medline].
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 Jan 23. CD003951. [Medline].
Allegaert K, Rayyan M, Anderson BJ. Impact of ibuprofen administration on renal drug clearance in the first weeks of life. Methods Find Exp Clin Pharmacol. 2006 Oct. 28(8):519-22. [Medline].
Burney K, Thayur N, Husain SA, Martin RP, Wilde P. Imaging of implants on chest radiographs: a radiological perspective. Clin Radiol. 2007 Mar. 62(3):204-12. [Medline].
Campbell DC, Hood RH Jr, Dooley BN. Patent ductus arteriosus. Review of literature and experience with surgical corrections. J Lancet. 1967 Oct. 87(10):415-8. [Medline].
Castaneda A. Congenital heart disease: a surgical-historical perspective. Ann Thorac Surg. 2005 Jun. 79(6):S2217-20. [Medline].
Mandhan PL, Samarakkody U, Brown S, et al. Comparison of suture ligation and clip application for the treatment of patent ductus arteriosus in preterm neonates. J Thorac Cardiovasc Surg. 2006 Sep. 132(3):672-4. [Medline].
Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation. 2006 Oct 24. 114(17):1873-82. [Medline].
Zupancic JA, Richardson DK, O'Brien BJ, et al. Retrospective economic evaluation of a controlled trial of indomethacin prophylaxis for patent ductus arteriosus in premature infants. Early Hum Dev. 2006 Feb. 82(2):97-103. [Medline].