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Patent Ductus Arteriosus (PDA) Workup

  • Author: Luke K Kim, MD; Chief Editor: Stuart Berger, MD  more...
 
Updated: Sep 16, 2015
 

Approach Considerations

The diagnosis of patent ductus arteriosus (PDA) is almost always based on careful clinical evaluation, including physical examination showing the characteristic murmur, typical electrocardiographic (ECG) abnormalities, radiographic changes, and echocardiographic/Doppler findings.

Echocardiography is the primary diagnostic study used to evaluate and diagnose patent ductus arteriosus (PDA). Chest radiography may provide some helpful information. Laboratory tests are generally not helpful in the workup of patent ductus arteriosus (PDA). Magnetic resonance angiography and cardiac computed tomography are alternative, more novel, diagnostic tools.

CBC and metabolic panel

A complete blood cell (CBC) count with differential and a chemistry profile are obtained to determine the overall health of the child. However, findings are usually within reference ranges in patients with this condition. Polycythemia may be present if the child has other congenital heart defects.

Pulse oximetry/ABG

Pulse oximetry/arterial blood gas (ABG) analysis usually demonstrate normal saturation because of pulmonary overcirculation. A large ductus arteriosus could cause hypercarbia and hypoxemia from congestive heart failure (CHF) and air space disease (atelectasis or intra-alveolar fluid/pulmonary edema).

In the event of pulmonary artery hypertension (PAH), right-to-left intracardiac shunting of blood, hypoxemia, cyanosis, and acidemia may be present.

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Doppler Echocardiography

The echocardiographic findings are typically diagnostic for patent ductus arteriosus (PDA). High velocity jets of turbulent flow in the pulmonary artery can be reliably detected by color flow Doppler imaging; this technique is sensitive in detecting even the small PDA. Relying on alternative imaging techniques to make the diagnosis of this condition is unusual. Additionally, echocardiography provides important diagnostic information regarding associated congenital cardiovascular malformations.

By 2-dimensional (2-D) echocardiography, the aortic end of the patent ductus arteriosus (PDA) is localized first, and then it is tracked back to the pulmonary artery. Precisely documenting the size, shape, and course of the ductus is difficult.

The patent ductus arteriosus (PDA) can be seen most easily in the parasternal short axis view and from the suprasternal notch. The classic patent ductus arteriosus (PDA) connects the junction of the main pulmonary artery and the left pulmonary artery with the aorta just below and opposite the left subclavian artery.

If no other abnormalities are present, Doppler echocardiography reveals continuous flow from the aorta into the main pulmonary artery. If the magnitude of the left-to-right shunt is large, continued flow around the aortic arch into the ductus arteriosus in diastole and flow reversal in the descending aorta are evident. Also, variable levels of continuous flow in the branch pulmonary arteries related to the magnitude of the shunt are observed. As the shunt magnitude increases, increased flow in the pulmonary veins is evident and the left atrium enlarges. With a small or moderate-sized patent ductus arteriosus (PDA), the left ventricular size is often normal, but as shunt magnitude increases, the left ventricular diastolic size also increases. (Qp/Qs can be calculated using Doppler velocity and left ventricular/right ventricular (LV/RV) outflow tract dimensions.)

One study evaluated the internal color Doppler diameter of the PDA and the pulsed Doppler flow pattern in 197 echocardiograms from 104 infants (gestational age < 31 wk). The data noted that while ductal diameter varied widely, it was significantly associated with flow patterns. Because results from the 2 methods may result in different treatment decisions, the use of both echocardiographic parameters may be helpful in managing preterm infants with PDA.[3]

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Chest Radiography

Findings on chest radiographs range from normal to those consistent for congestive heart failure (CHF). Cardiomegaly may be present with or without CHF.

If significant left-to-right shunt through the patent ductus arteriosus (PDA) is present, the pulmonary arteries, pulmonary veins, left atrium, and left ventricle are enlarged on chest films. Also, the ascending aorta may be prominent.

Usually, chest radiographic findings are normal until the magnitude of the ratio of pulmonary to systemic circulation (QP/QS) exceeds 2:1. Prominence of the main pulmonary artery segment is an early sign of increased pulmonary artery pressure and flow. With marked pulmonary overcirculation, pulmonary edema may occur. Accentuated peripheral pulmonary vascular markings and increased pulmonary venous markings may be noted. In elderly individuals, the patent ductus arteriosus (PDA) may calcify and may be visible on a standard radiograph.

Studies have shown that chest radiographs have limited predictive value in determining which infants will benefit from ligation.

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Electrocardiography

With a small patent ductus arteriosus (PDA), the electrocardiographic (ECG) findings are typically normal. Left ventricular hypertrophy may be present with a larger PDA. Left atrial enlargement may also be present with large shunts. In the presence of significant pulmonary hypertension, there may be evidence of right ventricular hypertrophy.

In the neonate, especially the premature neonate with a large patent ductus arteriosus (PDA), T-wave inversion and ST segment depression may be present, suggesting ischemia or a supply-demand mismatch. This is thought to be related to increased myocardial work due to the left-to-right shunt and pulmonary overcirculation in the face of low aortic and coronary diastolic blood pressure due to the runoff of blood from the aorta into the pulmonary arteries.

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Cardiac Catheterization and Angiography

Cardiac catheterization and angiography is not indicated for the uncomplicated patent ductus arteriosus (PDA). Color-flow Doppler mapping is more sensitive than cardiac catheterization in detecting a small patent ductus arteriosus (PDA). However, cardiac catheterization may be required for confirmation of clinical diagnosis in children with pulmonary hypertension and/or associated congenital cardiovascular malformations; response to pulmonary vasodilators can be important in planning operative intervention.

Cardiac catheterization may be used as a therapeutic procedure for coil embolization/occluder and to demonstrate the following:

  • The shunt
  • The amount of the shunt
  • The pulmonary pressure
  • Other coexisting cardiac abnormalities

During right heart catheterization, the measured oxygen saturation is increased in the pulmonary artery, except in Eisenmenger syndrome. The shunt (Qp/Qs) and the pulmonary vascular resistance (PVR) can be calculated to determine the size of the ductus and the presence of pulmonary vascular pathology.

Selective angiography is the definitive tool for determining the presence and size of the ductus. Angiography is also used to define the intracardiac anatomy when other defects are suspected.

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Histologic Features

Very rarely, a biopsy may be performed in severe cases. Histologic findings include the following:

  • The walls of the ductus contain intima, media, and adventitia
  • The medial layer of the structure is composed of longitudinal smooth muscle in the inner layer and circumferentially arranged smooth muscle in the outer layers; this is in contrast to true arterial structures, which contain a medium primarily composed of circumferential elastic fibers; these layers of smooth muscle contain concentric loose lamina of elastic tissue and a network of tiny thin-walled vessels.
  • The intimal layer is irregularly thickened and contains a considerable amount of mucoid material
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Contributor Information and Disclosures
Author

Luke K Kim, MD Assistant Professor of Medicine, Department of Internal Medicine, Division of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Acknowledgements

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Christopher I Doty, MD, FACEP, 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, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gehaan D'Souza, MD University of California-Irvine School of Medicine

Disclosure: Nothing to disclose.

Justin Galovich, MD Resident Physician, Department of Surgery, University of California, Irvine, School of Medicine

Justin Galovich, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Christopher Johnsrude, MD, MS Chief, Division of Pediatric Cardiology, University of Louisville School of Medicine; Director, Congenital Heart Center, Kosair Children's Hospital

Christopher Johnsrude, MD, MS is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology

Disclosure: St Jude Medical Honoraria Speaking and teaching

Steven R Neish, MD, SM Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine

Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association

Disclosure: Nothing to disclose.

Girish Sethuraman, MD, MPH Assistant Professor, University of Maryland School of Medicine

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.

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, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

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.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Park W Willis IV, MD Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. Sekar KC, Corff KE. Treatment of patent ductus arteriosus: indomethacin or ibuprofen?. J Perinatol. 2008 May. 28 Suppl 1:S60-2. [Medline].

  10. 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].

  11. McCarthy JS, Zies LG, Gelband H. Age-dependent closure of the patent ductus arteriosus by indomethacin. Pediatrics. 1978 Nov. 62(5):706-12. [Medline].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. Brion LP, Soll RF. Diuretics for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2008 Jan 23. CD001454. [Medline].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. 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.

  26. Weisz DE, More K, McNamara PJ, et al. PDA ligation and health outcomes: a meta-analysis. Pediatrics. 2014 Apr. 133(4):e1024-46. [Medline].

  27. 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].

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. Castaneda A. Congenital heart disease: a surgical-historical perspective. Ann Thorac Surg. 2005 Jun. 79(6):S2217-20. [Medline].

  33. 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].

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

  35. 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].

 
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Schematic diagram of a left-to-right shunt of blood flow from the descending aorta via the patent ductus arteriosus (PDA) to the main pulmonary artery.
Diagram illustrating the patent ductus arteriosus.
Diagram illustrating ligation of the patent ductus arteriosus.
Diagram illustrating division and oversewing of the patent ductus arteriosus.
Diagram illustrating patch closure of the patent ductus arteriosus.
 
 
 
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