Patent ductus arteriosus history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief:Cafer Zorkun, M.D., Ph.D. [2]; Keri Shafer, M.D. [3] Priyamvada Singh, MBBS [[4]]

Assistant Editor-In-Chief: Kristin Feeney, B.S. [[5]]

History and symptoms

Usually asymptomatic or may present with symptoms of heart failure, lower extremity clubbing, dyspnea. Depending on the size of the PDA, a cardiac murmur can be missed during the first physical exam of the newborn, because of the high pulmonary pressure that avoids the left-to-right shunt at that time. When the pulmonary pressure drops, the murmur is evident.

Clinical manifestation of patent ductus arteriosus depends on degree of left to right shunting which in turn is affected by-

• Size and length of the PDA
• Difference between pulmonary and systemic vascular resistances.

Small PDA(Qp:Qs <1.5 to 1, Qp:Qѕ=pulmonary to systemic flow ratio)

• May be asymptomatic.
• Sometimes identified incidentally on routine physical examinations (due to the presence of continuous flow murmurs) or on echocardiography performed for some other conditions.

Moderate PDA(Qp:Qs between 1.5 and 2.2 to 1)

• May present with exercise intolerance.
• The moderate left-to-right shunt increases the volume load on the left side of heart, which results in left ventricular dilation and dysfunction.

The characteristic continuous murmur (usually grade 2 or 3, occasionally grade 4) in the left infraclavicular area, which is louder than that associated with a small PDA, is typically accompanied by a wide systemic pulse pressure and signs of left ventricular overload, such as a displaced left ventricular apex.

Large PDA(Qp:Qs >2.2 to 1)can cause left ventricular overload. However, if the condition goes uncorrected progressive rise in pulmonary artery pressure may occur that in turn can cause a reversal of shunt i.e. right to left sided shunting. The right to left shunt can cause cyanosis and in later stages may progress to Eisenmenger syndrome.

Presentation of large PDA in infant and children are

Symptoms due to heart failure like-

• Failure to thrive
• Poor feeding
• Respiratory distress.

Presentation of large PDA in adults (Large — Qp:Qs >2.2 to 1)

Clinical features of Eisenmenger syndrome like cyanosis and clubbing can be found. The PDA patients typically have differential cyanosis i.e. cyanosis is more pronounced in lower extremities compared to upper.This is so because the ductus originates distal to the left subclavian artery. The left subclavian artery mainly supplies the upper extremities which escapes the shunting of blood.