Patent ductus arteriosus physical examination
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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]]
Physical Examination
Patients with a small PDA may have no symptoms. A large PDA can cause heart failure similar to a large ventricular septal defect VSD, wide pulse pressure, and bounding arterial pulses. An apical heave may be observed, and a thrill may be heard at the second left intercostal space. The characteristic continuous murmur has been described as a machinery or to and fro murmur heard in both systole and diastole. It can be less prominent or not heard at all in diastole in infants or in the patients with increased PVR.[1]
In adults with a large PDA, Eisenmenger's Syndrome may develop with presents as cyanosis due to a right-to-left shunt. The inversion of the shunt is produced because of the progressive increase in pulmonary vascular resistance. Severe pulmonary vascular resistance results in reversal of flow through the ductus, and unoxygenated blood is shunted to the descending aorta, and the toes, but not the fingers, become cyanotic and clubbed, a finding termed differential cyanosis.
Small PDA
Rarely a continuous thrill in the first or second intercostal space. A continuous murmur is present underneath the left clavicle, soft and high in frequency. At the beginning of systole, the flow into the PA is chiefly from the RV rather than through the duct, through the course of systole the contribution from the ductus increases progressively, and then during diastole the flow is through the ductus alone and vanishes as the gradient decreases. During the neonatal period, the PVR is high, and flow across the ductus is reduced.
Medium-sized PDA
As a result of the runoff from the aorta, there are bounding pulses, and the pulse pressure widens. A continuous thrill may be present in the first or second left intercostal space. The continuous murmur is louder and more machinery murmur than for the small PDA. Due to increased left sided return, there is a middiastolic flow murmur and sometimes a third heart sound.
Large PDAs
If there is no reduction in the size of ductus, after age 2, progressive obstructive disease develops in these patients. Usually present in adolescence or adulthood with the physical findings of pulmonary hypertension associated with some right-to-left shunt. There is preferential cyanosis and clubbing of the lower extremities. The fingers of the left hand may be mildly cyanosed and clubbed. The JVP may be elevated due to RV failure. Prominent a wave due to diminished RV compliance and RVH. Loud pulmonic component of the second heart sound. As the pulmonary hypertension increases, left to right flow across the duct decreases and there is no audible murmur. A murmur of pulmonic insufficiency may be noted Graham Steell's murmur due to dilation of the pulmonic valve ring resulting from pulmonary hypertension. Flow into a dilated pulmonary trunk causes a pulmonic ejection sound and pulmonic ejection murmur. The second pulmonic heart sound is closely split or not split.
References
- ↑ Giuliani et al, Cardiology: Fundamentals and Practice, Second Edition, Mosby Year Book, Boston, 1991, pp. 1653-1663.