Summary[edit | edit source]
Physical exam[edit | edit source]
Small PDA the patient may be asymptomatic.
All patients with a PDA will have a continuous flow murmur louder in systole than diastole “machinery” like—over left second intercostal space.
Bounding pulses with lower-than-expected diastolic pressures.
In large PDA the child may have failure to thrive, recurrent upper respiratory infection, and fatigue with exertion.
For infants – tachypnea, tachycardia and poor feeding, overactive precordium, wide pulse pressures and enlarge liver.
Past medical history: Possibly a premature infant, frequent respiratory infections and poor feeder.
System review (sample) - Pt may be small for age, slightly evaluate HR is elevated, upon auscultation a continuous murmur is noted- louder of 2nd intercostal space, wide pulse pressure, pulses are strong and bounding, breath sound are clear to auscultation, however, the patient is tachypnic, enlarge liver palpated upon assessment.
Murmur[edit | edit source]
Continuous machine hall murmur infra-clavicular left side
Only systolic murmur: can be small/insignificant PDA and no closure
No murmur: can be big PDA with laminar flow, either large shunt left to right or with increasing PVR after 6-12 months of age, decreasing shunt flow, decreasing left heart dilatation, decreasing pulse pressures and increasing right ventricular hypertrophy.
Imaging[edit | edit source]
Echocardiogram[edit | edit source]
Continuous left to right PDA shunt flow by continuous Doppler with high velocity ( peak systolic flow indicating below 50 % of systemic pressure by Bernoulli ) plus left atrial and may be left ventricular dilatation: Closure warranted.
No left sided dilatation but right ventricular hypertrophy and bidirectional PDA or even dominating right to left shunt : Eisenmenger, no surgery
Low velocity dominating left to right PDA flow sometimes with short systolic reversal can be either pulmonary hypertension or sometimes just non-restrictive PDA with laminar flow due to size of PDA. May need right heart cath for evaluation if age above approximately 2 years. Check foot saturation at rest and during some sort of activity. Check Hematocrit .
Supportive of large shunt:
Increased mitral and aortic flow velocity (typical 1,2 m/s peak diastolic) in the absence of valve stenosis.
Electrocardiogram (EKG)[edit | edit source]
Can be normal or LV hypertrophy noted in V5 &V6
Chest X-ray[edit | edit source]
Large LA, LV- increased pulmonary vascular markings and interstitial pulmonary edema noted
Treatment Plan Decision-Making[edit | edit source]
Most patients that are Premature babies, infants and 2 years of age are candidates for closure without further testing beyond an echocardiogram
Patients with Differential cyanosis on feet and not upper right body. Clubbing of toes, often left hand, sometimes not right hand. Have Eisenmenger Syndrome and should not be closed.
Eisenmanger syndrome in PDA patients article in Circulation
Pre-Operative Labs[edit | edit source]
Complete metabolic panel
Serum electrolytes
Arterial, venous or capillary blood gas
Type & screen.