Page data
Part of Cardiac Surgical Skills Training Module
Keywords surgery, cardiology, neonatology, Medical knowledge pages
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors Owen Robinson
Published 2021
License CC-BY-SA-4.0
Affiliations Global Surgical Training Challenge
Language English (en)
Impact Number of views to this page. Views by admins and bots are not counted. Multiple views during the same session are counted as one. 115

Summary[edit | edit source]

Journal article on PDA

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.

listen to PDA murmur

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.  

Patient and Family Consent[edit | edit source]