Patent ductus arteriosus
Patent ductus arteriosus or arteriosum (PDA) is a congenital cardiac anomaly where there is persistent patency of the ductus arteriosus, a normal connection of the fetal circulation between the aorta and the pulmonary arterial system that develops from the 6th aortic arch.
PDAs occur in ~1 in 2000 full-term neonates with a F:M of 2:1 7,8.
A large PDA classically gives a loud continuous machine-like murmur.
The ductus is a necessity in utero but usually undergoes functional closure 48 hours after birth. Patency of the ductus may be isolated or associated with other cardiac anomalies. In some circumstances, it is necessary to prolong life in patients with severe structural heart disease in whom a normal systemic circulation would be incompatible with life:
Chest radiographic features may vary depending on whether it is isolated or associated with other cardiac anomalies and with the direction of shunt flow (right to left or left to right). Can have cardiomegaly (predominantly left atrial and left ventricular enlargement if not complicated). Obscuration of the aortopulmonary window and features of pulmonary oedema may be evident.
Direct visualisation of PDA. Colour Doppler can provide information of the direction of flow.
MDCT can non-invasively provide detailed anatomical information1.
Krichenko classification based on CT angiography:
- type A: conical ductus, prominent aortic ampulla with narrowing at pulmonary artery end
- type B: window, short and wide ductus with blending of pulmonary artery
- type C: long tubular ductus with no constrictions
- type D: multiple constrictions with complex ductus
- type E: elongated ductus with remote constriction
A ductus may have a tortuous morphology that does not fit in the Krichenko classification. This ductus type is usually observed in premature children and some authors proposed to classify it as type F or fetal type. Compared to types A to E, a type F ductus is larger, longer, tapers minimally from the aortic to pulmonary end, with a tortuous connection to the pulmonary artery giving a hockey-stick appearance 9.
Treatment and prognosis
- prostaglandin E1: to keep ductus open
- indomethacin: to close the ductus
- various closure devices
- clipping or ligation to close
Congenital heart disease
There is more than one way to present the variety of congenital heart diseases. Whichever way they are categorised, it is helpful to have a working understanding of normal and fetal circulation, as well as an understanding of the segmental approach to imaging in congenital heart disease.
congenital heart disease
- normal relationship between chambers and valves
- atrioventricular valves
- outflow tract
- great vessels
- venous inflow
- anomalous valves
- abnormal relationship of chambers and valves
- atrioventricular abnormality
- great vessel connection abnormality
- conotruncal cardiac anomalies
- pentalogy of Cantrell
- Shone syndrome
- congenital heart disease - chest x-ray approach
surgical repairs (mnemonic)
- arterial switch procedure
- Blalock-Taussig shunt
- double switch procedure
- Fontan procedure
- Glenn procedure
- Mustard repair
- Norwood procedure
- Pott shunt
- pulmonary artery banding
- Rastelli procedure
- Sano shunt
- Senning repair
- total repair of tetralogy of Fallot (TOF)
- unifocalisation procedure
- Waterston shunt
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- 2. Higgins CB, Disessa T, Kirkpatrick SE et-al. Assessment of patent ductus arteriosus in preterm infants by single lateral film aortography. Radiology. 1980;135 (3): 641-7. Radiology (abstract) - Pubmed citation
- 3. Edwards DK, Higgins CB, Merritt TA et-al. Radiographic and echocardiographic evaluation of newborns treated with indomethacin for patent ductus arteriosus. AJR Am J Roentgenol. 1978;131 (6): 1009-13. doi:10.2214/ajr.131.6.1009 - Pubmed citation
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- 9. Philip R, Waller BR, Agrawal V, Wright D, Arevalo A, Zurakowski D, Sathanandam S. Morphologic characterization of the patent ductus arteriosus in the premature infant and the choice of transcatheter occlusion device. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 87 (2): 310-7. doi:10.1002/ccd.26287 - Pubmed