Patent duct arteriosus (PDA) occluder

Case contributed by Kirollos Bechay

Presentation

Patient with history of prematurity, sickle cell disease and patent ductus arteriosus, presenting with nasal congestion, cough and distended abdomen for 5 days.

Patient Data

Age: 3 years
Gender: Female

1. A PDA duct occluder is seen in the appropriate position in this girl 3-year-old girl with a history of PDA.

2. Mild-to-moderate bilateral peribronchial thickening may be due to reactive airway disease or a viral process.  No discrete focal pneumonia, effusion or pneumothorax.

The heart appears at upper limits with mild diffuse prominence of the main PA considering technique.

4. Suggestion of mild diffuse splenomegaly mild diffuse gaseous distension of few bowel segments in the left upper abdomen.

5. No acute osseous findings. Both femoral capital epiphysis and bilateral humeri appear intact.

Case Discussion

The ductus arteriosus (DA) is a fetal vessel that allows shunting of blood away from the pulmonary vasculature for the purpose of in-utero oxygenation. At birth, breathing decreases pulmonary vascular resistance, redirecting blood away from the DA and causing it to constrict and close by weeks 2-3 in a healthy newborn. If the DA remains patent after 8 weeks, it is unlikely to spontaneously close and requires surgical closure, termed a patent ductus arteriosus (PDA) 1. The continuous flow of the PDA results in a heart murmur, classically described as a machine-like, holosystolic murmur. 

The major risk factors for a PDA are prematurity and respiratory distress syndrome. One study demonstrated that 70% of infants weighing under 1000 grams will have a PDA at day 7, while 90% of term infants have a closed duct by day 4 2. Radiography may demonstrate pulmonary vascular markings but echocardiography is required for diagnosis. 

Initial management of a PDA is pharmacological induction of closure with indomethacin or ibuprofen. However, large-sized PDAs may not close and require surgical closure by an interventional cardiologist. Initially, these larger PDAs were treated with coil implantation, but the Amplatzer duct occluder (ADO), of which there are now multiple varieties/sizes, has become the device of choice 3. These self-expanding devices have proven to be less complicated in their deployment and lower rates of complications relative to coils. Studies have confirmed PDA occlusion rates of >99% with these devices after 6 months 4.

This case was submitted with supervision and input from:
Soni C. Chawla, M.D.
Health Sciences Clinical Professor,
Department of Radiological Sciences,
David Geffen School of Medicine at UCLA.
Attending Pediatric Radiologist,
Olive View - UCLA Medical Center.

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