History and exam
Key diagnostic factors
common
presentation in infancy
A large patent ductus arteriosus most often presents as pulmonary resistance falls, usually before 2 to 3 months of age. Diagnosis in adolescence or adulthood is much more unusual but does occur.
Other diagnostic factors
common
tachypnea/shortness of breath (SOB)
In moderate or large patent ductus arteriosus, pulmonary overcirculation often results in increased work of breathing and SOB. In older children, this SOB can sometimes be mistaken for reactive airways disease.
failure to thrive
In moderate or larger patent ductus arteriosus, failure to thrive is a common presenting symptom for infants.
exercise intolerance
In moderate or larger patent ductus arteriosus, exercise intolerance is a common presenting symptom for older children.
widened pulse pressure
With a hemodynamically significant shunt, a widened pulse pressure can be detected by blood pressure measurement or by palpation of bounding pulses. In preterm infants, bounding pulses are a poor independent predictor for the presence of a patent ductus arteriosus.[45]
machine-like continuous murmur/Gibson murmur in children born at full-term
This classic murmur, known as a Gibson murmur or machinery murmur, is best heard in the left infraclavicular area, peaks in late systole, and continues through into diastole.[40] However, some patients with a higher pulmonary pressure in diastole may have a murmur that is confined to systole. The lack of a continuous murmur does not rule out a patent ductus arteriosus.[2] A murmur is a less reliable sign in preterm infants, with high specificity but poor sensitivity.[45]
apnea
May be a symptom in premature infants.
low diastolic blood pressure (BP)
Low diastolic BP with circulatory instability may mimic sepsis in preterm infants.
irritability
This is a nonspecific symptom in full-term infants and children.
diaphoresis
This is a nonspecific symptom in full-term infants and children.
increased respiratory symptoms with upper respiratory infection
Full-term infants and children are prone to these infections.
murmur heard only during systole
This is a sign in newborns, irrespective of the size of the ductus.
hyperdynamic precordium
This is a sign in children with a moderate to large ductus.
systolic thrill
A systolic thrill may be palpable in the upper left sternal border. This is a sign in children with a moderate to large ductus.
third heart sound heard at apex
This is a sign in children with a moderate to large ductus.
mid-diastolic rumble heard at apex
This is a sign in children with a moderate to large ductus.
bounding peripheral pulses
This is a sign in children with a moderate to large ductus.
uncommon
pulmonary rales
Can be heard as a result of pulmonary edema or venous congestion secondary to higher left atrial pressures.
Risk factors
strong
prematurity
The relationship between delayed closure of the ductus arteriosus and prematurity has long been recognized.[28] The incidence of patent ductus arteriosus (PDA) in all preterm infants is about 8 per 1000 births, which is almost 10 times that seen in full-term infants.[2] This increases with decreasing gestational age and birth weight, with an incidence as high as 20% in preterm infants weighing <1750 g and 64% in preterm infants <1000 g.[8][9] Gestational age is related to ductal sensitivity to oxygen and prostaglandins, with a decreased reaction to oxygen and an increased sensitivity to prostaglandins seen in more premature infants.[18] Prematurity is also associated with generalized immaturity of the smooth muscle.[11] There is some evidence that the use of prophylactic protein-free synthetic surfactant in preterm infants may increase the risk of PDA.[29]
maternal rubella
Maternal rubella infection in the first trimester is associated with an increased incidence of patent ductus arteriosus (PDA).[30] While maternal rubella is associated with several congenital heart lesions, PDA is the most common, seen in up to 50% of cases in some early series.[31] The persistent ductus in these patients is histologically akin to an immature ductus.[32] The mechanism of this relationship is not well understood.
female sex
Seen predominantly in females. In one series, 64% of patent ductus arteriosus occurred in females (a ratio of almost 2:1).[6]
weak
respiratory distress syndrome (RDS)
There appears to be an association between severe RDS and patent ductus arteriosus (PDA), as a much higher incidence of PDA is seen in premature infants ill with RDS.[24] PDA is also associated with a 4.5-fold increase in the occurrence of bronchopulmonary dysplasia.[22] While the direction of this relationship would seem to implicate PDA as a causal factor, the decreased oxygenation occurring as a result of RDS and lung pathology may result in decreased metabolism of prostaglandins, thereby contributing to the continued persistence of the duct. This raises the possibility that PDA could instead be a consequence of RDS.[33]
high altitude
Children living at higher altitudes have a higher prevalence.[7] In addition, the effect of altitude is progressive, with lower ambient oxygen levels likely contributing to persistence of the ductus.
family history
Development is multifactorial with evidence for a genetic contribution in certain cases. Siblings of patients are at increased risk (3%) of the defect.[34] There is an increased occurrence with certain syndromes such as trisomy 21, 4p, and Holt-Oram syndrome.[32] In addition, Char syndrome, autosomal dominant inheritance of patent ductus arteriosus, is sometimes seen.[35] Other investigators have found a recessive gene locus that may be associated.[36]
black race
In the US, there is a racial differential, with a higher incidence found in black children compared with white children.[4]
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