Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

Patent Ductus Arteriosus 1143

Signs & Symptoms

■Rare for adult PDA to have associated symptoms, but if it occasionally

patient will develop CHF, DOE, CP, and palpitations

■Continuous “machinery” murmur, peaks in late systole, best heard

in left infraclavicular area, 2nd ICS

■Widened pulse pressure if significant left-to-right shunt is present

■Differential cyanosis with sparing of upper extremities in presence

of severe pulmonary hypertension

tests

Screening

■Physical examination with classic murmur

Imaging

■CXR may show calcification of the ductus, left atrial enlargement or

pulmonary artery enlargement

■ECHO: Color flow Doppler shows continuous high velocity flow

within the main pulmonary artery near the left branch; estimate

gradient across the PDA from velocity across ductus

■Right heart catheterization: gold standard; if PVR < 10 U/m^2 , surgery

for ligation and division of the PDA is low risk

differential diagnosis

DDx of continuous murmur

■Pulmonary A-V fistula

■Coronary-cameral fistula (coronary to cardiac chamber)

■Anomalous origin of left coronary artery from pulmonary artery

■VSD with aortic regurgitation

■Venous hum (external jugular compression obliterates murmur)

■Aortopulmonary window

■Coarctation of aorta (rarely causes a continuous murmur)

management

■Assess for evidence of shunt reversal and pulmonary hypertension

(physical exam/echo)

■Endocarditis prophylaxis indicated

specific therapy

■Surgical ligation is curative, can be done thorascopically or by

catheter based approach

■Contraindication: high PVR >10 U/m^2 or predominantly right-to-left

shunting