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  • • A congenital heart lesion that increases pulmonary artery (PA) blood flow

    • Results in left-to-right shunt, results in lung infection, pulmonary vascular congestion, PA hypertension, right heart failure, pulmonary vasoconstriction, pulmonary vascular obstructive disease

    Eisenmenger syndrome: Increased pulmonary hypertension such that left-to-right shunt ceases and shunt becomes right-to-left, requiring heart-lung transplant

    • Inhaled nitric oxide, oxygen, or IV tolazoline reverses PA vasoconstriction

    • PA band is palliative and can reduce PA flow to alleviate RV failure and progression of pulmonary hypertension

    • Ductus arteriosus normal component of fetal circulation connecting main PA to aorta distal to left subclavian artery

    • In utero, ductus carries 60% of ventricular output, patency maintained by high flow, prostaglandins (from placenta), low oxygen tension

    • At birth, increased pulmonary resistance, prostaglandin level decrease, increased oxygen tension causes duct closure

    • Closure occurs between 1 and 3 days

    • Closure does not always occur

    • Causes left-to-right shunt, heart failure, and pulmonary hypertension

    • Associated with other anomalies

    • May limit flow to systemic organs

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Epidemiology

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  • • Incidence of PDA: 2-3% of live births

    • Increases with prematurity, > 50% in infants born at 30 wks gestation

    • 5% of untreated PDA die of heart and pulmonary failure by age 1

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Symptoms and Signs

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  • Older patients:

    • -Often asymptomatic

      -Continuous murmur over pulmonary area

      -Loud S2

      -Bounding peripheral pulses

    Infants:

    • -Poor feeding

      -Respiratory distress

      -Frequent respiratory infection

      -Heart failure

    Diagnosis by physical exam:

    • -Wide pulse pressure

      -To-and fro-murmur (usually systolic, occasionally continuous)

    Large shunts (5%): Develop pulmonary vascular disease

    • Usually asymptomatic, found during routine exam

    Premature infant: Distinguish heart failure from pulmonary dysfunction of prematurity

    • Inability to wean from ventilator is common presentation

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  • • Echocardiography done on high-risk patients

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Rule Out

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  • • Primary pulmonary dysfunction from prematurity

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  • • Echocardiography diagnostic

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  • • Treatment varies with age

    Premature infant: Medical therapy with indomethacin (50% success)

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Surgery

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  • Term infant or child: Surgical obliteration by ligation, clipping, or division

    Larger infants/children: Video thoracoscopy

    • Transcatheter technique for larger patient may have fewer complications

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Indications

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  • • Term infant/older child

    • Failed medical therapy in premature infant

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Medications

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  • • Indomethacin (prostaglandin inhibitor) 50% success, efficacy decreases with age

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Complications

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  • • Injury to recurrent laryngeal nerve, hemorrhage, chylothorax uncommon

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Prognosis

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  • • Operative mortality near 0%

    • Recurrence < 1% among patients who are treated surgically

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References

Backer CL et al. Congenital Heart Surgery Nomenclature and Database Project: patent ductus arteriosus, coarctation of the aorta, interrupted aortic arch. Ann Thorac Surg. 2000;69:S298.

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