Professional Documents
Culture Documents
Patent Ductus Arteriosus
Patent Ductus Arteriosus
Patent Ductus Arteriosus
INTRODUCTION
The most common cardiac disease affecting neonates is patent ductus arteriosus
(PDA). Despite several research about it, the option to treat PDA is still heavily debated
by cardiologists, surgeons, and neonatologists.
DEFINITION
Patent ductus arteriosus (PDA) is a cardiac abnormality that appears in the days
or weeks following birth. The ductus arteriosus is a natural feature of fetal blood
circulation before a newborn is born, it's an additional blood vessel that links the
pulmonary artery to the aorta. The pulmonary artery is responsible for transporting
blood from the heart to the lungs. The aorta transports blood from the heart to the rest
of the body. The ductus arteriosus allows blood to circulate around (bypass) the lungs
prior to birth. This is because the infant receives oxygen from the mother.
This opening between the aorta and the pulmonary artery is present in all
newborns. However, it frequently closes on its own shortly after birth, after the baby can
breathe on its own. It is referred to as patent ductus arteriosus if it remains open
(patent). Extra blood rushes to the lungs as a result of PDA. A big PDA sends an
excessive amount of blood to the lungs. To accommodate the increased blood, the
blood arteries and lungs must work much harder. This might cause an accumulation of
fluid in the lungs. Breathing and feeding may be more difficult for the newborn. (Stanford
Children’s Health, n.d.).
A small patent ductus arteriosus may not cause any symptoms and may never
require treatment. However, if left untreated, a large patent ductus arteriosus can cause
poorly oxygenated blood to flow in the incorrect way, weakening the heart muscle and
leading to heart failure and other issues. A PDA is termed small if its dimension is less
than 1.5 mm, moderate if it is between 1.5 and 3 mm, and large if it surpasses 3 mm.
(Arlettaz, 2017).
SYMPTOMATOLOGY
ETIOLOGICAL FACTORS
PREDISPOSING RATIONALE
Age At 3 days of life, up to 80% of severely
preterm newborns, especially those with
respiratory distress syndrome, may have
a PDA (Gillam and Mahajan, 2021).
Gender The male-female ratio is 1:3. Patent
ductus arteriosus accounts for 5 to 10%
of congenital cardiac abnormalities
(Beerman, 2020).
Family history and other genetic Genetic disorder - PDA occurs with
conditions increased frequency in several genetic
syndromes, including those with defined
chromosomal aberrations, single-gene
mutations and X-linked mutations.
(Schneider & Moore, 2016).
PRECIPITATING RATIONALE
Premature birth The incidence of PDA is greater in pre-
term neonates, it is highly associated to
the lack of normal closure mechanisms
due to immaturity (Dice & Bhatia, 2016).
Rubella Infection during pregnancy The rubella virus crosses the placenta
and spreads through the baby's
circulatory system, damaging blood
vessels and organs, including the heart
(Mayo Clinic 2021).
Being born at a high altitude Failure of lower oxygen tension to
constrict the ductus leads to patency of
ductus arteriosus while the presence of
high pulmonary vascular resistance and
right atrial pressure at high altitude
inhibits early closure of foremen ovale
(Hasan, 2016).
Respiratory distress syndrome RDS causes PDA primarily through
hypoxemia, while pulmonary
hyperperfusion caused by PDA
decreases surfactant formation in alveolar
cells, implying that the link between PDA
and RDS is complex and bidirectional (Liu
et. Al., 2021).
PATHOPHYSIOLOGY
Diagram
Narrative
During fetal development, oxygenated blood travels from the placenta via the
umbilical vein, through the inferior vena cava (IVC), and to the right side of the heart. A
portion of this oxygenated blood is sent through the patent foramen ovale for delivery to
the brain, and the remainder is pumped by the right ventricle through the main
pulmonary artery. The PDA provides a low-resistance pathway to the aorta, and the
majority of the blood pumped from the right ventricle to the pulmonary artery will follow
this route, delivering oxygen and nutrients from the placenta to the organs and tissues
and then returning to the placenta through the umbilical arteries. Many factors may
cause failure of PDA closure; these may include misinterpretation of chemical or
environmental signals, failure to respond to oxygen, complications from disease
processes, and underdeveloped smooth muscle. The signals that normally lead to
constriction of the PDA and functional closure in the first days of life are not interpreted
in the same way in premature infants. Throughout development, tissue responsiveness
to different signals changes as the fetus matures. This process is programmed to help
orchestrate the extremely complex series of events required for successful fetal
development. When an infant is born prematurely, some tissues are not yet sensitive to
the signals in the extrauterine environment that allow them to properly adapt. The tissue
in the PDA has not yet developed optimal sensitivity to increased oxygen content in the
blood, which is important for stimulating constriction. Instead, the PDA is still very
sensitive to circulating prostaglandins that cause it to remain open. Circulating
prostaglandins decrease significantly after delivery in both term and preterm infants.
However, the premature ductal tissue may still respond, even to low concentrations of
prostaglandins, causing a failure of constriction. Certain disease processes, such as
sepsis and NEC, are accompanied by a surge of prostaglandins. This surge can cause
a functionally closed, constricted PDA to reopen and further complicate the disease
process. Some characteristics of the cardiopulmonary system of premature infants
make them especially susceptible to problems from the PDA. The lower vascular tone of
the pulmonary vessels at earlier gestational ages facilitates left to- right shunting when
the PDA is open, and this shunting perpetuates the failure of the ductus to constrict.
Thus, when the PDA exists, premature infants are more likely than term infants to go
into congestive heart failure. Additionally, the permeability of the capillaries in the
pulmonary bed is greater in premature infants, leaving them more susceptible to
developing pulmonary edema from the over circulation that accompanies left-to-right
shunting.
DIAGNOSTIC TESTS
Electrocardiogram. This test records the electrical activity of the heart, which
can aid in the diagnosis of cardiac abnormalities or irregular heartbeats (Mayo
Clinic, 2021).
Echocardiogram. Sound waves provide images of the heart that can aid in
identifying a PDA, determining whether the heart chambers are enlarged, and
determining how well the heart pumps. This test also aids in the evaluation of the
heart valves and the detection of any potential cardiac abnormalities by the
doctor (Mayo Clinic, 2021)
Chest X-ray. The state of your or your baby's heart and lungs can be seen via an
X-ray scan. Other than a heart abnormality, an X-ray may identify other issues
(Mayo Clinic, 2021).
Cardiac Catherization. This test isn't normally required to diagnose a PDA on its
own, but it may be used to look for other congenital heart problems that were
discovered during an echocardiography or if a catheter surgery is being explored
to treat a PDA. A thin, flexible tube (catheter) is placed into a blood vessel in the
groin or arm of you or your child and guided into the heart. The doctor may be
able to do operations to close the patent ductus arteriosus using catheterization
(Mayo Clinic, 2021).
MEDICAL MANAGEMENT
MEDICATIONS
SURGICAL MANAGEMENT
Transcatheter closure. Transcatheter closure has become the treatment of
choice for PDA in children over the age of one year, and some writers believe it
is also the best option for term newborns and newborn infants. There are a
number of catheter-delivered occlusion devices available (eg, coils, septal duct
occluder).
RT MANAGEMENT
OTHER MANAGEMENT
Fluid restriction and diuretics. To minimize volume overload and the resulting
congestive heart failure, the attentive care begins with better delivery room
management at birth and involves judicious fluid restriction with high
humidification (Sung et. Al., 2020). Fluid restriction (110 to 130ml/kg/d while urine
output is monitored) is part of conservative management. Diuretics are
contentious since there is little evidence that they improve outcomes in very
premature children, may hinder PDA closure, and induce electrolyte imbalances
that are difficult to treat in the extremely premature infant (Gillam et. Al., 2021).
REFERENCES
Arlettaz, R. (2017). Echocardiographic Evaluation of Patent Ductus Arteriosus in
Preterm Infants. Frontiers in Pediatrics. Retrieved from
https://www.frontiersin.org/articles/10.3389/fped.2017.00147/full
Beerman, L. B. (2020). Patent Ductus Arteriosus (PDA). MSD Manual. Retrieved from
https://www.msdmanuals.com/professional/pediatrics/congenital-cardiovascular-
anomalies/patent-ductus-arteriosus-pda.
Gillam, K. M. and Mahajan K. Patent Ductus Arteriosus (2021). In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430758/
Liu, C., Zhu, X., Li, D., & Shi, Y. (2021). Related Factors of Patent Ductus Arteriosus in
Preterm Infants: A Systematic Review and Meta-Analysis. Frontiers in
pediatrics, 8, 605879. https://doi.org/10.3389/fped.2020.605879
Stanford Children’s Health (n.d.). Patent Ductus Arteriosus (PDA). Retrieved from
https://www.stanfordchildrens.org/en/topic/default?id=patent-ductus-arteriosus-
pda-90-P01811
Sung, S. I., Chang, Y. S., Ahn, S. Y., Jo, H. S., Yang, M., & Park, W. S. (2020).
Conservative Non-intervention Approach for Hemodynamically Significant Patent
Ductus Arteriosus in Extremely Preterm Infants. Frontiers in pediatrics, 8, 605134.
https://doi.org/10.3389/fped.2020.605134