Download - PDA - Dr. D. Gunasekaran
ACYANOTIC CONGENITAL HEART DISEASE
ACYANOTIC CONGENITAL HEART DISEASE
Dr. D. Gunsekaran Consultant Paediatrician
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Patent Ductus Arteriosus
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Blood is flowing from Aorta to PA through ductus Ductus
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Ductus in foetus
Normal structure or not?
Why is it important in the foetal life? To maintain foetal circulation
Connects which structures? Aorta and PA
What keeps the ductus open in the foetus? Low Pa O2 & High Prostaglandin E
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Fate of ductus after birth
Functional closure? 12 hours (PaO2 increases & Prostaglandin E falls)
Anatomical closure? 2 weeks
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
PDA Preterms & TermsCommon in preterms:Usually they have hypoxia (O2 is potent vasoconstrictor)The actions of Prostaglandin E is more in themSmooth muscles in the ductus is immatureProstaglandin analogues may be tried to close PDA
Can PDA occur in terms?Yes; less common; Poor mucoid endothelial layer and poor muscle media So, they require surgery for their closure.
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Hemodynamic changes:
RARVPALungsPVLAMV LVAVAorta Other parts of the body
What organic murmur? Why?What flow murmurs? Why?Which chamber gets enlarged? Position of AI? Type of AI?Why recurrent RTI?
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Classification of PDA
Size:
Small, Moderate or Large (0.5cm2, 0.5-1cm2, >1 cm)
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Patent Ductus ArteriosusSymptoms may or may not present at birth
Look for Dysmorphic features
Rubella History essential
Gestational age at deliveryessential
Symptoms in PDASmall PDA: Asymptomatic; growth is normal; Murmur - routine clinical examination.Moderate to Large PDA: Breathlessness on exertionExercise intoleranceFeeding difficultiesFailure to thriveFrequent RTIForehead sweatingChest pain, palpitation, syncope ???
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Vitals in PDA
Pulse: Volume? Rate? Character? Rhythm?Blood pressure?
If there is CCF:
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
General examination
Undernourished, pallor & vitamin def may be +
Pedal edema or Pre sacral edema if CCF +
Look for signs of I.E
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Examination of heart Inspection: Precordial bulge (Cardiomegaly Pliable chest)
Harrison sulcus +/-
Respiratory distress (CCF, LRTI)
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Examination of heartPalpation: Position of apical impulse: Shifted down & out (LV enlargement) Type of apical impulse: Hyper dynamic Palpate in the left upper para-sternal area: Continuous thrill in the upper left sternal order Palpate in the PA for the presence of PHT: Palpable P2
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Examination of heartAuscultation: Heart sounds: Usually, no changes
Murmurs: Continuous left upper parasternal area - grade 4, 5 or 6 (heard throughout the systole & diastole, as the pressure in the Aorta > PA)Other possible murmurs: Flow murmurs: MDM at MA often drowned by the loud continuous murmur ESM at AA-often drowned by the loud continuous murmur
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Complications
Congestive Cardiac FailurePulmonary HypertensionRecurrent LRTIFailure to thriveEisenmengers syndromeInfective Endocarditis
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Complications Congestive Cardiac Failure:
Symptoms: Gen Exam: Vitals: Pulse: BP:Auscultation of Heart: RS: Abdomen examination:
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Complications Congestive Cardiac Failure:
Symptoms: Breathlessness, PND or Orthopnoea, cough Gen Exam: Pedal edemaVitals: Pulse: BP:Auscultation of Heart: GallopRS: Basal crepsAbdomen examination: Tender hepatomegaly
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
ComplicationsPulmonary Hypertension: Palpable P2 P2 loud
Ejection systolic murmur
Continuous murmur systolic murmur (In severe PHT, pressure in Aorta = pressure in PA in diastole; so, PDA murmur is heard only in systole)
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Blood is flowing from Aorta to PA through ductusWhen this can happen?What is its name?
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
ComplicationsEisenmengers syndrome:Shunt reversal in severe PHT; Cyanosis Can occur in all LR (VSD, ASD & PDA)Non-restrictive lesions, in late teens age
If it occurs in PDA: P2 becomes loudInstead of continuous murmur, only systolic murmur +
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Differential diagnosis (of continuous murmur)Venous hum: Murmur is heard above the clavicle, best between the sternomastoid heads; Well heard if head is turned to the R sideDisappears if the head is turned to the same side or when the pt. lies downAorto-Pulmonary window: Very difficult to differentiate; ECHO is necessaryRupture of Sinus of Valsalva: Diastolic component is accentuated; heard little lower down (3rd LICS)Coarctation of Aorta with Collaterals: Murmur is heard in the inter-scapular area
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Natural HistorySpontaneous closure : Possible in Preterms ; but, not in terms (abnormal smooth muscle of ductus).
In smaller PDAs, the risk of IE is more
In larger PDAs: Risk of CCF is more; (8 weeks of age)Risk of PHT is more
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection
ECG: Chamber enlargement
ECHO:
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Normal heart & cardiomegaly
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
ManagementMedical: Dental Hygiene Infective Endocarditis Prophylaxis Diet: high calorie and high protein Frequent short breast feeding Anemia correction, vitamin supplements
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
ManagementMedical: Drug used?Indomethacin Dose: 0.2 mg/kg /dose ; 3 doses; 12 hourlyBest before 3 days; at least by 10 daysIndication: only in PretermsContra indications: NEC, Renal impairment, thrombocytopenia
In renal impairment: Ibuprofen can be tried
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Management
Medical: Transcatheter closure
Indications: Term baby, PDA with cardiac failure
Devices used: Rashkind umbrella occluder Spring coils Amplatzer mush room occluder
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Blood is flowing from Aorta to PA through ductusWhen this can happen?What is its name?
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Blood is flowing from Aorta to PA through ductusWhen this can happen?What is its name?
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Management - Surgical
Closure: Ligation and division left lateral thorcotomy No need for cardiopulmonary bypass
Decision for surgery: Always operate, irrespective of the size Best between 6 months to 2 years (before PHT develops)Until surgery, IE prophylaxis
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
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Blood is flowing from Aorta to PA through ductusTie at both ends and then cut in between
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Management - Surgical
Contraindications for surgery:
Severe PHT (PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion > 12 wood units / m2 BSA)
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Syndromes associated with PDA
1. Chromosomal anomalies: Trisomy 18 (Edward synd) Trisomy 13 (Patau synd) Cri-du-chat syndrome Fragile X syndrome
2. Syndromes: CHARGE, VATER
3. Maternal conditions: Rubella, Phenytoin, Diabetes
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
PDA is a must to sustain life in
Aortic atresiaPulmonary atresiaTGA with intact atrial and ventricular septum
To keep it open: infuse Prostaglandin continuously
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA
Bye-Bye
Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI. Acyanotic Congenital Heart Disease - PDA