Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults
- Thomas Doyle, MD
Thomas Doyle, MD
- Associate Professor of Pediatrics
- Vanderbilt University School of Medicine
- Ann Kavanaugh-McHugh, MD
Ann Kavanaugh-McHugh, MD
- Associate Professor of Pediatrics
- Vanderbilt University School of Medicine
- Section Editors
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
- John K Triedman, MD
John K Triedman, MD
- Section Editor — Pediatric Cardiology
- Professor of Pediatrics
- Harvard Medical School
The ductus arteriosus (DA) is a fetal vascular connection between the main pulmonary artery and the aorta (figure 1) that diverts blood away from the pulmonary bed. After birth, the DA undergoes active constriction and eventual obliteration. A patent ductus arteriosus (PDA) occurs when the DA fails to completely close postnatally. (See "Physiologic transition from intrauterine to extrauterine life".)
The clinical manifestations and diagnosis of PDA in full term infants, older children, and adults will be reviewed here. PDA in the premature infant and the management of PDA are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants" and "Management of patent ductus arteriosus".)
DUCTAL EMBRYOLOGY AND ANATOMY
The ductus arteriosus (DA) is thought to derive from the embryonic left sixth aortic arch (figure 2 and image 1). In the typical left aortic arch, the aortic end of the DA arises distal to the left subclavian artery, and the pulmonary end inserts at the junction of the main and left pulmonary arteries.
The anatomy is more varied in the presence of a right aortic arch. Most commonly, the DA arises from the left innominate artery and inserts into the region of the proximal left pulmonary artery . Less frequently, the DA arises distal to the right subclavian artery and inserts near the proximal right pulmonary artery. In rare instances, there is a bilateral DA, usually in the presence of other complex congenital cardiovascular anomalies.
Regardless of the aortic arch orientation, the vascular structures remain anterior to the trachea and esophagus, and there is no vascular ring. One exception to this general rule occurs when there is a right aortic arch with an aberrant left subclavian artery. In this setting, the DA typically arises from the aberrant subclavian artery and inserts into the proximal left pulmonary artery. This creates a vascular ring with the aorta anterior to and rightward of the trachea and esophagus; the aberrant subclavian artery is posterior, and the DA is along the left side, connecting the subclavian to the pulmonary artery. (See "Vascular rings", section on 'R aortic arch with aberrant L subclavian artery and L ductus arteriosus/ligamentum'.)
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- DUCTAL EMBRYOLOGY AND ANATOMY
- FETAL AND TRANSITIONAL DUCTAL CIRCULATION
- Patency of the ductus
- Ductal constriction
- Genetic factors
- CLINICAL MANIFESTATIONS
- Small PDA
- Moderate PDA
- Large PDA
- - Two-dimensional echocardiography
- - Doppler color flow
- - Doppler echocardiography
- - M-mode echocardiography
- Other diagnostic tests
- - Chest radiograph
- - Electrocardiogram
- - MRI and CT
- DIFFERENTIAL DIAGNOSIS
- Heart failure
- Infective endocarditis
- Pulmonary hypertension
- Complications during pregnancy
- SUMMARY AND RECOMMENDATIONS