Patent ductus arteriosus
Signs and symptoms of PDA can present from infancy to adulthood and vary according to the size and length of the ductus. Preterm infants typically have severe presentations with pulmonary edema, bronchopulmonary dysplasia (BPD), pulmonary hemorrhage, heart failure, necrotizing enterocolitis, and intraventricular hemorrhage. They typically require ventilation and oxygenation while hospitalized prior to PDA closure. Full-term infants, children, and adults with a small PDA will be asymptomatic but may have a murmur. The murmur changes as the patient ages but is usually described as a continuous 3/6 murmur best heard at the left infraclavicular region. Patients with a moderately sized PDA can have exercise intolerance, difficulty feeding, and poor weight gain with failure to thrive. On examination, in addition to a murmur, they can have a wide systemic pulse pressure and evidence of left ventricular dysfunction. Large PDAs can present with cyanotic heart disease with clubbing and cyanosis worse in the lower extremities, wide pulse pressure, and precordial thrill.
The diagnosis is made based on clinical manifestations and confirmed with echocardiogram. Complications from PDAs include pulmonary hypertension, infective endocarditis, and heart failure.
Q25.0 – Patent ductus arteriosus
83330001 – Patent ductus arteriosus
Differential Diagnosis & Pitfalls
- Ventricular septal defect – Typically high frequency, short systolic murmur but can be holosystolic harsh murmur in larger defects; usually becomes louder after the first several hours of life, as pulmonary vascular resistance decreases.
- Peripheral pulmonary stenosis – Quiet, midsystolic ejection murmur; usually resolves by 6-12 months.
- Tricuspid regurgitation – Can be seen as part of tricuspid atresia, pulmonary atresia, and Ebstein anomaly. Murmur is holosystolic, "blowing."
- Pulmonary stenosis – "Harsh" midsystolic ejection murmur loudest at right upper sternal border.
- Aortic stenosis – Harsh midsystolic ejection murmur loudest at right upper sternal border, usually accompanied by systolic "click" and substernal systolic thrill.
- Coarctation of aorta – Murmur usually heard posteriorly, between scapulae.
- Still's murmur – "Musical" systolic murmur without radiation.
- Atrial septal defect – Subtle in children, often not detected until adulthood. Soft systolic murmur at the left upper sternal border, sometimes with diastolic murmur at lower left sternal border. Usually has fixed / split second heart sound (S2).
- Mitral regurgitation – Holosystolic murmur that radiates to the apex. Associated with other illnesses or from anomalies in coronary vasculature or collagen vascular disease.
- Bicuspid aortic valve – Most common congenital heart lesion. Early, holosystolic ejection click at the apex, sometimes with aortic stenosis / murmur and or aortic regurgitation.
- Aortic stenosis – Most common cause of left ventricular outflow obstruction. Presents with a systolic ejection murmur along with dyspnea, exertional angina, and syncope.
- Infectious endocarditis – Rare complication of PDA.