Cardiology Bedside Clinics Interesting Case Discussion

1. website: www.drsarma.in Cardiology Bedside ClinicsInteresting Case Discussion Prof. Dr. Sarma Rachakonda M.D., M.Sc., (Canada), FCGP, FIMSA, FRCP (Glasgow), Consultant Physician and Cardio-metabolic Specialist Visiting Professor of Internal Medicine, SBMC, FLL

2. Important Facts and Facets • 1888 – Munro – Cadaver Dissection – Ligation • 1940 – 50 years later surgical Rx. PDA closure • 1971 – Cather based closure Rx. Options Structures in close proximity to ductus • Recurrent Laryngeal nerve • Thoracic duct • Phrenic nerve

3. Most Important Evaluations • Pulmonary Vascular Resistance (PVR) • Associated Congenital Anomalies • Direction of shunt – L R or R L PVR = ( Mean pulmonary artery pressure – mean pulmonary capillary wedge pressure ) cardiac output = 1.7~2.0 mmHgL-1min or 144 dyne.sec.cm-5

4. Closure of Ductus • PGE2 Production by the ductus • PGE2 high levels from placenta • No clearance of PGE2 by fetal lungs • Difference in oxygen tensions • At birth – Placental supply of PGE2 is cut off • Metabolism by lungs removes PGE2 •  levels of PGE2 stimulate closure of Ductus

5. Normal Closure of Ductus • Functional Closure • Occurs with in 15 hours after birth • Anatomical Closure • Takes place with in 6 to 8 weeks • Spontaneous closure after birth • Can occur up to 2 years • Best time for surgical closure • 3 years of age

6. Definition of PDA Patent ductus arteriosus (PDA) is a congenital heart disease that is usually noted in the first few weeks or months after birth. It is characterized by a connection between the aorta and the pulmonary artery, which allows oxygen-rich blood intended for systemic circulation to reenter the lungs

7. Causes of PDA • Prematurity < 32 weeks – 20%; < 28 weeks 60% • Low birth weight • Maternal Rubella • Fetal Alcoholic Syndrome (FAS) • Asphyxia around term and delivery • Familial or Genetics • 5 to 10% of all C.H.Ds • Approximate incidence – 0.02% to 0.0006% • Gender: Male v/s Female – is 1:2

8. Location of PDA • Usually left side • Occasionally right side • From the bifurcation of PA to • The descending part of Aortic Arch • Distal to the origin of the Lt. subclavian A • Embryologically it is from 6th aortic arch

9. Embryology of Heart

10. Fetal v/s Maternal Circulation • http://www.indiana.edu/~anat550/cvanim/fetcirc/fetcirc.html

11. Types of PDA A B C D E

12. Mortality of PDA

13. Clinical Features • Effort intolerance • Pulmonary congestion • CHF in adults • Arrhythmias in adults • Wide pulse pressure • Collapsing pulse • Hyper dynamic apex • Displaced apex – LVH • Differential cyanosis • S1 and S2 muffled • Paradoxical split of S2 • Precordial thrill • SS notch, 2nd Lt. space • Continuous murmur • Machinery murmur • Train in tunnel murmur • Gibson’s murmur • Respiratory variation

14. DD of Continuous Murmur Congenital, Developmental Disorders • Patent ductus arteriosus • Coronary arteriovenous fistula • Anomalous origin coronary artery/sinus • Aortic septal defect / window Anatomic, Foreign Body, Structural Disorders • Sinus of Valsalva ruptured aneurysm • Pulmonary arteriovenous fistula Functional, Physiologic Variant Disorders • Cervical venous hum, Mammary soufflé

15. Direction of Shunt Right to Left Left to Right Direction of shunt depends on pressures

16. Features of Shunt Reversal • Effort intolerance • Signs of PHT and Right heart overload • Differential cyanosis • Clubbing • Disappearance of diastolic component of the continuous murmur • Pulse no more collapsing • Syncope is not a feature of PDA Indication for immediate closure

17. Chest X Ray of PDA

18. ECG in PDA • May be normal ECG • LVH may be seen • Pulmonary hypertension • ST-T changes due to LV strain • RVH, RAE may be seen

19. Imaging Studies in PDA

20. Imaging Studies in PDA

21. Imaging Studies in PDA

22. Imaging Studies in PDA

23. Alprostadil Available in boxes of 5 vials/ampules Cost per vial Rs. 2500 – 3200 500 mcg drug in one ml vial – dilute with 49 cc D5 Standard concentration 10 mcg/ml (NEOFAX) or (PROSTIN) 0.05-0.2 mcg/kg/min IV

24. Treatment of PDA • Spontaneous closure (with in 2 years) • If symptomatic treatment is prudent •  systemic O2 delivery • Respiratory distress • Medical management • IV Indomethacin (Indocin) 0.2mg/kg x 3 -12 hourly • IV Ibuprofen (NeoProfen) 10 mg/kg – 5mg/kg • Bacterial Endocarditis prophylaxis, Antibiotics • Diuretics/ Digoxin – BNP guided Rx.

25. Treatment of PDA contd.. 4. Catheter based closure of PDA • Gainturco – Spring Occluding Coils • Amplatzer Duct Occluder – ADO I & ADO II • Rashkind Duct Occluding Device – RDOD 5. Surgical closure • Ligation and Division – L&D – Open surgery • Video Assisted Thoracoscopic Surgery (VATS) • Ideal age for surgical / device closure – 3 yrs. • Contraindication – Any disease of pulm. valve

26. Gainturco – Spring Occluding Coils

27. Amplatzer Duct Occluder – ADO

28. Rashkind Duct Occluding Device – RDOD

29. Surgical Closure of PDA

30. Indications for PDA Closure • Age more than 3 years • Children less than who are symptomatic • Significant left-to-right shunt suggested by • Symptomatic – effort intolerance, recurrent LRI, • e/o left-sided volume overload, LVH, LAE • Reversible pulmonary arterial hypertension (PAH) • Irreversible pulmonary vascular disease (Eisenmenger syndrome) – e/o shunt reversal • Other associated congenital heart diseases

31. Schematic View of important Congenital Heart Diseases

32. Atrial septal defect Vent. septal defect

33. Patent Ductus Coarctation

34. Aortic Stenosis Pulmonic Stenosis

35. Tetralogy of Fallot Truncus Arteriosus

36. A-V canal defect Transposition

37. Ebstein's anomaly Hypoplasic Left H

38. Video Files on PDA • Echocardiography of PDA • Devise closure of PDA • Surgical closure of PDA Click on the enclosed video files in the folder

39. Thank You All