Patent ductus arteriosus

PDA
Last reviewed: December 21, 2009.

Patent ductus arteriosus (PDA) is a condition in which a blood vessel called the ductus arteriosus fails to close normally in an infant soon after birth. (The word "patent" means open.) The condition leads to abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart.

Causes, incidence, and risk factors

Before birth, the ductus arteriosus allows blood to bypass the baby's lungs by connecting the pulmonary arteries (which supply blood to the lungs) with the aorta (which supplies blood to the body). Soon after the infant is born and the lungs fill with air, this blood vessel is no longer needed. It will usually close within a couple of days. If the ductus arteriosus does not close, there will be abnormal blood circulation between the heart and lungs. PDA affects girls more often than boys. The condition is more common in premature infants and those with neonatal respiratory distress syndrome. Infants with genetic disorders, such as Down syndrome, and whose mothers had rubella during pregnancy are at higher risk for PDA. PDA is common in babies with congenital heart problems, such as hypoplastic left heart syndrome, transposition of the great vessels, and pulmonary stenosis.

Symptoms
A small PDA may not cause any symptoms. However, some infants may not tolerate a PDA, especially if it is large, and may have symptoms such as: Bounding pulse Fast breathing Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily Poor growth

Signs and tests

Babies with PDA often have a characteristic heart murmur that can be heard with a stethoscope. However, in premature infants, a heart murmur may not be heard. Doctor's may suspect the condition if the infant has breathing or feeding problems soon after birth. Changes may be seen on chest x-rays. The diagnosis is confirmed with an echocardiogram. Sometimes, a small PDA may not be diagnosed until later in childhood.

Treatment
The goal of treatment, if the rest of circulation is normal or close to normal, is to close the PDA. In the presence of certain other heart problems, such as hypoplastic left heart syndrome, the PDA may actually be lifesaving and medicine may be used to prevent it from closing. Sometimes, a PDA may close on its own. Premature babies have a high rate of closure within the first 2 years of life. In full-term infants, a PDA rarely closes on its own after the first few weeks. When treatment is appropriate, medications such as indomethacin or a special form of ibuprofen are generally the first choice. If these measures do not work or can't be used, a medical procedure may be needed. A transcatheter device closure is a minimally invasive procedure that uses a thin, hollow tube. The doctor passes a small metal coil or other blocking device through the catheter to the site of the PDA. This blocks blood flow through the vessel. Such endovascular coils have been used successfully as an alternative to surgery. Surgery may be needed if the catheter procedure does not work or cannot be used. Surgery involves making a small cut between the ribs to repair the PDA.

Expectations (prognosis)
If a small PDA remains open, heart symptoms may or may not eventually develop. Persons with a moderate or large PDA could eventually develop heart problems unless the PDA is closed. Closure with medications can work very well in some situations, with few side effects. Early treatment with medications is more likely to be successful. Surgery carries its own significant risks. It may eliminate some of the problems of a PDA, but it can also introduce a new set of problems. The potential benefits and risks should be weighed carefully before choosing surgery.

Complications

If the patent ductus is not closed, the infant has a risk of developing heart failure, pulmonary artery hypertension, or infective endocarditis -- an infection of the inner lining of the heart.

Calling your health care provider

This condition is usually diagnosed by a doctor examining your infant. Breathing and feeding problems in an infant can occasionally be due to an undiagnosed PDA.

Prevention
Preventing preterm deliveries, where possible, is the most effective way to prevent PDA.

Patent ductus arteriosus (PDA) is a congenital disorder in the heart wherein a neonate's ductus arteriosus fails to close after birth. Early symptoms are uncommon, but in the rst year of life include increased work of breathing and poor weight gain. With age, the PDA may lead to congestive heart failure if left uncorrected.
Contents [hide] 1 1 Overview 1 2 3 4 2 3 4 5 6 7 8 1.1 Etiology 1.2 Normal ductus arteriosus closure 1.3 Patent ductus arteriosus 1.4 Prognosis

2 Signs and symptoms 3 Diagnosis 4 Treatment 5 History 6 Additional images 7 References 8 External links

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Overview
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Etiology

A patent ductus arteriosus can be idiopathic (i.e. without an identiable cause), or secondary to another condition. Some common contributing factors in humans include: [edit] Preterm birth Congenital rubella syndrome Chromosomal abnormalities such as Down syndrome

Normal ductus arteriosus closure

In the developing fetus, the ductus arteriosus (DA) is the vascular connection between the pulmonary artery and the aortic arch that allows most of the blood from the right ventricle to bypass the fetus' uid-lled compressed lungs. During fetal development, this shunt protects the right ventricle from pumping against the high resistance in the lungs, which can lead to right ventricular failure if the DA closes inutero. When the newborn takes its rst breath, the lungs open and pulmonary vascular resistance decreases. After birth, the lungs release bradykinin to constrict the smooth muscle wall of the DA and reduce bloodow through the DA as it narrows and completely closes, usually within the rst few weeks of life. In most newborns with a patent ductus arteriosus the blood ow is reversed from that of in utero ow, i.e. the blood ow is from the higher pressure aorta to the now lower pressure pulmonary arteries. In normal newborns, the DA is substantially closed within 1224 hours after birth, and is completely sealed after three weeks. The primary stimulus for the closure of the ductus is the increase in neonatal blood oxygen content. Withdrawal from maternal circulating prostaglandins also contributes to ductal closure. The residual scar tissue from the brotic remnants of DA, called the ligamentum arteriosum, remains in the normal adult heart. [edit]

Patent ductus arteriosus

The ductus arteriosus is a normal fetal blood vessel that closes soon after birth. In a patent ductus arteriosus (PDA) the vessel does not close and remains "patent" resulting in irregular transmission of blood between two of the most important arteries close to the heart, the aorta and the pulmonary artery. PDA is common in neonates with persistent respiratory problems such as hypoxia, and has a high occurrence in premature children. In hypoxic newborns, too little oxygen reaches the lungs to produce sufcient levels of bradykinin and subsequent closing of the

DA. Premature children are more likely to be hypoxic and thus have PDA because of their underdeveloped heart and lungs. A patent ductus arteriosus allows a portion of the oxygenated blood from the left heart to ow back to the lungs by owing from the aorta (which has higher pressure) to the pulmonary artery. If this shunt is substantial, the neonate becomes short of breath: the additional uid returning to the lungs increases lung pressure to the point that the neonate has greater difculty inating the lungs. This uses more calories than normal and often interferes with feeding in infancy. This condition, as a constellation of ndings, is called congestive heart failure. In some cases, such as in transposition of the great vessels (the pulmonary artery and the aorta), a PDA may need to remain open. In this cardiovascular condition, the PDA is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the patent ductus arteriosus open. [edit]

Prognosis
Without treatments, the disease may progress from left-to-right (noncyanotic heart) shunt to right-to-left shunt (cyanotic heart) called Eisenmenger's syndrome. [edit]

Signs and symptoms

While some cases of PDA are asymptomatic, common symptoms include: tachycardia respiratory problems dyspnea - shortness of breath continuous machine-like heart murmur cardiomegaly - enlarged heart left subclavicular thrill bounding pulse widened pulse pressure patients typically present in good health, with normal respirations and heart rate. If the ductus is moderate or large, widened pulse pressure and bounding peripheral pulses are frequently present, reecting increased left ventricular stroke volume and diastolic runoff of blood into the initially lowerresistant pulmonary vascular bed. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.

 [edit]

poor growth[1] differential cyanosis, i.e. cyanosis of the lower extremities but not of the upper body.

Diagnosis

Phonocardiograms from normal and abnormal heart sounds

PDA is usually diagnosed using non-invasive techniques. Echocardiography, in which sound waves are used to capture the motion of the heart, and associated Doppler studies are the primary methods of detecting PDA. Electrocardiography (ECG), in which electrodes are used to record the electrical activity of the heart, is not particularly helpful as there are no specic rhythms or ECG patterns which can be used to detect PDA. A chest X-ray may be taken, which reveals the overall size of neonate's heart (as a reection of the combined mass of the cardiac chambers) and the appearance of the blood ow to the lungs. A small PDA most often shows a normal sized heart and normal blood ow to the lungs. A large PDA generally shows an enlarged cardiac silhouette and increased blood ow to the lungs. [edit]

Treatment

Neonates without adverse symptoms may simply be monitored as outpatients, while symptomatic PDA can be treated with both surgical and non-surgical methods.[2] Surgically, the DA may be closed by ligation (though support in premature infants is mixed),[3] wherein the DA is manually tied shut, or with intravascular coils or plugs that leads to formation of a thrombus in the DA. This was rst performed in humans by Robert E. Gross[citation needed]. Because Prostaglandin E1 is responsible for keeping the ductus patent, NSAIDS (inhibitors of prostaglandin synthesis) such as indomethacin or a special form of ibuprofen have been used to help close a PDA.[1][4] This is an especially viable alternative for premature infants.[citation needed] In certain cases it may be benecial to the neonate to prevent closure of the ductus arteriosus[citation needed]. For example, in transposition of the great vessels, a PDA may prolong the newborn's life until surgical correction is possible. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs such as alprostadil or misoprostol (prostaglandin E1 analogs)[citation needed]. More recently, PDAs can be closed by percutaneous interventional method[citation needed]. Via the femoral vein or femoral artery, a platinum coil can be deployed via a catheter, which induces thrombosis (coil embolization). Alternatively, a PDA occluder device (AGA Medical)[citation needed], composed of nitinol mesh, is deployed from the pulmonary artery through the PDA. The larger skirt of the device sits on the aortic side while the ampulla of the device hugs the walls of the PDA, with care taken to avoid occlusion of the pulmonary arterial lumen by the device [citation needed]. These methods permit closure without open heart surgery.

Ductus arteriosus
From Wikipedia, the free encyclopedia
Artery: Ductus arteriosus

Plan of the fetal circulation. ("Ductus arteriosus" visible at upper right.)

Heart cross-section with PDA

Gray's Source Branches Vein Precursor MeSH

subject #139 540 pulmonary artery aortic arch ductus venosus aortic arch 6 Ductus+Arteriosus

In the developing fetus, the ductus arteriosus (DA), also called the ductus Botalli, is a blood vessel connecting the pulmonary artery to the aortic arch. It allows most of the blood from the right ventricle to bypass the fetus's uid-lled nonfunctioning lungs. Upon closure at birth, it becomes the ligamentum arteriosum. There are two other fetal shunts, the ductus venosus and the foramen ovale. [edit]

Patent ductus arteriosus

Main article: Patent ductus arteriosus Failure of a child's DA to close after birth results in a condition called patent ductus arteriosus and the generation of a left-to-right shunt. If left uncorrected, patency leads to pulmonary hypertension and possibly congestive heart failure and cardiac arrhythmias. Prostaglandins are responsible for maintaining the ductus arteriosus. Closure may be induced with NSAIDs because these drugs inhibit prostaglandin synthesis. A patent ductus arteriosus affects around 40% of infants with Down syndrome (DS). A failure to thrive is a very common sign of this condition.[1]

oramen ovale (heart)

From Wikipedia, the free encyclopedia

Not to be confused with ostium secundum.

Foramen ovale (heart)

Sketch showing foramen ovale in a fetal heart. Red arrow shows blood from the inferior caval vein. HF: right atrium, VF: left atrium. HH og VH: right and left ventricle. The heart still has a common pulmonary vein (LV), instead of four.

Heart of human embryo of about thirty-ve days, opened on right side. Gray's subject #135 512 MeSH Foramen+Ovale

In the fetal heart, the foramen ovale ( /fremn ovli/), also ostium secundum of Born or falx septi, allows blood to enter the left atrium from the right atrium. It is one of two fetal cardiac shunts, the other being the ductus arteriosus (which allows blood that still escapes to the right ventricle to bypass the pulmonary circulation). Another similar adaptation in the fetus is the ductus venosus. In most individuals, the foramen ovale closes at birth. It later forms the fossa ovalis.
Contents [hide] 1 2 3 4 5 1 Development 2 Closure 3 Clinical relevance 4 References 5 External links

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Development

The foramen ovale forms in the late fourth week of gestation. Initially the atria are separated from one another by the septum primum except for a small opening in the septum, the ostium primum. As the septum primum grows, the ostium primum narrows and eventually closes. Before it does so, bloodow from the inferior vena cava wears down a portion of the septum primum, forming the ostium secundum. Some embryologists postulate that the ostium secundum may be formed through programmed cell death.[1] The ostium secundum provides communication between the atria after the ostium primum closes completely. Subsequently, a second wall of tissue, the septum secundum, grows over the ostium secundum in the right atrium. Bloodow then only passes from the right to left atrium by way of a small passageway in the septum secundum and then through the ostium secundum. This passageway is called the foramen ovale. [edit]

Closure
Normally this opening closes in the rst three months following birth. When the lungs become functional at birth, the pulmonary pressure decreases and the left atrial pressure exceeds that of the right. This forces the septum primum against the septum secundum, functionally closing the foramen ovale. In time the septa eventually fuse, leaving a remnant of the foramen ovale, the fossa ovalis. [edit]

Clinical relevance
In about 30% of adults the foramen ovale does not close completely, but remains as a small patent foramen ovale. PFO has long been studied because of its demonstrated role in some cases of paradoxical embolism. After exclusion of more common causes of stroke and TIA, transesophageal echocardiography should be considered in order to exclude cardiogenic foci of embolism. The presence of a patent foramen ovale should be considered as a possible cause of the cerebrovascular event, even though it may simply be an occasional nding in patients with cryptogenic stroke.

CIRCULATORY CHANGES AT BIRTH

Objectives 1. Review of Fetal Circulation 2. Changes at Birth 3. Postnatal circulation 4. Defects

I. Review of Fetal Circulation

The development of the cardiovascular system Begins to develop toward the end of the third week Heart starts to beat at the beginning of the fourth week The critical period of heart development is from day 20 to day 50 after fertilization. Many critical events occur during cardiac development, and any deviation from this normal pattern can cause congenital heart defects, if development of heart doesnt occur properly. However, we will concern ourselves with the events surrounding the circulatory changes at birth. Trace path of blood in diagram of fetal circulation (see diagram)

Three shunts in the fetal circulation

1. Ductus arteriosus protects lungs against circulatory overload allows the right ventricle to strengthen hi pulmonary vascular resistance, low pulmonary blood ow carries mostly med oxygen saturated blood

2. Ductus venosus fetal blood vessel connecting the umbilical vein to the IVC blood ow regulated via sphincter carries mostly hi oxygenated blood 3. Foramen ovale shunts highly oxygenated blood from right atrium to left atrium

II. Review of respiratory changes and other changes at birth

Overview As soon as the baby is born, the foramen ovale, ductus arteriosus ductus venosus and umbilical vessels are no longer needed. The sphincter in the ductus venosus constricts, so that all blood entering the liver passes through the hepatic sinusoids. Occlusion of the placental circulation causes an immediate fall of blood pressure in the IVC and right atrium.

Circulatory Adjustments at birth:

Increasing uptake of oxygen by lungs (rst and subsequent breaths) induces a vasoconstriction of ductus venosus and ductus arteriosis Aeration of the lungs at birth is associated with 1. a dramatic fall in pulmonary vascular resistance due to lung expansion. 2. a marked increase in pulmonary blood ow (thus raising the left atrial pressure above that of IVC) 3. a progressive thinning of the walls of the pulmonary arteries (due to stretching as lungs increase in size with rst few breaths)

The rst breath: the pulmonary alveoli open up: pressure in the pulmonary tissues decreases Blood from the right heart rushes to ll the alveolar capillaries Pressure in the right side of the heart decreases Pressure in the left side of the heart increases as more blood is returned from the well-vascularized pulmonary tissue via the pulmonary veins to the left atrium Resulting circulatory changes include: blood pressure is now high in the aorta and systemic circulation is well established Control of circulation is a reex function regulated: Peripherally by the baroreceptors in the aortic artch and carotid sinus Centrally by baroreceptors in the cardiovascular center of the medulla (in close proximity of the chemoreceptors that regulate respiration) Respiratory and circulatory reexes are usually strong in the healthy full-term newborn, but their efciency in controlling cardiovascular function is susceptible to environmental factors. What happens to these shunts at birth? Foramen ovale (see drawing) Before birth the foramen ovale allows most of the oxygenated blood entering the right atrium from the IVC to pass into the left atrium Prevents passage of blood in the opposite direction because the septum primum closes against the relatively rigid septum secundum. Closes at birth due to decreased ow from placenta and IVC to hold open foramen, and More importantly because of increased pulmonary blood ow and pulmonary venous return to left heart causing the pressure in the left atrium to be higher than in the right atrium. The increased left atrial pressure then closes the foramen ovale against the septum segundum. The output from the right ventricle now ows entirely into the pulmonary circulation. Other changes in the heart The right ventricular wall is thicker than the left ventricular wall in

fetuses and newborn infants because the right ventricle has been working harder. By the end of the rst month the left ventricular wall is thicker than the right because it is now working harder than the right one. The right ventricular wall becomes thinner because of atrophy associated with its lighter workload.

II. Ductus Arteriosus

The DA constricts at birth, but there is often a small shunt of blood from the aorta to the left pulmonary artery for a few days in a healthy, fullterm infant. In premature infants and in those with persistent hypoxia the DA may remain open for much longer. Oxygen is the most important factor in controlling closure of the DA in full-term infants. Closure of the DA appears to be mediated by bradykinin, a substance released by the lungs upon initial ination. Bradykinin has potent contractile effects on smooth muscle. Action depends upon the high oxygen content of the aortic blood resulting from aeration of the lungs at birth. When the PO2 of blood passing through the DA reaches about 50 mm Hg, the wall of the DA constricts. (May be mediated direct or may be mediated by Oxygens effect on decreasing PG E2 and prostacylcin secretion. (unlike in a coarctation of aorta which requires PGE2 infusion to reopen the DA for blood ow. As a result of reduced pulmonary vascular resistance, the pulmonary arterial pressure falls below the systemic level and the blood ow thru the ductus arteriosis is diminished. Umbilical Arteries constrict at birth To prevent loss of infants blood. Umbilical cord is not tied for 30-60 seconds so that blood ow thru umbilical vein continues, transferring fetal blood from placenta to the infant. Blood change from fetal to adult pattern of circulation is not a sudden occurrence in some changes occur during the rst breath, others over hours and days.

 During the transitional stage right to left ow may occur through the foramen ovale. The closure of the fetal vessels and the foramen ovale is initially a functional change; later anatomic closure results from proliferation of endothelial and brous tissues.

Adult Derivatives of Fetal Vascular Structures

Because of certain changes in the cardiovascular system at birth, certain vessels and structures are no longer required. Over a period of months these fetal vessels form nonfunctional ligaments, and fetal structures such as the foramen ovale persist as anatomic vestiges of the prenatal circulatory system.  Fetal Structure Adult Structure Foramen Ovale Fossa Ovalis Umbilical Vein Ligamentum teres (intra-abdominal part) Ductus Venosus Ligamentum venosum Umbilical Arteries medial umbilical ligaments, and abdominal superior vesicular artery (supplies ligaments bladder) Ductus Arteriosum Ligamentum arteriosum

Two common defects:

 1. patent ductus arteriosus common in females 2-3 times more than males, unknown reason why If instead of functional closure after birth there is patent structure then aortic blood is shunted into the pulmonary artery. Most common congenital anomaly associated with maternal rubella infection during early pregnancy (mode of action by virus unclear)

 Premature infants usually have a PDA due to hypoxia and immaturity. Surgical closure of PDA is achieved by ligation and division of the DA. 2. Patent foramen ovale most common form of an Atrial Septal Defects (ASDs) a small isolated patent foramen ovale is of no hemodynamic signicance; but if other defects present (e.g. pulmonary stenosis or atresia), blood is shunted through the foramen ovale into the left ventricle, producing cyanosis, a dark bluish coloration of the skin and mucous membranes resulting from decient oxygenation of the blood. A probe patent foramen ovale is present in up to 25% of people. A probe can be passed from one atrium to the other through the superior part of the oor of the fossa ovalis. Though not clinically signicant (usually small) but may be forced open because of other cardiac defects and contribute to functional pathology of the heart. Results from incomplete adhesion between the original ap of the valve of the foramen ovale and the septum secundum after birth.

What Is Patent Ductus Arteriosus?

Patent ductus arteriosus (PDA) is a heart problem that affects some babies soon after birth. In PDA, abnormal blood flow occurs between two of the major arteries connected to the heart. These arteries are the aorta and the pulmonary (PULL-mun-ary) artery. Before birth, these arteries are connected by a blood vessel called the ductus arteriosus. This blood vessel is a vital part of fetal blood circulation. Within minutes or up to a few days after birth, the ductus arteriosus closes. This change is normal in newborns. In some babies, however, the ductus arteriosus remains open (patent). The opening allows oxygen-rich blood from the aorta to mix with oxygen-poor blood from the pulmonary artery. This can strain the heart and increase blood pressure in the lung arteries.

Normal Heart and Heart With Patent Ductus Arteriosus

Figure A shows a cross-section of a normal heart. The arrows show the direction of blood flow through the heart. Figure B shows a heart with patent ductus arteriosus. The defect connects the aorta and the pulmonary artery. This allows oxygen-rich blood from the aorta to mix with oxygen-poor blood in the pulmonary artery. Go to the "How the Heart Works" section of this article for more details about how a normal heart works compared with a heart that has PDA.

Overview
PDA is a type of congenital (kon-JEN-ih-tal) heart defect. A congenital heart defect is any type of heart problem that's present at birth. If your baby has a PDA but an otherwise normal heart, the PDA may shrink and go away. However, some children need treatment to close their PDAs. Some children who have PDAs are given medicine to keep the ductus arteriosus open. For example, this may be done if a child is born with another heart defect that decreases blood flow to the lungs or the rest of the body. Keeping the PDA open helps maintain blood flow and oxygen levels until doctors can do surgery to correct the other heart defect.

Outlook
PDA is a fairly common congenital heart defect in the United States. Although the condition can affect full-term infants, it's more common in premature infants.

On average, PDA occurs in about 8 out of every 1,000 premature babies, compared with 2 out of every 1,000 full-term babies. Premature babies also are more vulnerable to the effects of PDA. PDA is twice as common in girls as it is in boys. Doctors treat the condition with medicines, catheter-based procedures, and surgery. Most children who have PDAs live healthy, normal lives after treatment.

How the Heart Works

To understand patent ductus arteriosus (PDA), it helps to know how a normal heart works. Your child's heart is a muscle about the size of his or her fist. The heart works like a pump and beats 100,000 times a day. The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. The left side of the heart receives the oxygen-rich blood from the lungs and pumps it to the body. The heart has four chambers and four valves and is connected to various blood vessels. Veins are blood vessels that carry blood from the body to the heart. Arteries are blood vessels that carry blood away from the heart to the body.

A Healthy Heart Cross-Section

Figure A shows the location of the heart in the body. Figure B shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows through the heart to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs into the heart and then out to the body.

Heart Chambers
The heart has four chambers or "rooms." The atria (AY-tree-uh) are the two upper chambers that collect blood as it flows into the heart. The ventricles (VEN-trih-kuhls) are the two lower chambers that pump blood out of the heart to the lungs or other parts of the body.

Heart Valves
Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart. The tricuspid (tri-CUSS-pid) valve is in the right side of the heart, between the right atrium and the right ventricle. The pulmonary (PULL-mun-ary) valve is in the right side of the heart, between the right ventricle and the entrance to the pulmonary artery. This artery carries blood from the heart to the lungs. The mitral (MI-trul) valve is in the left side of the heart, between the left atrium and the left ventricle. The aortic (ay-OR-tik) valve is in the left side of the heart, between the left ventricle and the entrance to the aorta. This artery carries blood from the heart to the body.

Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries. Then they shut to keep blood from flowing backward. When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope. The first soundthe "lub"is made by the mitral and tricuspid valves closing at the beginning of systole (SIS-toe-lee). Systole is when the ventricles contract, or squeeze, and pump blood out of the heart. The second soundthe "DUB"is made by the aortic and pulmonary valves closing at the beginning of diastole (di-AS-toe-lee). Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

Arteries

The arteries are major blood vessels connected to your heart. The pulmonary artery carries blood from the right side of the heart to the lungs to pick up a fresh supply of oxygen. The aorta is the main artery that carries oxygen-rich blood from the left side of the heart to the body. The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function.

Veins
The veins also are major blood vessels connected to your heart. The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped to the body. The superior and inferior vena cavae are large veins that carry oxygenpoor blood from the body back to the heart.

For more information about how a healthy heart works, go to the Health Topics How the Heart Works article. The article contains animations that show how your heart pumps blood and how your heart's electrical system works.

The Heart With Patent Ductus Arteriosus

The ductus arteriosus is a blood vessel that connects the aorta and pulmonary artery in unborn babies. This vessel allows blood to be pumped from the right side of the heart into the aorta, without stopping at the lungs for oxygen. While a baby is in the womb, only a small amount of his or her blood needs to go to the lungs. This is because the baby gets oxygen from the mother's bloodstream. After birth, the baby no longer is connected to the mother's bloodstream. Thus, the baby's blood must travel to his or her own lungs to get oxygen. As the baby begins to breathe on his or her own, the pulmonary artery opens to allow blood into the lungs. Normally, the ductus arteriosus closes because the infant no longer needs it. Once the ductus arteriosus closes, blood leaving the right side of the heart no longer goes into the aorta. Instead, the blood travels through the pulmonary artery to the lungs. There, the blood picks up oxygen. The oxygen-rich blood returns to the left side of the heart and is pumped to the rest of the body. Sometimes the ductus arteriosus remains open (patent) after birth. A PDA allows blood to flow from the aorta into the pulmonary artery and to the lungs. The extra blood flowing into the lungs strains the heart. It also increases blood pressure in the lung's arteries.

Effects of Patent Ductus Arteriosus

Full-term infants. A small PDA might not cause any problems, but a large PDA likely will cause problems. The larger the PDA, the greater the amount of extra blood that passes through the lungs. A large PDA that remains open for an extended time can cause the heart to enlarge, forcing it to work harder. Also, fluid can build up in the lungs. A PDA can slightly increase the risk of infective endocarditis (IE). IE is an infection of the inner lining of the heart chambers and valves. In PDA, increased blood flow can irritate the lining of the pulmonary artery, where the ductus arteriosus connects. This irritation makes it easier for bacteria in the bloodstream to collect and grow, which can lead to IE. Premature infants. PDA can be more serious in premature infants than in full-term infants. Premature babies are more likely to have lung damage from the extra blood flowing from the PDA into the lungs. These infants may need to be put on ventilators. Ventilators are machines that support breathing. Increased blood flow through the lungs also can reduce blood flow to the rest of the body. This can damage other organs, especially the intestines and kidneys.

What Causes Patent Ductus Arteriosus?

If your child has patent ductus arteriosus (PDA), you may think you did something wrong during your pregnancy to cause the problem. However, the cause of patent ductus arteriosus isn't known. Genetics may play a role in causing the condition. A defect in one or more genes might prevent the ductus arteriosus from closing after birth.

Who Is at Risk for Patent Ductus Arteriosus?

Patent ductus arteriosus (PDA) is a fairly common congenital heart defect in the United States. Although the condition can affect full-term infants, it's more common in premature infants. On average, PDA occurs in about 8 out of every 1,000 premature babies, compared with 2 out of every 1,000 full-term babies. PDA also is more common in: Infants who have genetic conditions, such as Down syndrome Infants whose mothers had German measles (rubella) during pregnancy

PDA is twice as common in girls as it is in boys.

What Are the Signs and Symptoms of Patent Ductus Arteriosus?

A heart murmur may be the only sign that a baby has patent ductus arteriosus (PDA). A heart murmur is an extra or unusual sound heard during the heartbeat. Heart murmurs also have other causes besides PDA, and most murmurs are harmless. Some infants may have signs or symptoms of volume overload on the heart and excess blood flow in the lungs. These signs and symptoms may include: Fast breathing, working hard to breathe, and shortness of breath. Premature infants may need extra oxygen or a ventilator to help them breathe. Poor feeding and poor weight gain. Tiring easily. Sweating with exertion, such as while feeding.

How Is Patent Ductus Arteriosus Diagnosed?

In full-term infants, patent ductus arteriosus (PDA) usually is first suspected if a heart murmur is heard during a routine checkup. A heart murmur is an extra or unusual sound heard during the heartbeat. Heart murmurs have other causes besides PDA, and most murmurs are harmless. If a PDA is large, an infant also may have symptoms of volume overload and increased blood flow to the lungs. If a PDA is small, it may not be diagnosed until later in childhood. If your child's doctor thinks your child has PDA, he or she may refer you to a pediatric cardiologist. This is a doctor who specializes in diagnosing and treating heart problems in children. Premature babies who have PDA may not have the same signs and symptoms as full-term babies, such as heart murmurs. Doctors may suspect PDA in premature babies who have breathing problems soon after birth. Tests can help confirm a diagnosis.

Diagnostic Tests Echocardiography

Echocardiography (echo) is a painless test that uses sound waves to create a moving picture of your baby's heart. The sound waves (called ultrasound) bounce off the structures of the heart. A computer converts the sound waves into pictures on a screen. The test allows the doctor to clearly see any problems with the way the heart is formed or the way it's working. Echo is an important test for both diagnosing a heart defect and following the problem over time. Echo can show the size of a PDA and how the heart is responding to the defect. When medical treatments are used to try to close a PDA, echo can show how well the treatments are working.

EKG (Electrocardiogram)

An EKG is a simple, painless test that records the heart's electrical activity. For babies who have PDA, an EKG can show whether the heart is enlarged. The test also can show other subtle changes that may suggest the presence of a PDA.

How Is Patent Ductus Arteriosus Treated?

Patent ductus arteriosus (PDA) is treated with medicines, catheter-based procedures, and surgery. The goal of treatment is to close the PDA. Closure will help prevent complications and reverse the effects of increased blood volume. Small PDAs often close without treatment. For full-term infants, treatment is needed if the PDA is large or causing health problems. For premature infants, treatment is needed if the PDA is causing breathing problems or heart problems. Talk with your child's doctor about treatment options and how your family prefers to handle treatment decisions.

Medicines
Your child's doctor may prescribe medicines to help close your child's PDA. Indomethacin (in-doh-METH-ah-sin) is a medicine that helps close PDAs in premature infants. This medicine triggers the PDA to constrict or tighten, which closes the opening. Indomethacin usually doesn't work in full-term infants. Ibuprofen also is used to close PDAs in premature infants. This medicine is similar to indomethacin.

Catheter-Based Procedures
Catheters are thin, flexible tubes that doctors use as part of a procedure called cardiac catheterization (KATH-eh-ter-ih-ZA-shun). Catheter-based procedures

often are used to close PDAs in infants or children who are large enough to have the procedure. Your child's doctor may refer to the procedure as "transcatheter device closure." The procedure sometimes is used for small PDAs to prevent the risk of infective endocarditis (IE). IE is an infection of the inner lining of the heart chambers and valves. Your child will be given medicine to help him or her relax or sleep during the procedure. The doctor will insert a catheter in a large blood vessel in the groin (upper thigh). He or she will then guide the catheter to your child's heart. A small metal coil or other blocking device is passed through the catheter and placed in the PDA. This device blocks blood flow through the vessel. Catheter-based procedures don't require the child's chest to be opened. They also allow the child to recover quickly. These procedures often are done on an outpatient basis. You'll most likely be able to take your child home the same day the procedure is done. Complications from catheter-based procedures are rare and short term. They can include bleeding, infection, and movement of the blocking device from where it was placed.

Surgery
Surgery to correct a PDA may be done if: A premature or full-term infant has health problems due to a PDA and is too small to have a catheter-based procedure A catheter-based procedure doesn't successfully close the PDA Surgery is planned for treatment of related congenital heart defects

Often, surgery isn't done until after 6 months of age in infants who don't have health problems from their PDAs. Doctors sometimes do surgery on small PDAs to prevent the risk of IE. For the surgery, your child will be given medicine so that he or she will sleep and not feel any pain. The surgeon will make a small incision (cut) between your child's ribs to reach the PDA. He or she will close the PDA using stitches or clips. Complications from surgery are rare and usually short term. They can include hoarseness, a paralyzed diaphragm (the muscle below the lungs), infection, bleeding, or fluid buildup around the lungs.

After Surgery

After surgery, your child will spend a few days in the hospital. He or she will be given medicine to reduce pain and anxiety. Most children go home 2 days after

surgery. Premature infants usually have to stay in the hospital longer because of their other health issues. The doctors and nurses at the hospital will teach you how to care for your child at home. They will talk to you about: Limits on activity for your child while he or she recovers Followup appointments with your child's doctors How to give your child medicines at home, if needed

When your child goes home after surgery, you can expect that he or she will feel fairly comfortable. However, you child may have some short-term pain. Your child should begin to eat better and gain weight quickly. Within a few weeks, he or she should fully recover and be able to take part in normal activities. Long-term complications from surgery are rare. However, they can include narrowing of the aorta, incomplete closure of the PDA, and reopening of the PDA.

Living With Patent Ductus Arteriosus

Most children who have PDAs live healthy, normal lives after treatment. Fullterm infants will likely have normal activity levels, appetite, and growth after PDA treatment, unless they had other congenital heart defects. For premature infants, the outlook after PDA treatment depends on other factors, such as: How early the child was born Whether the child has other illnesses or conditions, such as other congenital heart defects

Ongoing Care
Children who have PDAs are at slightly increased risk for infective endocarditis (IE). IE is an infection of the inner lining of the heart chambers and valves. Your child's doctor will tell you whether your child needs antibiotics before certain medical procedures to help prevent IE. According to the most recent American Heart Association guidelines, most children who have PDAs don't need antibiotics.