Age: 68
Gender: Female
Occupation: Housewife
Working diagnosis: Patent ductus arteriosus
HISTORY
The patient had a normal birth and upbringing but was told a cardiac murmur was present.
Within the previous year she had two episodes of pneumonia. The workup that ensued included an echocardiogram, which suggested a PDA.
CURRENT SYMPTOMS
She is generally healthy and asymptomatic. She experiences shortness of breath after climbing three flights of stairs. She denies palpitations, unexplained fevers, or hemoptysis.
NYHA class: I
Comments: Patients with a small PDA often remain asymptomatic throughout a normal lifespan.
PHYSICAL EXAMINATION
General: Moderate build. Pink.
BP (right upper limb) 140/50 mm Hg, HR 65 bpm, oxygen saturation 98% in both fingers and toes
Height 163 cm, weight 56 kg, BSA 1.59 m 2
Neck veins: Venous pulse was not elevated and the waveform was normal.
Lungs/chest: Clear
Heart: Normal precordial examination. There were normal first and second heart sounds, with a grade 2/6 continuous murmur at the upper left sternal edge and the infraclavicular area.
Abdomen: Normal
Extremities: No cyanosis or clubbing of fingers or toes
Comments: The wide pulse pressure and low diastolic pressure suggest a moderately large PDA (most commonly seen in aortic regurgitation, but common in high to low pressure communications involving the aorta).
In patients with a PDA and severe pulmonary hypertension there may be differential cyanosis and clubbing seen only in the toes and not in the fingers (see Case 17 ). This is due to the right-to-left shunt being distal to the upper limb circulation.
The continuous murmur is typical of a PDA, and is classically described as machinelike due to its “rough” quality. There are a number of other lesions producing continuous murmurs, including ruptured sinus of Valsalva aneurysm and coronary AV fistulas.
ELECTROCARDIOGRAM
FINDINGS
Heart rate: 65 bpm
QRS axis: −10°
QRS duration: 106 msec
Sinus rhythm with normal axis, intervals, and segments. Normal ECG.
Comments: There is no evidence of LV or LA overload in this ECG, which would suggest a substantial left-to-right shunt. Likewise, there is no evidence of right ventricular hypertrophy, which would be expected in a patient with a large PDA that has caused pulmonary arterial hypertension (see Case 17 ).
CHEST X-RAY
FINDINGS
| Cardiothoracic ratio: | 62% |
The cardiac silhouette is enlarged. There is mild prominence of the main pulmonary artery segment.
Comments: Cardiomegaly can occur in older patients even with relatively small shunts due to long-standing volume overloading of the heart. For patients with a PDA, the left-to-right shunt involves the LA and LV as well as the proximal aorta and pulmonary arteries. If the PDA was very large, the left-to-right shunt would have reversed early in childhood, due to the development of severe PAH. This clearly does not apply in this patient.
Ductal calcification can be seen superimposed on the aortic knuckle.
ECHOCARDIOGRAM
FINDINGS
Normal LV size and systolic function. The LVEDD was 4.9 cm. The LA dimension was 3.8 cm. RV chamber sizes were normal. The main pulmonary artery was dilated and measured 40 mm. There was mild tricuspid regurgitation with a calculated RV systolic pressure of 42 mm Hg.
This revealed turbulent flow from the aorta (seen in cross section) toward the pulmonary trunk (toward the transducer, top of the image).
Comments: Color flow from the aorta into the pulmonary artery, especially the left pulmonary artery, as in this case, confirms the diagnosis of a PDA. Rarely, a native, small aortopulmonary window can present with a somewhat similar color flow pattern in an adult patient. The communication in such a case is much more proximal in the main pulmonary artery and not at the level of bifurcation as with PDA. Mild pulmonary hypertension is seen in this patient as a result of a long-standing left-to-right shunt, but pulmonary vascular resistance is not likely to be significantly elevated.
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