Caso 4/2007: lactente de 16 meses com canal arterial

Abstract

A sixteen-month-old white female infant with history of fatigue during feeding since she was 30 days old, which was progressive in nature. In the first year, she experienced recurrent upper respiratory tract infections, and two months ago had bronchopneumonia. At the age of eleven months, she was diagnosed with a heart defect, and since then had been taking anticongestive medication. On physical examination she was in good general condition, with mild tachypnea and wide pulse pressure in the upper and lower extremities. No cyanosis was observed. She weighed 9,860 g and was 76.5 cm tall. Oxygen saturation was 96%, heart rate was 125 bpm and blood pressure was 100/50 mm Hg. The aorta was not palpable. Chest examination showed mild impulses along the left sternal border, and a muscular apical impulse +/++ was located at the fourth left intercostal space limited by the breadth of two fingers. Heart sounds were very loud, and the second sound was single. A continuous, ++, mild murmur was heard at the 2 nd , 3 rd , and 1 st left intercostal space that radiated to the tricuspid area. The liver was palpable 2 cm from the right costal margin. Radiographic examinationRadiographic findings included an enlarged cardiac silhouette due to a markedly displaced left ventricular arch; a straight mid-arch; and a rightward deviation of the trachea, considering the aorta enlargement with the aortic arch to the left and clearly increased pulmonary vascularity. (Fig. 1). Diagnostic impressionThis image suggests an increase in pulmonary shunt flow secondary to patent ductus arteriosus, as shown by the enlargement of both arteries and the left ventricle. Differential diagnosisDuctus arteriosus-related heart diseases, such as arteriovenous fistula and aortopulmonary window, must be recognized. Diagnostic confirmationClinical findings are consistent with ductus arteriosus, based on the continuous murmur heard at the high left sternal border and rarely found in other types of systemicto-pulmonary communication. The echocardiogram (Fig. 2) showed moderately dilated left chambers with an 8-mm patent ductus arteriosus and a large, continuous, left-to-right flow. The following measurements were found: right ventricle 10 mm, left ventricular diastolic diameter 39 mm, aorta 15 mm, and septal and wall thickness 5 mm. ManagementDuring surgery, the 3-mm ductus arteriosus was sectioned and sutured. The baby girl evolved favorably, and the heart murmur disappeared completely.