Persistence of ductus arteriosus with left to right shunt in the older patient.

Abstract

SUMMARY Eight hundred and four patients with persistence of the ductus arteriosus were seen in Edinburgh between 1940 and 1979. Thirty-seven of them reached the age of 50 years, and in 32 the shunt was exclusively from left to right. Fifteen of the 32 were subsequently treated surgically.None of the 32 was lost to follow-up. Duration ofclinical observation averaged 17 years and extended to over 30 years in eight patients. Their features have been correlated with those from reports of 48 comparable patients in an attempt to clarify the management of the persistent ductus in the older patient. Impairment of left ventricular function is shown as the major risk, even when the ductus is small. Bacterial endarteritis is infrequent.Surgical treatment carries greater risk than in childhood and early adult life but usually reduces heart size and restores exercise tolerance. Left ventricular dysfunction, however, occasionally vitiates the benefits; symptoms are then incompletely relieved and death from heart failure may occur months or years after operation. Experience in older patients thus emphasises the value of elective operation in childhood, however well the child, however trivial the shunt.It is concluded that in older patients, the presence or the development of symptoms or cardiac enlargement are almost always indications for surgical treatment. As age increases, especially by the eighth decade, medical treatment may be preferable. Continued follow-up of symptomless patients without cardiomegaly is important because increase in heart size usually precedes further deterioration which can then be prevented by timely surgical treatment.Most patients with persistence of the ductus arteriosus die before 50 years of age'-3 unless treated surgically.4 5 Occasional patients, however, survive with little disability and a few live a normal life span.6-9 In the majority of adults, exercise tolerance is liable to deteriorate rapidly'I and in them surgical treatment has been of great benefit, even at over 65 years of age. 1"12 Available information, however, has been based on single case reports with little long term follow-up.The Edinburgh experience of the persistent ductus since 1940, with and without surgical treatment, has therefore been analysed and correlated with earlier reports in an attempt to amplify knowledge of the clinical course and improve the management of these older patients. The 40 years, 1940 to 1979, have been selected in order to encompass periods before and after 1%1 when the first older patient with a persistent ductus was treated surgically in Edinburgh. During this time 37 patients (among a total of 804 with persistence of the ductus) had reached 50 years of age before death, surgical treatment, or their last medical assessment. Twentynine were women and eight were men. In five patients, severe pulmonary hypertension was associated with a right to left shunt. The progress of the 32 patients, in whom the shunt was exclusively from left to right, is the subject of the present study (Table). One of the...

Patent Ductus Arteriosus with Infective Endocarditis at Age 92

“…Today, presentation in adult life is rare since the lesion is usually diagnosed and closed surgically in infancy or early childhood. Marquis et al (12) reported that 804 patients with PDA were seen in Edinburgh and 37 of them reached the age of 50. Campbell found that 34% of PDA patients died before the age of 40 and 61% before the age of 60 (2).…”

Clinical Use of Electrocardiography in Adults With Congenital Heart Disease

“…With a moderately sized PDA, sinus rhythm is usually present, although atrial fibrillation may occur in older individuals. 42 Left atrial enlargement may be present, and PR prolongation is found in 10% to 20% of patients. 43 The QRS axis is usually normal.…”

“…Left ventricular volume overload may be characterized by deep S waves in V 1 and tall R waves in leads V 5 and V 6 , accompanied by nonspecific repolarization changes. 42,43 …”

Clinics in diagnostic imaging (155)

“…(4) These usually involve relatively small left-to-right shunts that do not significantly overload the pulmonary vascular tree; hence, this subset of patients survive longer. (4,6,10) Fisher et al suggested that some patients may tolerate very high pulmonary arterial pressure for long periods without deterioration of their clinical status. (9) However, unrepaired PDA in these asymptomatic patients may eventually become clinically significant, particularly in conjunction with an acquired physiological insult from recurrent pneumonia, development of chronic obstructive pulmonary disease, ischaemic heart disease or calcific aortic stenosis.…”

“…(9) Calcification and atherosclerotic lesions make the ductus fragile and friable, increasing the technical difficulty of the surgical procedure. (3,10,14) Three-dimensional volume-rendered CT reconstruction allows for clear visualisation of the ductal morphology and demonstrates its spatial relationship to adjacent structures, including the aorta and pulmonary artery (Fig. 5).…”