Batal duct in newborns is. What is dangerous open ductus arteriosus? Indications for the operation

general information

This congenital defect, related to the pathology of the cardiovascular system, is the absence of closure of the arterial (botall) duct, which connects the pulmonary artery and the aorta of the baby in the prenatal period.

What happens if a child has open ductus arteriosus? The baby begins to form a functioning "vessel" between the indicated anatomical formations, which is unnecessary for the body that exists outside the womb, which leads to obvious disruptions in the work of not only the heart, but also the respiratory system.

Causes and risk factors

Knowing the etiological factors that contribute to the failure of this fetal communication is especially important not only for doctors, but also for expectant mothers, so that they can, in case of any suspicion, sound the alarm in a timely manner and apply for medical care. Also, this knowledge is no less significant for the prevention of the occurrence of PDA.

However, some factors can affect its overgrowth. Among the main causes of patent ductus arteriosus and congenital heart defects of the newborn, in general, there are:

Types and phases of the flow

There are isolated PDA, which occurs in approximately 10% of all cases of this defect, and combined with other heart defects (atrial septal defect in children, coarctation of the aorta in newborns, forms of stenosis pulmonary artery).

It is also customary to classify open bottles according to the phases of its development:

  • Stage 1 is called "primary adaptation" and lasts for the first 3 years of a baby's life. This is the most intense stage in terms of the severity of clinical symptoms, which can even lead to death if suitable surgical treatment is not provided.
  • Stage 2 is characterized by relative compensation of the clinical picture of the disease and lasts 3 to 20 years. There is a decrease in pressure in the vessels of the small (pulmonary) circulation and an increase in pressure in the cavity of the right ventricle, which leads to its functional overload during the work of the heart.
  • At stage 3, irreversible sclerosis of blood vessels in the lungs progresses steadily, which causes pulmonary hypertension.

Given the level of pressure in the lumen of the pulmonary artery and pulmonary trunk, the following degrees of PDA are distinguished:

  1. When the systolic pressure of the pulmonary artery is not more than 40% of the body's blood pressure.
  2. The presence of symptoms of moderate hypertension in the pulmonary artery (40-75%).
  3. When there are symptoms of severe hypertension in the pulmonary artery (over 75%) and there is blood flow from left to right.
  4. When severe hypertension develops in the pulmonary vessels, and the pressure, equal to the systemic arterial pressure, promotes blood flow from right to left.

What is dangerous: possible complications

  • The development of endocarditis of a bacterial nature, leading to damage to the inner layer of the wall of the chambers of the heart, primarily in the region of the valvular apparatus.
  • Bacterial endarteritis.
  • Myocardial infarction with risk of arrhythmia or death.
  • Heart failure of varying severity.
  • Swelling of lung tissues due to increased pressure in the pulmonary vessels, which requires extremely rapid action by medical personnel.
  • Rupture of the main vessel of the human body - the aorta.

Symptoms

The symptoms that manifest in this type of congenital heart disease are entirely dependent on the degree of hemodynamic changes in the body. In certain cases, the clinical picture will not be traced.

In others, it progresses to extreme degrees of severity and manifests itself in the development of a “heart hump” (a convex deformity of the anterior chest wall in the area of ​​the projection of the heart), movement of the apex beat of the heart downwards along with the expansion of its zone, heart trembling in its lower and left sections, persistent shortness of breath with the position of orthopnea and severe cyanosis.

The main symptoms of PDA in less severe clinical cases are:

  • increased heart rate;
  • quickening of breathing;
  • enlargement of the liver (hepatomegaly) and spleen;
  • electrocardiographic signs of an increase in the left sections;
  • specific noise during auscultation of the heart in the second left intercostal space near the sternum (systolic-diastolic);
  • rapid high heart rate on the radial arteries;
  • an increase in the level of systolic systemic pressure and a decrease in diastolic (sometimes to zero).

When to See a Doctor

Not in every case, parents can notice changes in the state of health of their child and suspect this congenital pathology, which, of course, worsens the prognosis for the baby.

Parents should remember that a trip to the doctor is necessary if they have identified the following symptoms in their baby:

  • sleep disturbance;
  • drowsiness;
  • slow weight gain;
  • shortness of breath at rest or after light exertion;
  • bluish skin tone after exercise;
  • lethargy, refusal of games and entertainment;
  • frequent acute respiratory infections and SARS.

Your appeal should be made to the local pediatrician, who, in the presence of pathological symptoms, can send for a consultation with other specialists: a pediatric cardiologist, a pediatric cardiac surgeon.

Diagnostics

Diagnosis of an open ductus arteriosus includes several groups of research methods. With an objective examination of the child, the doctor can determine:

  • rapid pulse;
  • increase in systolic pressure with a simultaneous decrease in diastolic;
  • changes from the apex beat;
  • expansion of the boundaries of cardiac dullness (boundaries of the heart);
  • the above-described Gibson murmur (systolic-diastolic);
  • anamnestic symptoms associated with possible exposure to risk factors for this defect.

Among the instrumental diagnostic techniques, the following are actively used:

  1. ECG (electrocardiography). There is a tendency to hypertrophy of the left parts of the heart, and in more severe stages of the right parts with a deviation of the cardiac axis to the right. As the disease progresses, signs of a violation of the rhythm of heart contractions appear.
  2. Echocardiography. Also gives information about the expansion of the left cardiac cavities. If you add a Doppler study, then a mosaic pattern of blood flow through the pulmonary artery is determined.
  3. X-ray of organs chest. Characterized by an increase in the contours of the pattern of the lungs, an increase in the transverse size of the heart due to the left ventricle with initial stages manifestations of PDA symptoms. If hypertension of the pulmonary vessels develops, the drawing of the lungs, on the contrary, becomes depleted, the trunk of the pulmonary artery swells, the heart is enlarged.

Differentiation of the diagnosis is necessarily carried out with other congenital heart defects, such as:

  • combined aortic defect;
  • incomplete atrioventricular canal;
  • defective septum between the ventricles;
  • defective septum of the aorta and pulmonary artery.

Treatment

A conservative method of treatment is used only in premature babies and consists in the introduction of inhibitors of the formation of prostaglandin in order to medically stimulate the self-closing of the duct.

The main drug in this group is Indomethacin. If there is no effect with a three-fold repetition of the administration of the drug in children older than three weeks of age, then surgical obliteration is performed.

Surgically, babies are treated at the age of 2-4 years, this is the best period for this method of therapy. In an expanded application is the method of ligation of the botallian duct or its transverse intersection with subsequent suturing of the remaining ends.

Forecast and prevention

With an unoperated duct, death occurs in people aged about 40 years due to the development of severe hypertension in the pulmonary arteries and severe degrees of heart failure. Surgical treatment provides favorable outcomes in 98% of small patients.

Preventive actions:

  1. Smoking cessation, abuse alcoholic drinks, drugs.
  2. Avoidance of stress.
  3. Compulsory medical genetic counseling both before and during pregnancy;
  4. Sanitation of foci of chronic infection.

Patent ductus arteriosus is a serious congenital pathology that carries high mortality rates in case of untimely or inadequate treatment.

The debut of his clinical picture is the development of signs of pulmonary hypertension and insufficiency of the heart. However, if this disease is diagnosed in time, its outcome is very favorable, which is confirmed by modern statistics.

Open ductus arteriosus (OAP): causes of non-closure in children, symptoms, how to treat

Patent ductus arteriosus (PDA) is a disease that occurs as a result of a violation of the normal development of the heart and great vessels in the prenatal and postnatal period. Congenital heart defects usually form in the first months of fetal development as a result of atypical formation of intracardiac formations. Persistent pathological changes in the structure of the heart lead to its dysfunction and the development of hypoxia.

Arterial (Botallov) duct - a structural formation of the fetal heart, through which the blood ejected from the left ventricle into the aorta passes into the pulmonary trunk and returns again to the left ventricle. Normally, the arterial duct undergoes obliteration immediately after birth and turns into a connective tissue cord. Filling the lungs with oxygen leads to the closure of the duct by thickened intima and a change in the direction of blood flow.

In children with a developmental defect, the duct does not close in time, but continues to function. This disrupts the pulmonary circulation and the normal functioning of the heart. PDA is usually diagnosed in newborns and infants, somewhat less often in schoolchildren, and sometimes even in adults. Pathology is found in full-term children living in highlands.

Etiology

The etiology of PDA is currently not fully understood. Experts identify several risk factors for this disease:

  • premature birth,
  • Low weight newborn
  • avitaminosis,
  • Chronic fetal hypoxia,
  • hereditary predisposition,
  • Marriages between relatives
  • Mother's age over 35
  • Genomic pathologies - Down syndrome, Marfan syndrome, Edwards syndrome,
  • Infectious pathology in the 1st trimester of pregnancy, congenital rubella syndrome,
  • Alcohol and drug use during pregnancy, smoking,
  • Irradiation with x-rays and gamma rays,
  • Taking medication during pregnancy
  • Impact chemical substances on the body of a pregnant woman,
  • Systemic and metabolic diseases of the pregnant woman,
  • Intrauterine endocarditis of rheumatic origin,
  • Endocrinopathy of the mother diabetes, hypothyroidism and others.

The causes of PDA are usually combined into 2 large groups - internal and external. Internal causes are associated with hereditary predisposition and hormonal changes. External causes include: poor ecology, industrial hazards, diseases and addictions of the mother, toxic effects on the fetus of various substances - drugs, chemicals, alcohol, tobacco.

PDA is most often detected in preterm infants. Moreover, the lower the weight of the newborn, the higher the likelihood of developing this pathology. Heart disease is usually combined with anomalies in the development of the digestive, urinary and reproductive systems. The immediate causes of ductus arteriosus occlusion in this case are respiratory distress, fetal asphyxia, prolonged oxygen therapy, and parenteral fluid therapy.

Video: medical animation about the anatomy of the ductus arteriosus

Symptoms

The disease can be asymptomatic or extremely severe. With a small diameter of the duct, hemodynamic disturbances do not develop, and pathology long time not diagnosed. If the diameter of the duct and the volume of the shunt are significant, the symptoms of the pathology are pronounced and appear very early.

Clinical signs:


Children with PDA often suffer from broncho-pulmonary pathology. Newborns with a wide ductus arteriosus and a large shunt volume are difficult to feed, they gain weight poorly and even lose weight.

If the pathology was not detected in the first year of life, then as the child grows and develops, the course of the disease worsens and manifests itself more vividly. clinical symptoms: asthenia of the body, shortness of breath, tachypnea, cough, frequent inflammatory diseases bronchi and lungs.

Complications

severe complications and dangerous consequences PDA:

  • Bacterial endocarditis is an infectious inflammation of the inner lining of the heart, leading to valvular dysfunction. Patients have fever, chills and sweating. Signs of intoxication are combined with headache and lethargy. Hepatosplenomegaly develops, hemorrhages appear in the fundus and small painful nodules on the palms. Treatment of pathology is antibacterial. Patients are prescribed antibiotics from the group of cephalosporins, macrolides, fluoroquinolones, aminoglycosides.
  • Heart failure develops in the absence of timely cardiac surgical care and consists in insufficient blood supply. internal organs. The heart ceases to pump blood in full, which leads to chronic hypoxia and a deterioration in the functioning of the whole organism. Patients develop shortness of breath, tachycardia, swelling of the lower extremities, fatigue, sleep disturbance, constant dry cough. Pathology treatment includes diet therapy, drug therapy aimed at normalizing blood pressure, stabilization of the work of the heart and improvement of blood supply.
  • myocardial infarction - acute illness due to the appearance of foci of ischemic necrosis in the heart muscle. Pathology is manifested by characteristic pain, which is not stopped by taking nitrates, agitation and anxiety of the patient, pallor of the skin, sweating. Treatment is carried out in a hospital. Patients are prescribed thrombolytics, narcotic analgesics, nitrates.
  • The reverse flow of blood through the wide ductus arteriosus can lead to cerebral ischemia and intracerebral hemorrhage.
  • Pulmonary edema develops when fluid passes from the pulmonary capillaries into the interstitial space.

Rarer complications of PDA include: aortic rupture incompatible with life; aneurysm and rupture of the arterial duct; pulmonary hypertension sclerotic nature; cardiac arrest in the absence of corrective therapy; frequent acute respiratory infections and SARS.

Diagnostics

Diagnosis of PDA is carried out by doctors of various medical specialties:

  1. Obstetrician-gynecologists monitor heart contractions and the development of the cardiovascular system of the fetus,
  2. Neonatologists examine the newborn and listen for heart murmurs
  3. Pediatricians examine older children: they conduct auscultation of the heart and, if pathological noises are detected, they refer the child to a cardiologist,
  4. Cardiologists make the final diagnosis and prescribe treatment.

Common diagnostic measures include visual inspection patient, palpation and percussion of the chest, auscultation, instrumental research methods: electrocardiography, radiography, ultrasound of the heart and large vessels, phonocardiography.

During the examination, deformation of the chest, pulsation of the heart region, and displacement of the cardiac impulse to the left are detected. Palpation reveals systolic trembling, and percussion - an expansion of the boundaries of cardiac dullness. Auscultation is the most important method in the diagnosis of PDA. Its classic feature is a coarse, continuous "machine" noise due to the unidirectional flow of blood. Gradually, it disappears, and an accent of 2 tones appears over the pulmonary artery. In severe cases, multiple clicks and rumbling noises occur.

Instrumental diagnostic methods:

  • Electrocardiography does not reveal pathological symptoms, but only signs of left ventricular hypertrophy.
  • X-ray signs of pathology are: mesh pattern of the lungs, expansion of the shadow of the heart, dilatation of its left chambers, bulging of a segment of the pulmonary artery trunk, flocculent infiltrate.
  • Ultrasound of the heart allows you to visually assess the work of different parts of the heart and valve apparatus, determine the thickness of the myocardium, the size of the duct. Dopplerography allows you to accurately establish the diagnosis of PDA, determine its width and blood regurgitation from the aorta to the pulmonary artery. Ultrasound examination of the heart allows you to detect anatomical defects in the heart valves, determine the location of the main vessels, and evaluate the contractility of the myocardium.
  • Phonocardiography is a simple method that allows diagnosing heart defects and defects between cavities by graphic recording of heart tones and murmurs. Using phonocardiography, you can objectively document the data obtained when listening to the patient, measure the duration of sounds and the intervals between them.
  • Aortography - informative diagnostic method, which consists in supplying a contrast fluid into the cavity of the heart and conducting a series x-rays. Simultaneous staining of the aorta and pulmonary artery indicates non-occlusion of the ductus arteriosus. The resulting images remain in the electronic memory of the computer, allowing you to work with them repeatedly.
  • Catheterization and probing of the heart in PDA allows you to make an absolutely accurate diagnosis if the probe freely passes from the pulmonary artery through the duct into the descending aorta.

Sounding of the heart cavities and angiocardiography are necessary for more accurate anatomical and hemodynamic diagnosis.

Treatment

The sooner the disease is detected, the easier it is to get rid of it. When the first signs of pathology appear, you should consult a doctor. Early diagnosis and timely therapy will increase the patient's chances for a full recovery.

If a child loses weight, refuses active games, turns blue when crying, becomes drowsy, experiences shortness of breath, coughs and cyanosis, often suffers from acute respiratory viral infections and bronchitis, it should be shown to a specialist as soon as possible.

Conservative treatment

Drug therapy is indicated for patients with mild clinical signs and no complications. Drug treatment PDA is carried out in premature babies and children under one year old. If, after 3 courses of conservative therapy, the duct does not close, and the symptoms of heart failure increase, they proceed to surgical intervention.

  1. A sick child is prescribed a special diet that limits fluid intake.
  2. Respiratory support is essential for all preterm infants with PDA.
  3. Patients are prescribed prostaglandin inhibitors, which activate the independent obliteration of the duct. Usually use intravenous or enteral administration of "Indomethacin" or "Ibuprofen".
  4. Antibiotic therapy is carried out in order to prevent infectious complications - bacterial endocarditis and pneumonia.
  5. Diuretic drugs - "Veroshpiron", "Lasix", cardiac glycosides - "Strophanthin", "Korglikon", ACE inhibitors- "Enalapril", "Captopril" are prescribed to persons with a clinic of heart failure

Cardiac catheterization

Cardiac catheterization is prescribed for children for whom conservative therapy has not given the expected result. Cardiac catheterization is a highly effective treatment for PDA with a low risk of complications. The procedure is performed by specially trained pediatric cardiologists. A few hours before catheterization, the child should not be fed or watered. Immediately before the procedure, he is given a cleansing enema and an injection of a sedative. After the child relaxes and falls asleep, manipulation begins. The catheter is inserted into the chambers of the heart through one of the large blood vessels. There is no need to make skin incisions. The doctor monitors the progress of the catheter by looking at the monitor screen of a special x-ray machine. By examining blood samples and measuring blood pressure in the heart, he obtains information about the defect. The more experienced and qualified the cardiologist, the more effective and successful the cardiac catheterization will be.

Cardiac catheterization and duct clipping during thoracoscopy - an alternative surgical treatment vice.

Surgical treatment

Surgical intervention allows you to completely eliminate the PDA, reduce the patient's suffering, increase his resistance to physical activity and significantly extend the life. Surgical treatment consists of open and endovascular operations. The PDA is tied with a double ligature, vascular clips are placed on it, crossed and sutured.

The classic surgical intervention is an open operation, which consists in ligation of the Botalla duct. The operation is performed on a "dry" heart when the patient is connected to a ventilator and under general anesthesia.

Endoscopic method surgical intervention is minimally invasive and less traumatic. A small incision is made on the thigh, through which a probe is inserted into the femoral artery. With the help of it, an occluder or a spiral is delivered to the PDA, which closes the lumen. The entire course of the operation is monitored by doctors on the monitor screen.

Video: operation for PDA, anatomy of the Botallian duct

Prevention

Preventive measures are to exclude the main risk factors - stress, alcohol intake and medicines, contacts with infectious patients.

After surgical correction of the pathology with the child, it is necessary to engage in dosed physical exercises and massage at home.

Smoking cessation and screening for genetic abnormalities will help reduce the risk of CHD.

Prevention of the occurrence of CHD comes down to careful planning of pregnancy and medical genetic counseling for individuals at risk.

It is necessary to carefully observe and examine women infected with rubella virus or with concomitant pathology.

Proper care should be provided to the child: enhanced nutrition, physical activity, physiological and emotional comfort.

- a functioning pathological communication between the aorta and the pulmonary trunk, which normally provides embryonic blood circulation and undergoes obliteration in the first hours after birth. An open ductus arteriosus is manifested by a developmental delay in the child, increased fatigue, tachypnea, palpitations, interruptions in cardiac activity. Data from echocardiography, electrocardiography, radiography, aortography, and cardiac catheterization help to diagnose an open ductus arteriosus. Treatment of the defect is surgical, including ligation (ligation) or intersection of the patent ductus arteriosus with suturing of the aortic and pulmonary ends.

ICD-10

Q25.0

General information

Open ductus arteriosus (Botallov) is a non-closure of an additional vessel connecting the aorta and the pulmonary artery, which continues to function after the expiration of its obliteration period. The arterial duct (dustus arteriosus) is a necessary anatomical structure in the embryonic circulatory system. However, after birth, due to the appearance of pulmonary respiration, the need for the arterial duct disappears, it ceases to function and gradually closes. Normally, the functioning of the duct stops in the first 15-20 hours after birth, complete anatomical closure lasts from 2 to 8 weeks.

Complications of an open ductus arteriosus can be bacterial endocarditis, duct aneurysm and its rupture. The average life expectancy in the natural flow of the duct is 25 years. Spontaneous obliteration and closure of the patent ductus arteriosus is extremely rare.

Diagnostics of the open ductus arteriosus

When examining a patient with an open ductus arteriosus, chest deformity (heart hump) and increased pulsation in the projection of the apex of the heart are often detected. The main auscultatory sign of an open ductus arteriosus is a coarse systolic-diastolic murmur with a "machine" component in the II intercostal space on the left.

Mandatory minimum investigations for patent ductus arteriosus include chest x-ray, aortopulmonary septal defect, truncus arteriosus, sinus of Valsalva aneurysm, aortic insufficiency, and arteriovenous fistula.

Treatment of an open ductus arteriosus

In preterm infants, conservative management of patent ductus arteriosus is used. It involves the introduction of prostaglandin synthesis inhibitors (indomethacin) in order to stimulate self-obliteration of the duct. In the absence of the effect of a 3-fold repetition of the drug course in children older than 3 weeks, surgical closure of the duct is indicated.

In pediatric cardiac surgery, open ductus arteriosus is used for open and endovascular operations. Open interventions may include ligation of the patent ductus arteriosus, its clipping with vascular clips, duct transection with suturing of the pulmonary and aortic ends. Alternative Methods closure of the open ductus arteriosus are its clipping during thoracoscopy and catheter endovascular occlusion (embolization) with special spirals.

Forecast and prevention of open ductus arteriosus

An open ductus arteriosus, even of a small size, is associated with an increased risk of premature death, since it leads to a decrease in compensatory reserves of the myocardium and pulmonary vessels, with the addition of serious complications. Patients who underwent surgical closure of the duct have better hemodynamic parameters and a longer life expectancy. Postoperative mortality is low.

To reduce the likelihood of having a child with an open ductus arteriosus, it is necessary to exclude all possible risk factors: smoking, alcohol, taking medications, stress, contacts with infectious patients, etc. If close relatives have congenital heart disease, a genetics consultation is necessary at the stage of pregnancy planning.

Botall duct (S. ductus arteriosus) was first described in 1564 by Leonardo Botallo. In the uterine period, it connects two large vessels: the pulmonary artery and the aorta. The duct carries blood from the right heart and pulmonary artery to the aorta. The size of an open ductus ductus arteriosus varies considerably from a few millimeters to several centimeters.

Through the open ductus arteriosus, blood flows from the aorta to the pulmonary artery during systole, since the pressure in the aorta at this time is higher than in the pulmonary artery. The pulmonary artery overflows with blood coming from the right ventricle and from the ductus arteriosus. This causes dilation of the pulmonary artery and hypertrophy of the right ventricular muscle. During diastole, the pressure in the aorta drops, it is higher in the pulmonary artery, and blood returns to the aorta during diastole. The increased amount of blood in the aorta, in turn, is the cause of hypertrophy of the left ventricular muscle.

Non-closure of the ductus arteriosus is more common in women.

The establishment of a clinical diagnosis of an open ductus arteriosus was reported in 1847 by Bernutz. J. Skoda described a peculiar lingering murmur with systolic amplification in this disease. In recent years, a large number of works have been devoted to the study of noise in this defect.

Of considerable interest to researchers is the question of the mechanism of pulmonary hypertension in cleft ductus arteriosus.

It can be assumed that high blood pressure in the pulmonary circulation occurs in early childhood. There is an assumption about the combination of patent ductus arteriosus with congenital primary pulmonary hypertension due to the preservation of the intrauterine nature of the pulmonary vessels that maintain high pressure in the pulmonary circulation even after birth.

clinical picture. Cyanosis in this heart disease is usually absent. During palpation, a push of a hypertrophied right ventricle and epigastric pulsation are determined. In the second intercostal space to the left of the sternum, systolic trembling is noted - "cat's purr". It does not occur immediately, not together with the I tone, but has the character of a mesosystolic tremor, that is, it begins in the middle of systole.

With percussion to the left of the sternum, it is possible to determine a band of dullness one and a half to two fingers wide. The latter depends on the presence of an enlarged pulmonary artery here. Cardiac dullness increases to the right and somewhat to the left due to the expansion of the right and left ventricles. When listening in the second intercostal space on the left, a peculiar rough systolic lingering noise (“machine noise”, “train noise in the tunnel”) is determined.

The mesosystolic character of noise is easily established by means of the phonocardiograph. However, listening to the patient, we quite clearly determined the features of the noise with this defect and without a phonocardiograph.

During inhalation systolic murmur weakens or disappears, this symptom is even more demonstrative when straining during inspiration (Valsalva experiment), with fluoroscopy at this moment, a decrease in the pulmonary artery arch is observed. II tone on the pulmonary artery is usually accentuated.

With a large diameter of the botallian duct, slight cyanosis, pallor, carotid dance, pulsus celer et differens are sometimes noted.

X-ray examination can detect bulging and sharp pulsation of the pulmonary artery arch. When straining due to increased pressure in the pulmonary artery, blood flow from the aorta through the duct decreases, so the pulmonary artery arch decreases. With a large diameter of the ductus arteriosus, the right and left ventricles are dilated.

During diastole, blood returning from the pulmonary artery through the ductus arteriosus into the aorta causes a diastolic murmur. Therefore, a typical noise with this defect is systolic, increasing to the II tone, passing to the diastole and subsiding to the beginning of the I tone.

With a significant non-closure of the ductus botulinum, an electrocardiogram reveals a right axis deviation and a decrease in tooth 7, in some cases a levogram is noted. Blood pressure is usually not elevated, and the minimum pressure is often low. The pulse pressure is increased.

Non-closure of the ductus arteriosus predisposes to the development of slow sepsis in it. According to L. I. Fogelson, slow sepsis in the ductus botulinum developed in 25-30% of cases, according to A. N. Bakulev, in 90%. The septic process usually affects the duct, then spreads to the valves.

The diagnosis of an open ductus arteriosus in most patients can be made without special studies on the basis of characteristic clinical and radiological symptoms.

An aortographic examination confirms the diagnosis of the defect. The contrast medium, introduced into the aortic arch in large quantities and in high concentration, enters through the duct into the pulmonary artery and into the lungs. During catheterization in the right ventricle, blood pressure is higher than normal, the amount of oxygen in the blood of the right ventricle is usually normal.

Current and forecast. In patients with a small lumen of the ductus arteriosus, decompensation is not observed for a long time. In the presence of a large opening between the aorta and the pulmonary artery, a typical picture of congenital heart disease develops with cyanosis and shortness of breath. The prognosis in these cases is unfavorable. In a quarter of all cases in the post-war period, patients died at a young age from slow sepsis, and half from decompensation. Patients with a defect complicated by slow sepsis are prescribed antibiotics and red blood cell transfusion.

When establishing the diagnosis, it should be remembered that the radiologist can sometimes mistake an expanded arch of the pulmonary artery for an expanded arch of the left atrium. Systolic murmur in a patient with non-closure of the ductus arteriosus differs sharply from that in mitral heart disease, it has a "machine" character, occurs after the onset of systole (mesosystolic); in these patients, unlike those with rheumatic disease, systolic trembling is determined high - in the second intercostal space; when straining, it disappears and weakens.

Systolic trembling in the second left intercostal space also occurs with stenosis of the pulmonary artery. However, in this case, only a systolic murmur is heard above the pulmonary artery, while in case of non-closure of the ductus arteriosus it is most often systolic and diastolic. II tone over the pulmonary artery with pulmonary artery stenosis weakens or disappears, with X-ray examination with stenosis of the pulmonary artery, along with post-stenotic expansion of the pulmonary artery, the root branches have a small caliber, and lung pattern represented by gentle narrow shadows.

With stenosis of the isthmus of the aorta, a systolic rough noise can be heard on the left in the second - third intercostal space. However, with this defect, there is a sharp difference in the pulse of the arteries of the upper and lower half of the body. Pulse on vessels upper limbs, radial artery, neck vessels are well expressed, while on lower limbs it has poor filling, the abdominal aorta pulsates poorly. As a result of collateral circulation between the ascending and descending parts of the thoracic aorta, palpation can detect pulsation of dilated intercostal arteries and superficial arteries of the occiput and scapulae. With a congenital defect of the interventricular septum, a systolic murmur is heard, however, it is determined much lower than in patients with non-closure of the ductus botulus; systolic trembling is usually not observed on the sternum at the level of the third-fourth intercostal space.

Surgical treatment is indicated for a patent ductus arteriosus, but vital indications arise in the presence of a large shunt of arterial blood from the aorta to the pulmonary artery and difficulty in the work of the heart. With septic endarteritis, there are also absolute indications for surgical treatment. The operation consists in closing the botallian duct by stitching it

Open ductus arteriosus

Patent ductus arteriosus (PDA) is a congenital heart disease (CHD) characterized by abnormal vascular communication between the aorta and the pulmonary artery (Figure 10).

PDA can occur in an isolated form or be combined with other cardiovascular anomalies. Previously, it was called the “uncovered ductus botalis”, which was associated with the name of the doctor Leonardo Botallo, however, the first descriptions of the PDA were made a millennium earlier and belong to Galen (130–200). The PDA is a vessel whose shape can vary considerably. In the prenatal period, everyone has a PDA; this is a normal component of the fetal circulation.

In the fetus, mixed blood enters the right heart and is expelled by the right ventricle into the pulmonary artery, and from there through the PDA (because the lungs do not function) it enters the descending aorta.

After the first breath, the pulmonary vessels open, the pressure in the right ventricle drops, the PDA gradually ceases to function and closes (obliterates). Obliteration of the duct occurs at different times. In 1/3 of children, it closes by two weeks, in the rest - within eight weeks of life.

Circulatory disorders

Hemodynamic disturbances are associated with abnormal shunting of blood from the aorta into the pulmonary artery, since the pressure in the aorta is much higher than in the pulmonary artery.

The volume of discharged blood depends on the size of the duct (Figure 11). As a result of circulatory disorders, a smaller volume of blood enters the systemic circulation, which affects vital organs (brain, kidneys), skeletal muscles. Passing through the vessels of the lungs, this blood returns to the left atrium, the left ventricle, which, experiencing excessive stress, increase in size (hypertrophy), then, under the influence of an ever-increasing volume of oxygenated blood, changes in the vessels of the lungs occur and pulmonary hypertension occurs.

Manifestations and natural course of the defect

Children are born with normal weight and body length. Further manifestations of the disease are associated with the size of the duct. The shorter and wider the PDA, the more blood is discharged through it and the more pronounced the clinic (manifestations) of the disease. With narrow and long PDA, sick children are no different from healthy ones. The only sign indicating the presence of CHD is the noise heard by the pediatrician over the region of the heart. With wide and narrow PDA already in the first months and even days of a child's life, all the symptoms (manifestations) of the defect can be detected. In such children, constant pallor is observed, with physical exertion (straining, sucking, crying), transient cyanosis (blue skin tone) is noted, mainly on the legs. Children are lagging behind in physical development. They have a tendency to recurring bronchitis, pneumonia.

The most difficult periods during the defect are the adaptation phase during the neonatal period and the phase of terminal pulmonary hypertension in older children. During these periods, children die from heart failure, cerebrovascular accident (stroke), pneumonia, and infective endocarditis. Average life expectancy in PDA without surgical treatment- 25 years, although many patients with narrow and long PDA survive to old age. Most dangerous complication PDA, even in the case of its asymptomatic (latent) course, is infective endocarditis, which develops due to the fact that the abnormal flow of blood entering through the PDA injures its wall, often underdeveloped, and the wall of the pulmonary artery. An infection develops in the injured area of ​​the vessel, thrombotic masses grow, which can break away from the vessel and be carried away by the blood to other places, clogging the vessels of vital organs. The presence of a PDA is reliably confirmed by echocardioscopy, which should be performed in children with suspected congenital heart disease, regardless of age.

It is important to know that the indication for the treatment of PDA is its presence. There are two methods of treating PDA: conservative, or medical, and surgical. Drug treatment of PDA is used only in the maternity hospital for newborns during the first two weeks of life, later it becomes ineffective. This method is far from always effective, has many contraindications, so the main treatment is mechanical closure of the duct.

Previously, the most common intervention was ligation of the duct after a thoracotomy. Now the PDA ligation operation is performed less and less frequently, and the indications for the so-called endovascular occlusion of the PDA are expanding, it is performed much more often than other methods of closing the PDA. Endovascular occlusion of the PDA consists in sealing the duct with specially made spirals, the technique has almost no complications, it is performed for young children under anesthesia, and for older adults - under local anesthesia. Its effectiveness is almost one hundred percent, occasionally there is recanalization of the PDA, which is subsequently eliminated in the same way. For wide and short PDAs, when endovascular occlusion of the PDA is technically impossible, the PDA is closed using specially designed catheters.

Option 2

Patent ductus arteriosus is one of the most common congenital heart defects, it is a non-closure of the ductus arteriosus (Botallov) which is a necessary function in the fetus, and should normally close in the first hours after the birth of the child.

The arterial duct is located between the trunk of the pulmonary artery and the aorta, ensuring that the mother's blood enters the systemic circulation of the fetus, bypassing the pulmonary circle. Since the lungs of the fetus do not work before birth, the saturation of arterial blood with oxygen is possible only due to the influx of maternal blood. But immediately after birth, as soon as the baby begins to breathe, blood gas exchange takes place in his lungs, so the need for the arterial duct disappears, and it begins to close.

This process is carried out in stages, during the first 10-15 hours from the moment spontaneous breathing begins. The ductus arteriosus is shortened, and the muscle layer located in the vessel wall is reduced. Then there is a gradual proliferation of connective tissue. At the site of the former duct, platelets are intensively deposited, forming a thrombus, which clogs the opening of the duct that has become very small. The final fusion of the arterial duct occurs by the third week of a child's life.

Cases of non-closure of the Botallian duct occur with a frequency of 1 per 2000 births. They are more common in premature babies, although they also occur in children born at a normal term. The dimensions of the arterial duct vary in length from 4 to 12 mm, and the width of the vessel lumen ranges from 2 to 8 mm.

What is dangerous ductus arteriosus

As you know, blood from the heart enters the aorta. Contractions of the heart muscle create a certain pressure in the aorta, which exceeds the pressure in any other part of the vascular bed, including the pulmonary artery. With an open arterial duct, blood from the aorta is partially ejected into the pulmonary artery. It turns out that part of the arterial blood circulates in the pulmonary circulation, while the whole body experiences a lack of it. In some cases, the amount of blood in the lungs exceeds that in the systemic circulation by three times. Specific indicators depend on the size of the open ductus arteriosus and the volume of blood flowing through it.

An organism that does not receive arterial blood is in a state of oxygen starvation, while increased pressure is created in the vessels of the lungs. This leads to stagnation in them, conditions are created for the development of pulmonary diseases, inflammation of the lungs easily occurs. Sclerosis of the vessels gradually develops, their functioning becomes difficult. Also, the heart experiences an additional load, which must pump an increased volume of blood from the pulmonary circle. This is how the prerequisites for the development of infectious inflammation of the heart muscle - endocarditis, appear.

Symptoms of an open ductus arteriosus

Children suffering from non-closure of the Botallian duct, as a rule, lag behind in development. They have increased fatigue, characterized by the appearance of shortness of breath even with little physical exertion. In newborns with such a heart disease, rapid breathing often occurs; at an older age, children may complain of interruptions in the heart, increased heart rate. Such babies, as a rule, are inactive, lag behind in growth. They often get pneumonia.

All of these signs are more pronounced in premature babies who already have problems associated with lung immaturity. These children develop symptoms of congestive heart failure earlier.

Diagnostics of the open ductus arteriosus

The first diagnostic sign of patent ductus arteriosus is a characteristic heart murmur, which occurs in connection with the turbulent flow of blood from the aorta to the pulmonary artery through the open ductus arteriosus. This is rough, so-called. "machine" noise, which is heard during both systole and diastole. In combination with a specific noise during the examination, expanded borders of the heart are revealed.

The diagnosis is confirmed by the results of cardiography, which shows the existence of blood flow in a typical place for an open ductus arteriosus between the aorta and the pulmonary artery, towards the latter.

A chest x-ray shows an increase in the size of the heart and changes in lung tissue.

At the same time, there are no specific changes in the activity of the heart on the electrocardiogram. With large defects in the aortopulmonary septum, the ECG shows an overload of the right heart, hypertrophy of both ventricles.

Treatment of an open ductus arteriosus

A conservative method of treating patent ductus arteriosus is possible only in newborns who were born in a normal pregnancy and do not suffer from signs of severe heart failure. During this period, given the potential for self-closing of the duct, drugs such as indomethacin or ibuprofen can be used, which help reduce muscle tissue in the walls of the duct and its closure. However, these drugs have side effects such as adverse effects on kidney function or an increased tendency to bleed. Therefore, the appointment of drug treatment is carried out only after a preliminary laboratory examination. If the test results reveal contraindications for taking medicines, then treatment can be performed by one of the surgical methods.

In premature babies, in older infants, and in older children, surgical methods of treatment are also used to eliminate non-closure of the ductus arteriosus. They include the operation of suturing the duct, or its double ligation (ligation). The method of cutting the duct and suturing at both ends is also used.

The first surgical treatment of an open ductus arteriosus was performed in 1938. It was the first operated congenital heart disease. The operation is carried out, practically, with 100% success. The rehabilitation period lasts about a year, its length depends on the degree of damage to the lungs. The optimal age for surgery is between 3 and 5 years. However, it can be performed at any age. In premature babies. as well as in patients suffering from severe damage to the body, it is desirable to perform the operation as early as possible in order to prevent the development of pathological changes in the lungs. Open surgery is especially recommended if there is a very large diameter of the ductus arteriosus and some other unusual features of the anatomy of the heart.

In recent years, in Israel, as in other countries in the West, mini-operations are increasingly being used, which are less traumatic and are characterized by a faster recovery. These include cardiac catheterization. To perform it, a catheter is inserted through the inguinal artery and moves through the circulatory system to the heart. The process is monitored using radiography, for contrast, a radiopaque substance is injected into the bloodstream. When a catheter is inserted into the area of ​​an aortopulmonary septal defect, the existing duct is blocked using endoscopic devices - spirals, balloons, etc. Their choice depends on the size of the duct.

In Israel, where cardiac surgery is traditionally one of the strongest branches of medicine, open aortic duct surgery is one of the most successful operations, the risk of complications is minimal. Patients whose physical condition does not allow for an immediate operation undergo a preparatory course of treatment, the purpose of which is to stabilize and strengthen their health to the parameters of a state that allows the surgical treatment to be carried out safely.

The ductus botulus was first described as early as 1564. In intrauterine circulation, it plays an important role, since it drains most of the blood from the pulmonary artery directly into the aorta. It departs from the place where the pulmonary artery divides into 2 branches, sometimes from its left branch. The duct flows into the aorta below the so-called isthmus into its descending part 2-3 mm below and opposite the mouth of the left subclavian artery. The length of the duct, according to Kushev, in newborns and infants is 6.9-6.2 mm, the diameter is 4.3-3 mm. The duct differs from large vessels in the predominance of muscle elements with a weak development of elastic tissue.

After birth, the ductus botulinum closes first, and later the fusion of the ductus arteriosus occurs. In this case, an increase in blood pressure in the aorta, as well as the movement of the chest organs, is important. Following physiological closure, anatomic obliteration of the duct begins, which ends within the first 6 weeks, but sometimes drags on up to 3-4 months. By the end of the obliteration process, the duct turns into lig. arteriosum magnum. If the fusion of the duct is incomplete or does not take place at all, then a malformation occurs. Non-closure of the ductus arteriosus can be the only heart defect, sometimes it is combined with other defects, such as stenosis and atresia of the pulmonary arteries, stenosis of the aortic orifice, its isthmus, narrowing of the left venous atrioventricular orifice, etc. In cases of combination with other defects of the botallus duct, the duct performs a compensatory role. Out of 1000 patients with early congenital heart defects, an open ductus botalis was found in 242. The width of its lumen is different - from 4 to 12 mm, on average 7 mm, and it can expand even more depending on blood pressure. Through it, a large amount of blood entering the aorta can be ejected into the pulmonary arteries. Diagnosis of an open ductus arteriosus in many cases is simple, accessible and based on well-studied clinical signs. But it should be remembered that occasionally there are cases of non-closure of the ductus botulinum, which do not manifest themselves in any way during life and are only accidentally discovered on the section of people who died from other diseases. The severity of the clinical picture does not always depend on the width of the lumen.

In a small proportion of cases, there is a slight cyanotic staining of the skin or transient cyanosis in early age associated with physical stress. In most cases, cyanosis is absent and the skin appears normally colored or even excessively pale.

In this regard, children with an open botallic duct never have fingers in the form of drumsticks, nails in the form of watch glasses. In many cases, there is an easy onset of shortness of breath and fatigue. Often prone to disease respiratory tract. Quite often there is a lag in physical development. But many children adapt to the environment and the requirements of life, attend a normal school.

When examining a patient, a clear pulsation in the retrosternal fossa is sometimes noted. On palpation of the cardiac region, one can sometimes note the presence of systolic trembling in the second intercostal space on the left. The borders of the heart during percussion are often slightly expanded both to the left and to the right. In some children (in 20%), it is possible to determine a ribbon-like dullness of percussion sound to the left of the sternum in the first, second and third intercostal space, observed mainly in older children. This dullness, first noted by Gerhardt, corresponds partly to an enlarged ductus arteriosus and partly to an enlarged pulmonary artery.

The most typical are auscultatory data. A distinct loud rough murmur is heard at the base of the heart in the second gap on the left. The noise is long, continuous, resembling the operation of a machine or the noise of a mill wheel. This noise is well carried out throughout the region of the heart, it is heard in the subclavian region and in the left half of the chest. It is usually not conducted into the vessels of the neck, but is sometimes auscultated. On the back, the noise in the interscapular space is well heard. It fills most of systole and diastole and disappears only at the end of diastole. In the supine position, it is more pronounced. Noise is perceived as systolic-diastolic, has a vortex character. Sometimes, up to 3 years, only a rough systolic murmur can be heard, which sometimes increases during inspiration and decreases during expiration. Sometimes the maximum noise is heard to the right of the sternum or on the back. An audible rough murmur to the right of the sternum may sometimes be a manifestation of relative aortic stenosis or subaortic stenosis.

Along with the noise, there is a significant increase in the second tone in the pulmonary artery, but this is not always observed.

As a result of increased blood supply to the pulmonary artery, the amount of blood flowing through pulmonary veins into the left atrium and later into the left ventricle. But on the other hand, one can easily imagine that at the same time, due to the flow of blood from the aorta to the pulmonary artery, obstacles are created for the emptying of the right ventricle.

According to the clinic, the maximum blood pressure with an open ductal duct, it turns out to be normal, the minimum is reduced, and with a wide duct, it can reach zero. Because of this, the amplitude of the pulse pressure increases, i.e., the difference between the maximum and minimum pressure.

In the study of hemodynamics with an open ductus arteriosus, sounding of the heart was of great importance. The greater the difference between the pressure in the aorta and the pulmonary artery, the more blood will pass through the duct from the aorta to the lungs and the more distinct the noise will be. In the presence of the same diastolic pressure in both vessels, only the flow of blood from the aorta to the pulmonary artery during systole can take place. With an open ductus arteriosus, both the oxygen capacity and the content of O2 and CO2 in arterial and venous blood almost do not differ from the norm, and blood saturation reaches 95-96%.

Sometimes it was possible to notice the presence of a significant increase in pressure in the pulmonary circulation. At the same time, some features of the clinical picture are also found in patients. They usually do not have a diastolic component of the noise, they do not tolerate their defect well, during a test with a load, they notice an undersaturation of arterial blood with oxygen, a decrease in the oxygen utilization coefficient, they more easily develop cyanosis.

Based on the foregoing, an increase in pressure in the pulmonary artery and a higher oxygen content in it than in the right ventricle, due to the admixture of arterialized blood from the aorta, can be considered characteristic of the open ductus arteriosus.

Of the other, less characteristic and less permanent symptoms with an open botallic duct, one can point to the irregularity of the pulse on the hands, noticed by D. A. Sokolov, palpation of a stronger pulse on the right. Occasionally, the pulse takes on a paradoxical character, the disappearance of pulse fluctuations can be observed with a deep breath. In isolated cases, it is possible to observe the phenomena of aphonia due to compression of the left recurrent nerve. Systolic pressure with an open ductus arteriosus is normal, diastolic pressure is reduced, and as a result, the amplitude of pulse pressure increases (above 40-50 mm Hg). Accordingly, pulsus celer et altus is often observed, as in aortic valve insufficiency.

The electrocardiogram with an open ductus arteriosus has no regular and characteristic changes. The right type is often noted, at an older age, a levogram. More often, the deviation of the axis to the vertical, violation of vascular excitability, lengthening of P-Q and Q-T.

X-ray examination usually confirms the presence of expansion of the heart to the left, less often to the right. The increase in the cone of the pulmonary artery is striking, which gives the left contour of the heart a typical shape. Characterized by an increase in the vascular pattern and a strong systolic pulsation of the pulmonary artery arch, hilus and aortic arch. Translucence is best done in the anteroposterior and left oblique position. An X-ray kymogram shows the presence of an intermediate diastolic tooth of the pulmonary artery arch.

With the help of the probing method, it is sometimes possible to establish with full certainty the presence of a passable ductus arteriosus. From the superior vena cava, the probe can be passed into the right atrium, right ventricle and pulmonary artery, and through the preserved duct into the aorta, from where it is directed inward vertically down into the abdominal aorta by turning from the outside. But this method is very difficult, you need to have a lot of patience to bring the probe to the right place, and often this does not work at all. Therefore, most often the diagnosis is confirmed on the basis of a study of blood oxygen saturation in the cavities of the heart. Increasing the oxygen content in a. pulmonalis, compared to venous blood in the right ventricle, indicates the presence of a message between the aorta and the pulmonary artery, i.e., the existence of the ductus arteriosus.

The angiocardiographic method of research also provides valuable data. The contrast agent is injected through the cubital vein and superior vena cava into the right atrium. By tracing the movement of the contrast further in seconds, it is possible to establish signs characteristic of the open ductus arteriosus. First of all, the expansion of the pulmonary artery and especially its left branch. After the filling of the left parts of the heart on the angiocardiogram, a long-term contrasting of the vessels of the lungs, the left atrium, the left ventricle and aorta is observed.

Gotts proposed a new diagnostic feature. When the contrast passes through the pulmonary artery, after 2-3 seconds, a defect can be noted on the contour of the arch of the pulmonary artery. This defect is created due to dilution of the contrast by the mass of blood coming from the aorta through the ductus arteriosus into the pulmonary artery.

Sometimes, to resolve the issue, you have to use aortography, with which you can see the flow of contrast from the aorta into the pulmonary artery.

The described picture is characteristic of pure forms of the open ductus arteriosus. The picture changes in the case of a combination of this defect with another, for example, with pulmonary artery stenosis, aortic stenosis and other defects. It is always necessary to differentiate this defect from the narrowing of the mouth of the pulmonary artery, since with the latter, a systolic murmur is also heard in the second intercostal space on the left. Therefore, we must remember that when the mouth of the pulmonary artery is narrowed, the II tone of the pulmonary artery is usually weakened, and sometimes it is not heard at all.

The cleft ductus arteriosus is generally not a severe malformation and gives a relatively favorable prognosis. Children can lead a normal life, go to school. But it should be remembered that in this case there is a predisposition to congestion in the lungs, and this in turn leads to a more frequent development of pneumonia. 2/3 of our patients had a history of recurrent pneumonia. Every kind infectious diseases such children endure worse. You can always be afraid of the development of endocarditis in them, the addition of a rheumatic infection and, which is of particular importance, sclerosis of the vessels of the lungs, followed by hypertension in the pulmonary artery system. According to Shapiro and Case, 40% of patients die from subacute endocarditis, some from rupture of the duct or pulmonary artery.

Treatment of the ductus botulinum is possible only by surgery and consists in ligation of the duct or its intersection. Children endure the operation relatively easily; after the operation, auscultatory phenomena disappear in them, the noise ceases to be heard or becomes weaker. The working capacity of patients increases sharply.

The risk of surgery is less than the risk of possible complications in later life. If a complication of endocarditis is suspected, it is necessary to pre-treat with antibiotics. According to domestic scientists, the mortality rate during operations for the ductus arteriosus is 0.5-2%. In children, surgery is rational even in the absence of any symptoms.

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