The function of the circulatory system is to deliver oxygen and nutrients to all organs of the body, remove decay products and carbon dioxide from the body, as well as humoral function.

The circulatory system is mainly of mesodermal origin.

Evolution of the circulatory system in invertebrate animals.

In lower invertebrate animals, i.e. in sponges, coelenterates and flatworms, the delivery of nutrients and oxygen from the place of their perception to parts of the body occurs through diffuse currents in tissue fluids. But some animals develop pathways along which circulation occurs. This is how primitive vessels arise.

The further evolution of the circulatory system is associated with the development of muscle tissue in the walls of blood vessels, due to which they can contract, and even later, evolution is associated with the transformation of the fluid filling the vessels into a special tissue - blood, in which various blood cells are formed.

The circulatory system can be closed or open. The circulatory system is called closed if blood circulates only through vessels, and open if the vessels open into slit-like spaces in the body cavity, called sinuses and lacunae.

The circulatory system first appeared in annelids; it is closed. There are 2 vessels - dorsal and abdominal, connected to each other by annular vessels running around the esophagus. The movement of blood occurs in a certain direction - on the dorsal side towards the head end, on the abdominal side - backwards due to the contraction of the spinal and annular vessels.

Arthropods have an open circulatory system. On the dorsal side there is a pulsating vessel, divided into separate chambers, the so-called hearts, between which there are valves. With successive contractions of the hearts, blood enters the vessels and then pours into the slit-like spaces between the organs. Having given up nutrients, the blood slowly flows into the pericardial sac, and then through paired openings into the hearts.

Mollusks also have an open circulatory system. The heart consists of several atria into which veins flow and one fairly developed ventricle from which arteries arise.

Evolution of the circulatory system in chordates.

Lower chordates, in particular the lancelet, have a closed circulatory system, but no heart. The role of the heart is performed by the abdominal aorta, from which the afferent branchial arteries depart, in the number of 100-150 pairs, carrying venous blood. Passing through the gill septa in an unbranched form, the blood in the arteries has time to oxidize and through the efferent paired gill arteries, arterial blood enters the roots of the dorsal aorta, which merge into the unpaired dorsal aorta, from which vessels carry nutrients and oxygen to all parts of the body.

Venous blood from the dorsal part is collected in the anterior and posterior cardinal veins, which merge into the left and right ducts of Cuvier, and from them into the abdominal aorta. Blood from the abdominal side is collected in the intestinal vein, which carries the blood to the liver, where it is disinfected, and from there, along the hepatic vein, it also flows into the duct of Cuvier and then into the abdominal vessel.

In higher chordates, in particular in lower vertebrates, i.e. in cyclostomes and fish, the complication of the circulatory system is expressed in the appearance of a heart, which has one atrium and one ventricle. The heart contains only venous blood. There is only one circulation in which arterial and venous blood do not mix. The circulation of blood throughout the body is similar to the circulatory system of the lancelet. From the heart, venous blood goes to the gills, where it is oxidized, and from them the oxidized (already arterial) blood spreads throughout the body and returns through the veins to the heart.

With the emergence of animals on land and with the advent of pulmonary respiration, a second circle of blood circulation appears. The heart receives not only venous, but also arterial blood, and therefore the further evolution of the circulatory system follows the path of separation of two circles of blood circulation. This is achieved by dividing the heart into chambers.

Amphibians and reptiles have a three-chambered heart, which does not ensure complete separation of the two circulation circles, so mixing of arterial and venous blood still occurs. True, in reptiles the ventricle is already divided by an incomplete septum, and in a crocodile there is a four-chambered heart, so the mixing of arterial and venous blood is observed to a lesser extent than in amphibians.

In birds and mammals, the heart is completely divided into four chambers - two atria and two ventricles. The two circles of blood circulation, arterial and venous blood do not mix.

Let's look at the evolution of gill arches in vertebrates.

In all embryos of vertebrate animals, an unpaired abdominal aorta is formed in front of the heart, from which the branchial arches of the arteries arise. They are homologous to the arterial arches in the circulatory system of the lancelet. But their number of arterial arches is small and equal to the number of visceral arches. So fish have six of them. The first two pairs of arches in all vertebrates experience reduction, i.e. atrophy. The remaining four arcs behave as follows.

In fish, they are divided into the gill arteries that bring them to the gills and those that carry them out from the gills.

The third arterial arch in all vertebrates, starting with tailed amphibians, turns into the carotid arteries and carries blood to the head.

The fourth arterial arch reaches significant development. From it, in all vertebrates, again starting with tailed amphibians, the aortic arches themselves are formed. In amphibians and reptiles they are paired, in birds the right arch (the left one atrophies), and in mammals the left arch of the aorta (the right one atrophies).

The fifth pair of arterial arches in all vertebrates, with the exception of caudate amphibians, atrophies.

The sixth pair of arterial arches loses connection with the dorsal aorta, and the pulmonary arteries are formed from it.

The vessel that connects the pulmonary artery with the dorsal aorta during embryonic development is called the ductus bottalus. In adulthood, it is preserved in tailed amphibians and some reptiles. As a result of disruption of normal development, this duct may persist in other vertebrates and humans. This will be a congenital heart defect and in this case surgical intervention will be necessary.

Anomalies and malformations of the circulatory system in humans.

Based on the study of the phylogenesis of the cardiovascular system, the origin of a number of anomalies and deformities in humans becomes clear.

1. Cervical ectopia of the heart- location of the heart in the neck. The human heart develops from paired mesoderm layers that merge and form a single tube in the neck. During development, the tube moves to the left side of the chest cavity. If the heart is delayed in the area of ​​the original anlage, then this defect occurs, in which the child usually dies immediately after birth.

2. Destrocardia (heterotopia) - location of the heart on the right.

3. Two-chambered heart- arrest of heart development at the stage of two chambers (heterochrony). In this case, only one vessel leaves the heart - the arterial trunk.

4. Non-closure of the primary or secondary atrial septum(heterochrony) in the area of ​​the fossa ovale, which is an opening in the embryo, as well as their complete absence leads to the formation of a three-chambered heart with one common atrium (incidence rate 1:1000 births).

5. Non-fusion of the interventricular septum(heterochrony) with an incidence of 2.5-5:1000 births. A rare defect is its complete absence.

6. Persistence(impaired differentiation) arterial, or Bottallov, duct, which is part of the root of the dorsal aorta between the 4th and 6th pairs of arteries on the left. When the lungs do not function, a person has a ductus bottallus during embryonic development. After birth, the duct closes up. Its preservation leads to serious functional disorders, since mixed venous and arterial blood passes through. The incidence is 0.5-1.2:1000 births.

7. Right aortic arch- the most common anomaly of the branchial arches of the arteries. During development, the left arch of the 4th pair is reduced instead of the right one.

8. Persistence of both aortic arches 4th pair, the so-called " Aortic ring“- in the human embryo, sometimes reduction of the right artery of the 4th branchial arch and the aortic root on the right does not occur. In this case, instead of one aortic arch, two arches develop, which, going around the trachea and esophagus, connect into an unpaired dorsal aorta. The trachea and esophagus end up in the aortic annulus, which shrinks with age. The defect is manifested by impaired swallowing and suffocation.

9. Persistence of the primary embryonic trunk. At a certain stage of development, the embryo has a common arterial trunk, which is then divided by a spiral septum into the aorta and pulmonary trunk. If the septum does not develop, then the common trunk is preserved. This leads to mixing of arterial and venous blood and usually ends in the death of the child.

10. Vascular transposition- a violation of the differentiation of the primary aortic trunk, in which the septum takes on a straight rather than spiral shape. In this case, the aorta will arise from the right ventricle, and the pulmonary trunk from the left. This defect occurs with a frequency of 1:2500 newborns and is incompatible with life.

11. Open carotid duct- preservation of the commissure between the 3rd and 4th pairs of arterial arches (carotid artery and aortic arch). As a result, blood flow to the brain increases.

12. Persistence of the two superior vena cavae. In humans, a developmental anomaly is the presence of an additional superior vena cava. If both veins flow into the right atrium, the anomaly is not clinically manifested. When the left vein flows into the left atrium, venous blood is discharged into the systemic circulation. Sometimes both vena cava empty into the left atrium. Such a vice is incompatible with life. This anomaly occurs with a frequency of 1% of all congenital malformations of the cardiovascular system.

13. Underdevelopment of the inferior vena cava- a rare anomaly in which the outflow of blood from the lower part of the torso and legs occurs through collaterals of the azygos and semi-gypsy veins, which are rudiments of the posterior cardiac veins. Rarely, atresia (absence) of the inferior vena cava occurs (blood flow is through the azygos or superior vena cava).

14. Absence of the liver portal system.

One of the least “severe” heart defects is considered to be patent ductus arteriosus in children or adults. This problem has many options for invasive or non-invasive treatment, which makes it possible to choose a method of treating the defect that is suitable for the patient. Let us note that in newly born children, a patent ductus arteriosus is not a pathology, but the norm. With proper development, it will close in 2-3 weeks and will not remind itself in the future. However, there are children whose duct does not close even after three weeks. What to do in this case, and what parents should prepare for, is further in the article.

What is patent ductus Botallus?

Congenital heart disease, which is a continuation of the functioning of an additional vessel between the aorta and the pulmonary trunk, is one of the most common.

During the prenatal period of development, the Botallic duct is needed to supply the fetus with blood from the mother's body. When the lungs are not yet functioning and there is no access to oxygen, this duct is the connecting element for communication between the circulatory system and the respiratory tract. Throughout pregnancy, everything necessary for the life of the fetus is supplied through it. Immediately after birth, when the baby takes his first breath, the body begins the process of closing (obliteration) of the duct.

Botall's duct

Typically, this blood pathway should disappear within three weeks of the baby's birth. During this time, the body will produce a special substance – bradykinin. It provokes a narrowing of the duct, gradually turning it into a simple ligament. If, after the above-mentioned time, non-closure of the Botallov duct is observed, then we can talk about the formation of a heart defect. This pathology is typical for premature babies.

Important! The degree of danger of this UPS(congenital heart function) depends on the width of the duct.

In premature babies, a patent ductus arteriosus is treated with medication, by administering special drugs that stimulate its closure. This doesn't always help. In such cases, surgical intervention is indicated. At the same time, doctors try to wait until the patient is at least three years old. It happens that as you grow older, the body begins to independently produce the necessary substance, and the duct becomes obliterated.

Opening of the pulmonary-cardiac arterial duct: what is its danger?

As mentioned above, the Botallic duct in children who have just been born is the norm. Doctors have no problem giving babies to their parents and do not keep them until the duct closes. Often the latter neglect preventive visits to the cardiologist and limit themselves to only a general examination and vaccination. This approach to children’s health is unacceptable, as it can result in a serious threat to health and even life.

Blood circulation in OAPA

Normally, the vessels of the greater and lesser circles do not interfere with each other’s functioning. In both systems, a certain pressure is maintained; venous blood does not mix with arterial blood. If closure of the ductus arteriosus does not occur:

• pressure in the circulatory system increases;
• the heart enlarges to cover the load;
• The direction of blood flow may change.

All this disrupts the functioning and circulation patterns and, although the body adapts to the additional load, the heart muscle wears out faster. The average lifespan of people with this diagnosis is only 40 years.

Due to an increase in the size of the heart, deformation of the chest and displacement of internal organs are possible. With age, a noticeable hump forms over the heart, which becomes a characteristic sign of the disease.

This congenital heart defect imposes certain restrictions on physical activity, nutrition, and the permissibility of taking certain medications.

Symptoms of patent ductus arteriosus in children

In adolescence or older age, a person himself understands that he has heart problems. Children aged three years and younger only react to pain and severe discomfort by crying, so parents should pay attention to the following symptoms:

• pulse more than 150 beats in 60 seconds;
• constant shortness of breath;
• lethargy, fatigue;
• poor sleep;
• delay in growth and physical development.

Slow weight gain or a clear reluctance to participate in outdoor games may also indicate that the ductus arteriosus has not closed.

As a rule, 50% of premature and about 2% of full-term infants suffer from a patent ductus arteriosus. In this case, the newborn may not show obvious signs: the skin will not have a bluish tint, and when listening, the attending physician may only hear faint noises. To avoid mistakes and detect a threat in time, there are many ways. Read more about what methods are used for diagnosis.

Diagnosis of patent arterial flow

There are many ways to diagnose the activity of the cardiovascular system, but not every method will allow you to see whether the ductus arteriosus is closed. The list of available methods and their effectiveness is below:

• electrocardiography – rarely shows abnormalities, only at the stage of pathological changes;
• radiography - shows an enlarged heart and overflow of veins and arteries with blood;
• angiography – monitors the direction of blood flow;
• phonocardiography – reveals characteristic heart murmurs;
• echocardiography (ultrasound) – gives the most detailed report on internal processes, allows you to visualize the duct;
• catheterization – focuses on the pressure and oxygen saturation of the blood in the vessel;
• computed tomography - shows the size and location of the ductus arteriosus.

X-ray of a baby with PDA

Each method has its own advantages. Therefore, during the initial diagnosis, you can use more affordable methods. If the ductus arteriosus is not closed, the results will show this. A more detailed and, accordingly, expensive examination should be carried out if there is confidence in the presence of violations.

Based on the data obtained, the attending physician can determine the extent of the problem and how much the ductus arteriosus disrupts hemodynamics. On this basis, recommendations are written and orders are made.

Any open arterial flow must be eliminated. The dangers of untimely detection of a defect are described above. Early intervention will help avoid unpleasant consequences.

Patent ductus arteriosus: what is the treatment?

A small patent ductus arteriosus of 2 mm does not pose a serious threat and may well be observed accompanied by drug treatment. The drugs used are:

1. Cycloxygenase inhibitors. Essentially, it is an anti-inflammatory that affects the amount of substance that prevents duct fusion. It is administered intravenously.
2. Diuretics. Needed to facilitate the work of the heart muscle. They produce a diuretic effect, thereby reducing the amount of arterial blood.
3. Cardiac glycosides. They lengthen diastole, thereby giving the heart more time to rest.

This course of treatment for a duct defect is repeated no more than two times. During this time, the ductus botallus in children should disappear. A similar approach to treatment is desirable for children under three years of age - before this age, surgical intervention is highly undesirable.

Only if non-invasive methods have given no results, surgery to close the duct is prescribed. This method is indicated for:

• lack of effect from medications;
• blood entering the lungs from the aorta;
• blood stagnation;
• increased pressure in the pulmonary artery;
• frequent respiratory diseases;
• heart failure and other disorders.

Removing PDA surgically is not always possible. Thus, the entry of blood from the lungs into the aortic segment of the blood supply is a sign of fundamental disturbances in the functioning of the body. It must be treated according to a special program - it is prescribed by a doctor based on the patient’s data.

Important! At an early age, patent ductus arteriosus is easily eliminated. The optimal age for surgery is 3-5 years.

The invasive process itself can be of two types:

1. Endovascular. A special instrument is inserted through a large vessel. They install a special plug (occluder) that blocks the unwanted channel. This is the least traumatic intervention.
2. Open. A small incision is made through which the pathology is eliminated. Such ligation of the patent ductus arteriosus will lead to gradual healing of the defect.

It must be said that a relapse of the opening of the duct in a baby is possible, most often during puberty, when the body is rebuilt.

Recovery after surgery

If you cannot manage with non-invasive and minimally invasive methods, it is worth understanding what an operation to eliminate the imperfection of the ductus arteriosus is. Before it, all the necessary tests will be done and the presence of hereditary diseases and personal intolerances will be clarified. After the intervention, the patient is transferred to intensive care. Within 24 hours he recovers from anesthesia. At the same time, blood pressure, heart rate, and general well-being are carefully recorded. The patient is connected to an artificial respiration apparatus, so it will be impossible to speak for 24 hours.

Newborn after surgery

If there are no alarming signs, on the second day the patient is transferred to intensive care. For the first days, strict bed rest is prescribed, but from the second day you can do exercises for the hands and feet, and conduct breathing exercises every hour. It is important not to skip bandaging and treating the wound. The speed of recovery depends on the characteristics of the body. However, in most cases, after 5-7 days the patient is discharged home. A tightening corset, which prevents the seams from coming apart, should be worn as long as the doctor tells you. This will allow the wound to heal faster and eliminate unnecessary blood loss.

Since a person’s ability to work is impaired, it is recommended to call a housekeeper for a while.

Important! The wound should be treated with anti-inflammatory and bactericidal agents such as brilliant green. After healing, anti-scar ointment can be applied.

In the first month, physical activity for people with a patent ductus arteriosus is strictly limited, but you can take leisurely walks of up to 200 meters. Upon discharge, the doctor gives recommendations regarding exercise and diet. If you follow the recommendations, full recovery is possible within a month.

Why doesn't the ductus arteriosus seal?

There may be several reasons why a patent ductus arteriosus is observed:

• early birth (up to 37 weeks);
• hypoxia during childbirth;
• chromosomal diseases;
• underdevelopment of the muscle layer;
• increased levels of prostaglandins.

It should be noted that a patent ductus arteriosus in a child is possible if the mother is pregnant and has suffered rubella or other infectious diseases. Negatively affects the fetus.

- a functioning pathological communication between the aorta and the pulmonary trunk, which normally provides embryonic blood circulation and is subject to obliteration in the first hours after birth. A patent ductus arteriosus is manifested by a child’s developmental delay, increased fatigue, tachypnea, palpitations, and interruptions in cardiac activity. Data from echocardiography, electrocardiography, radiography, aortography, and cardiac catheterization help diagnose patent 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

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

Complications of patent ductus arteriosus can include bacterial endocarditis, ductal aneurysm and rupture. The average life expectancy in the natural course of the duct is 25 years. Spontaneous obliteration and closure of the patent ductus arteriosus occurs extremely rarely.

Diagnosis of patent ductus arteriosus

When examining a patient with an open ductus arteriosus, a deformation of the chest (cardiac hump) and increased pulsation in the projection of the apex of the heart are often revealed. The main auscultatory sign of a patent ductus arteriosus is a rough systole-diastolic murmur with a “machine” component in the second intercostal space on the left.

The required minimum investigations for patent ductus arteriosus include chest radiography, aortopulmonary septal defect, truncus arteriosus, sinus of Valsalva aneurysm, aortic insufficiency and arteriovenous fistula.

Treatment of patent ductus arteriosus

Conservative management of patent ductus arteriosus is used in premature infants. It involves the administration of prostaglandin synthesis inhibitors (indomethacin) to stimulate spontaneous obliteration of the duct. If there is no effect from repeating the drug course 3 times in children older than 3 weeks, surgical closure of the duct is indicated.

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

Prognosis and prevention of patent ductus arteriosus

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

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

Children are not immune from congenital anomalies, so it is important for parents to know what signs may indicate certain developmental defects. For example, about such a pathology as patent ductus arteriosus in newborns.

The ductus arteriosus is a small vessel that connects the pulmonary artery to the fetal aorta, bypassing the pulmonary circulation. This is normal before birth because it provides fetal circulation necessary for the fetus, which does not breathe air in the womb. After the baby is born, the small duct closes in the first two days after birth and turns into a cord of connective tissue. In premature babies, this period can last up to 8 weeks.

But there are cases when the duct remains open and leads to disturbances in the functioning of the lungs and heart. More often, this pathology is observed in premature babies and is often combined with other congenital defects. If the ductus arteriosus remains open for 3 or more months, we are talking about a diagnosis such as PDA (patent ductus arteriosus).

By what signs can one suspect that the duct remains open?

The main symptoms in children under one year of age are shortness of breath, rapid heartbeat, slow weight gain, pale skin, sweating, and difficulty feeding. The reason for their appearance is heart failure, which occurs due to congestion of the vessels of the lungs, to which blood returns when the duct is open, instead of rushing to the organs.

The severity of symptoms depends on the diameter of the duct. If it has a small diameter, the disease may be asymptomatic: this is due to a slight deviation from normal pressure in the pulmonary artery. With a large diameter of the open vessel, the symptoms are more severe and are characterized by several other signs:

• hoarse voice;
• cough;
• frequent infectious diseases of the respiratory system (pneumonia, bronchitis);
• weight loss;
• poor physical and mental development.

Parents should know that if a child slowly gains weight, gets tired quickly, turns blue when screaming, breathes quickly and holds his breath when crying and eating, then it is necessary to urgently consult a pediatrician, cardiologist or cardiac surgeon.

If a patent ductus arteriosus has not been diagnosed in a newborn, then as the child grows, the symptoms usually worsen. In children over one year of age and adults, the following signs of PDA can be observed:

• frequent breathing and lack of air even with minor physical exertion;
• frequent infectious diseases of the respiratory tract, persistent cough;
• cyanosis – blue discoloration of the skin of the legs;
• weight deficiency;
• rapid fatigue even after short outdoor games.

For what reasons does the ductus arteriosus not close?

Until now, doctors cannot give an exact answer to this question. It is assumed that risk factors for abnormal development include:

• a number of other congenital heart defects (congenital heart defects);
• premature birth;
• insufficient body weight of the newborn (less than 2.5 kg);
• hereditary predisposition;
• oxygen starvation of the fetus;
• genomic pathologies, such as Down syndrome;
• diabetes mellitus in a pregnant woman;
• infection with rubella during pregnancy;
• chemical and radiation effects on a pregnant woman;
• consumption of alcoholic beverages and drugs by pregnant women;
• taking medications during pregnancy.

Moreover, statistics show that this pathology occurs twice as often in girls as in boys.

How do doctors make a diagnosis?

First of all, the doctor listens to the newborn’s heart with a stethoscope. If the noises do not stop after two days, the examination is continued using other methods.

A chest x-ray shows changes in the lung tissue, expansion of the cardiac borders and vascular bundle. High load on the left ventricle is detected using an ECG. To detect an increase in the size of the left ventricle and atrium, echocardiography or ultrasound of the heart is performed. To determine the volume of blood discharged and the direction of its flow, Doppler echocardiography is needed.

In addition, the pulmonary artery and aorta are probed, with the probe passing through the open duct from the artery into the aorta. During this examination, the pressure in the right ventricle is measured. Before performing aortography, a contrast agent is injected into the aorta with a catheter, which enters the pulmonary artery with the blood.

Early diagnosis is very important, since the risk of complications and severe consequences is very high, even with an asymptomatic course.

Spontaneous closure of the pathological ductus arteriosus can occur in children under 3 months of age. In a later period, self-healing is almost impossible.

Treatment depends on the patient’s age, severity of symptoms, diameter of the pathological duct, existing complications and concomitant congenital malformations. The main methods of treatment: medication, catheterization, ligation of the duct.

Conservative treatment is prescribed in case of mild symptoms, in the absence of complications and other congenital defects. Treatment of patent ductus arteriosus with various drugs is carried out before the age of one year under constant medical supervision. For treatment, drugs can be used: non-steroidal anti-inflammatory drugs (ibuprofen, indomethacin), antibiotics, diuretics.

Catheterization is performed for adults and children over the age of one year. This method is considered effective and safe in terms of complications. The doctor carries out all actions using a long catheter, which is inserted into a large artery.

Often, a patent ductus arteriosus is treated surgically by ligating it. If a defect is detected while listening to extraneous sounds in the heart of a newborn, the duct is closed through surgery when the child reaches the age of 1 year to avoid possible infectious diseases. If necessary (with a large diameter of the duct and heart failure), the operation can be performed on a newborn, but it is optimal to perform it before the age of three years.

Don't forget about prevention

In order to protect the unborn child from developing PDA, during pregnancy you should avoid taking medications, stop smoking and drinking alcohol, and be wary of infectious diseases. If family members and relatives have congenital heart defects, you should contact a geneticist before conception.

What's the prognosis?

The vice is dangerous because there is a high risk of death. Patent ductus arteriosus can be complicated by a number of diseases.

• Bacterial endocarditis is an infectious disease that affects the heart valves and can cause complications.
• Myocardial infarction, in which necrosis of an area of ​​the heart muscle occurs due to impaired blood circulation.
• Heart failure develops when the diameter of the unclosed ductus arteriosus is large if left untreated. Signs of heart failure, which is accompanied by pulmonary edema, include: shortness of breath, rapid breathing, high pulse, low blood pressure. This condition poses a threat to the child's life and requires hospitalization.
• Aortic rupture is the most severe complication of PDA, leading to death.

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Patent ductus arteriosus in children

Patent ductus arteriosus in children refers to congenital heart defects. This pathology is considered quite mild. In most cases, it does not cause serious health problems in newborns and older children.

One child in every 2,000 births has this defect. And in premature babies, almost every second child is diagnosed with this condition. Manifestations of the disease and treatment tactics depend on the size of the duct.

Congenital causes

• the child was born premature, up to 37 weeks, the shorter the term and the lower the weight of the baby, the higher the risk of developing PDA;
• the child experienced oxygen starvation (hypoxia) during pregnancy and a few minutes after birth;
• during pregnancy, the mother had rubella and the child developed congenital rubella;
• a child was born with Down syndrome, Edwards syndrome or other chromosomal diseases;
• maternal use of alcohol, hormonal or sleeping pills or other toxic substances during pregnancy;
• underdevelopment of the muscle layer, which should ensure compression and closure of the ductus arteriosus;
• a high level of biologically active substances - prostaglandins, which prevent the walls of the duct from contracting.

Symptoms and external signs

Well-being

Doctors classify patent ductus arteriosus in children as “white” defects. This means that at the time of birth the baby's skin is pale and does not have a bluish tint. With such defects, venous blood with a small amount of oxygen does not enter the left half of the heart and the aorta, which means the child’s organs do not lack oxygen. Therefore, in most cases, full-term babies feel normal.

The size of the ductus arteriosus at which symptoms of the disease appear in newborns:

1. Full-term children - the size of the duct is almost equal to the diameter of the aorta, more than 9 mm;
2. Premature babies - the duct size is more than 1.5 mm.

If the duct is smaller in width, then the disease manifests itself only as a heart murmur.

Child's well-being

• rapid pulse more than 150 beats per minute;
• shortness of breath, rapid breathing;
• the child gets tired quickly and cannot breastfeed normally;
• breathing problems, the child requires artificial ventilation;
• sleeps little, often wakes up and cries;
• delay in physical development;
• poor weight gain;
• early pneumonia, which is difficult to treat;
• Older children refuse active games.

Objective symptoms

In premature infants and children with medium and large defects, the following symptoms of PDA appear:

• the heart is greatly enlarged and occupies almost the entire chest, this is revealed by tapping;
• When listening, strong and frequent heart contractions are heard. In this way, the heart tries to increase the volume of blood flowing to the organs, because part of it goes back to the lungs;
• pulsation is clearly visible in large vessels, the result of increased blood pressure in the arteries after a strong contraction of the ventricles;
• using a stethoscope, a heart murmur is listened to, which occurs when blood passes from the aorta to the pulmonary artery through the ductus botallis;
• the skin is pale due to a reflex spasm of small vessels;
• With age, an elevation appears on the chest - the “chest hump”.

Diagnostics

1. Electrocardiogram- in most cases no change. Signs of overload on the right side of the heart appear after the vessels of the lungs compress in response to blood overflow. It becomes difficult for the heart to pump blood through them and its chambers stretch.
2. Chest X-ray shows changes associated with the overflow of the pulmonary vessels with blood and the load on the right atrium and ventricle:
   • enlargement of the right half of the heart;
   • bulging of the pulmonary artery;
   • dilation of large vessels of the lungs.
3. Angiography a type of x-ray examination in which a contrast agent is injected into the vessels to study the direction of blood flow:
   • “colored” blood from the left half of the heart enters the pulmonary artery through the duct;
   • filling the pulmonary trunk with blood and a contrast agent.
4. Phonocardiography– graphic recording of heart sounds.
   • identifies specific noise, which is commonly called “machine noise”.
5. Echocardiography or ultrasound of the heart allows:
   • see the presence of a patent ductus arteriosus;
   • set the hole diameter;
   • calculate the amount and direction of blood passing through it (using Doppler ultrasound).
6. Catheterization of the heart(probing or coronogram) reveals:
   • increased pressure in the right ventricle;
   • blood oxygen saturation in the right side of the heart and in the pulmonary artery;
   • Sometimes a catheter can be inserted from the pulmonary artery into the aorta.
7. Computed tomography with PDA determines:
   • open duct;
   • its dimensions and location features.

More information about diagnostic methods
Electrocardiogram . The study of electrical currents that arise in the heart and cause it to contract. These discharges are detected by the device's sensitive sensors, which are attached to the chest. Then the electrical potentials are recorded in the form of a curve, the teeth of which reflect the spread of excitation in the heart. Changes with patent ductus arteriosus:

• overload and thickening of the walls of the left ventricle;
• overload and thickening of the right heart, develops after a significant increase in pressure in the vessels of the lungs.

Chest X-ray. Research based on the properties of X-rays. They pass through the human body almost unhindered, but some tissues absorb some of the radiation. As a result, images of internal organs appear on sensitive film. Signs of PDA:

• the large vessels of the lungs are dilated. This is due to the stagnation of large amounts of blood in them;
• enlargement of the boundaries of the heart;
• an increase in the pulmonary trunk, into which an additional volume of blood flows from the aorta;
• in severe cases, signs of pulmonary edema are visible.

Phonocardiography . Registration and analysis of sounds that occur in the heart during its contraction and relaxation. Unlike conventional listening with a stethoscope, the results of phonocardiography are recorded on paper tape in the form of a curved line. Characteristic sign of the defect:

• a continuous “mechanical” noise that is heard both during contraction and relaxation of the heart.

Echocardiography (ultrasound of the heart). The diagnostic device creates an ultrasonic wave that passes into the body and is reflected or absorbed by different organs at different frequencies. The sensor converts the “ultrasonic echo” into a moving image on the monitor screen. This makes it possible to consider:

• diameter of the hole in it;
• condition and thickness of the heart muscle;
• blood flow that is thrown from the aorta into the pulmonary artery (Doppler study).

Catheterization of the heart. A small incision is made in the artery on the top of the thigh. A thin and flexible catheter (probe), hollow inside, is inserted through it. Under X-ray control, it is advanced towards the heart. The probe can measure pressure and oxygen content in the arteries and different chambers of the heart. Changes with patent ductus arteriosus:

• increased oxygen content in the right atrium, ventricle and pulmonary artery;
• increased pressure in the right heart and pulmonary trunk;
• if the hole in the duct is large enough, then a probe can be inserted from the pulmonary artery into the aorta.

The catheter can not only clarify the diagnosis, but also block the ductus arteriosus using a special device - an occluder, which is attached to its end.

Angiography . A diagnostic procedure in which a contrast agent is injected through an opening in the catheter. It spreads through the vessels with the blood flow and is clearly visible on x-rays. If a patent ductus ductus is suspected, the blood in the left ventricle is stained with “contrast” and it flows into the aorta. If the ductus arteriosus is open, then through it the colored blood enters the pulmonary artery and into the vessels of the lungs. Within a minute, an x-ray will determine the presence of this substance in the lungs.

Spiral computed tomography with 3D image reconstruction. This method combines the properties of X-ray radiation and the capabilities of a computer. After the body is scanned with X-rays from different sides, the computer creates a three-dimensional image of the area of ​​the body being examined with all the smallest details:

• its length, width;
• the presence of narrowings in its different parts;
• the structure and condition of the vessels through which the probe is planned to be inserted;
• Features of blood movement through the ductus botallus.

In most cases, this study is carried out before surgery so that the surgeon can draw up a plan of action.

Treatment

Drug treatment

Drug treatment for patent ductus arteriosus is aimed at blocking the production of prostaglandins, which prevent this vessel from closing. Diuretics and non-steroidal anti-inflammatory drugs can help with this. In the first days after birth, the chance of successful treatment is much higher.

Cycloxygenase inhibitors: Indomethacin, Nurofen.

These non-steroidal anti-inflammatory drugs block the action of substances that interfere with the natural closure of the duct. As a result, a spasm of the smooth muscle wall of the ductus arteriosus occurs, and it closes.

A regimen for administering indomethacin intravenously has been developed:

1. the first two days: initial dose of 200 mcg/kg, then 2 doses of 100 mcg/kg every 12 hours.
2. Days 2-7: initial dose of 200 mcg/kg, then 2 doses of 200 mcg/kg at daily intervals.
3. Days 7-9: initial dose of 200 mcg/kg, then 2 doses of 250 mcg/kg at daily intervals.

Diuretics, diuretics: Lasix, Furosemide, Hypothiazide

These drugs speed up the formation and elimination of urine, thereby helping to reduce the volume of blood that circulates in the body. This relieves swelling and makes it easier for the heart to work. The drugs are dosed based on a ratio of 1-4 mg/kg per day.

Cardiac glycosides: Isolanide, Celanide

They improve the functioning of the heart, helping it contract more intensely and powerfully. These drugs reduce the load on the heart muscle and give it the opportunity to rest, lengthening the periods of relaxation (diastole). At the first stage, to saturate the body, take 0.02-0.04 mg/kg per day. From the fourth day, the dose is reduced by 5-6 times.

Usually two courses of drug treatment are given. If they do not produce results and the duct does not close, then in this case an operation is prescribed.

Surgical treatment of PDA

Surgery is the most reliable method of treating patent ductus arteriosus in children and adults.

1. Drug treatment did not help close the duct.
2. There were signs of blood stagnation and increased pressure in the vessels of the lungs.
3. Long-term bronchitis and pneumonia that are difficult to treat.
4. Cardiac dysfunction - heart failure.

The optimal age for surgery is 2-5 years.

Contraindications for surgery

1. The reflux of blood from the pulmonary artery into the aorta, which indicates severe changes in the lungs that cannot be corrected with surgery.
2. Severe liver and kidney diseases.

Advantages of the operation:

1. The cause of circulatory disorders is completely eliminated,
2. Immediately after the operation, it becomes easier to breathe and lung function is gradually restored.
3. A very small percentage of mortality and complications after surgery is 0.3-3%.

Disadvantage of the operation
In approximately 0.1% of cases, the aortic duct may open again after a few years. Repeated surgery is associated with a certain risk due to the formation of adhesions.

Types of operations

1. – a low-traumatic operation that does not require opening the chest. The doctor inserts a special device into the arterial duct through a large vessel - an occluder, which blocks the flow of blood.
2. Open surgery. The doctor makes a relatively small incision in the chest and closes the defect. As a result of the operation, the blood flow stops, and connective tissue is gradually deposited in the duct itself and it becomes overgrown.
   • suturing of the ductus arteriosus;
   • ligation of the duct with a thick silk thread;
   • clamping the duct with a special clip.

Treatment of patent ductus arteriosus
The most effective treatment for patent ductus arteriosus is surgery, during which the doctor cuts off the flow of blood from the aorta to the pulmonary artery.

At what age is it better to have surgery?

The optimal age for eliminating a medium-sized defect (4-9 mm) is 3-5 years.

If the duct is wide (more than 9 mm) or if the duct is more than 1.5 mm in a premature baby, surgery is performed a few days after birth.

In the case where the patent ductus arteriosus appears after puberty, the operation can be performed at any age.

Open surgery to close the PDA

The heart surgeon makes an incision between the ribs and closes the duct.

Indications for surgery

1. The size of the duct in full-term babies is more than 9 mm, in premature babies it is more than 1.5 mm.
2. Return of blood from the aorta to the pulmonary artery.
3. Dependence of a newborn on a ventilator when the child cannot breathe on his own.
4. Early prolonged pneumonia, difficult to treat.
5. The duct remains open after two courses of treatment with non-steroidal anti-inflammatory drugs (Indomethacin).
6. Signs of disruption of the lungs and heart due to the reflux of additional blood into the pulmonary vessels.

Contraindications

1. Severe heart failure - the heart cannot cope with pumping blood throughout the body, internal organs suffer from a lack of nutrients and oxygen. Symptoms: interruptions in the functioning of the heart, blueness of the skin and mucous membranes, pulmonary edema, impaired kidney function, enlarged liver, swelling of the extremities, accumulation of fluid in the abdomen.
2. High pulmonary hypertension is the sclerosis of small pulmonary vessels and alveoli, the vesicles in which the blood is enriched with oxygen. The pressure in the vessels of the lungs rises above 70 mm Hg. st and this leads to the fact that blood is thrown from the pulmonary artery into the aorta.
3. Severe concomitant diseases that can cause death during and after surgery.

Advantages of the operation

• doctors have extensive experience in performing such operations, which guarantees a good result;
• the surgeon can eliminate a defect of any diameter;
• The operation can be performed for any width of the vessels, which is especially important when the child was born prematurely.

Disadvantages of the operation

• in approximately one percent of cases, the ductus arteriosus reopens;
• the operation is a physical injury and rehabilitation requires 2-6 weeks;
• During and after surgery, complications associated with bleeding or inflammation of the wound may occur.

Stages of open surgery

1. Preparation for surgery:
   • blood test for group and Rh factor, for coagulation;
   • blood test for AIDS and syphilis;
   • general blood test;
   • general urinalysis;
   • stool analysis for worm eggs;
   • chest x-ray;
   • Ultrasound of the heart.

   If concomitant diseases are identified, they are treated first to avoid complications after surgery.
   

2. Consultation with doctors. Before the operation, you will definitely meet with the surgeon and anesthesiologist, who will tell you about the procedure and allay your fears. You will be asked if you are allergic to medications in order to choose the right drug for anesthesia.
3. The night before surgery, it is advised to take sleeping pills to ensure you have a good rest.
4. Before the operation, the doctor administers drugs intravenously for general anesthesia. After a few minutes, deep medicated sleep occurs.
5. The heart surgeon makes a small incision between the ribs, through which he gains access to the heart and aorta. During this operation, there is no need to connect a heart-lung machine, since the heart independently pumps blood throughout the body.
6. The doctor eliminates the defect in the most appropriate way:
   • ties with thick silk thread;
   • compresses the duct with a special clamp (clip);
   • cuts the ductus arteriosus and then sutures both ends.
7. The doctor sutures the wound and leaves a rubber tube to drain the fluid. Then a bandage is applied.

The operation to close the ductus arteriosus is performed in the same way in both children and adults.

Endovascular closure of the ductus arteriosus
Recently, most operations are performed through large vessels in the upper thigh.

1. If the diameter of the duct is less than 3.5 mm, then use a “Gianturco” spiral;
2. If the diameter of the duct is larger, then use the Amplatzer occluder.

Indications for surgery

1. Patent ductus arteriosus of any size.
2. Return of blood from the aorta to the pulmonary artery.
3. Ineffectiveness of drug treatment.

Contraindications

1. Return of blood from the pulmonary artery to the aorta.
2. Irreversible changes in the lungs and heart.
3. Constriction of the blood vessels through which the catheter must pass.
4. Sepsis and inflammation of the heart muscle (myocarditis).

Advantages

• does not require opening the chest;
• quick recovery after the procedure 10-14 days;
• minimal risk of complications.

Flaws

• not carried out if there is an inflammatory process or blood clots in the heart;
• not effective if the duct is not located typically;
• will not improve the condition if the pressure in the vessels of the lungs is so high that blood flows from the pulmonary artery into the aorta (third degree of pulmonary hypertension);
• the diameter of the femoral artery must be greater than 2 mm.

Operation stages

1. A few days before the procedure, you will need to do an ultrasound of the heart, a cardiogram and tests to make sure that there is no inflammatory process that could cause complications.
2. Consultation with a cardiac surgeon and anesthesiologist. Doctors will answer your questions, clarify your health status and response to medications.
3. Adults are operated on under local anesthesia - the site where the probe is inserted is numbed. Children are given general anesthesia.
4. The procedure is performed in an X-ray room. Using the equipment, the doctor sees how the catheter is moving and how the operation is going.
5. The surgeon disinfects the skin at the top of the thigh and makes a small incision in the artery and inserts a catheter into it. With its help, a special device is delivered to the arterial duct, which blocks the lumen and does not allow blood to flow into the aorta.
6. After installing the “plug,” a contrast agent is injected through the catheter, which enters the blood vessels. The operation is considered successful if the x-ray shows that it does not pass from the aorta to the pulmonary trunk.
7. The doctor removes the catheter and sutures the artery wall and skin. After this, the person will be taken to the ward.
8. On the first day, you should not sit down or bend your legs to prevent a blood clot from forming in the artery. But then the recovery will go quickly and in 3-5 days you will be able to return home.

Rehabilitation after open surgery for PDA

From the operating room you will be transferred to the intensive care unit; you may need to be connected to special devices that will monitor your pulse, blood pressure, heart rhythm and support your body. To ensure uninterrupted breathing, a special breathing tube is inserted into your mouth; it will prevent you from speaking.

Modern anesthesia eliminates problems when waking up. To prevent chest pain from bothering you, you will be prescribed painkillers that prevent inflammation of the wound.

The first day you will have to observe strict bed rest. This means you can't get up. But within 24 hours you will be transferred to the intensive care ward and allowed to move around the ward.

Until the stitch heals, you will need to go to the dressing every day. A day later, the drainage will be removed from the wound and you will be advised to wear a special corset that will prevent the seam from coming apart.

During the first 3-4 days, the temperature may rise slightly - this is how the body reacts to the operation. It's okay, but it's best to tell your doctor.

Do breathing exercises with a jerk-like exit every hour and do physical therapy: stretch your hands. While lying in bed, bend your knees without lifting your feet off the bed. Abduct your arms at the shoulder joint without lifting them out of bed.

You will have to stay in the hospital for 5-7 days. When the doctor is satisfied that your condition is steadily improving, you will be discharged home. At first, your capabilities will be somewhat limited, so you need to have someone nearby who will help you with the housework.

Before you leave, you will be told how to treat your stitches. They need to be lubricated with brilliant green or calendula tincture once a day. In the future, the doctor will recommend you an ointment to prevent scarring: Contractubex.
You can take a shower after the wound has healed. Simply wash the seam with warm soapy water and then carefully dry it with a soft towel.

Increase physical activity gradually. Start with walks for short distances - 100-200 meters. Increase your load a little every day. In 2-3 weeks you will be almost completely recovered.

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In what cases does the botal duct not close?

This pathology is most often found in children born much prematurely. In children born at term, such a heart defect is practically undetectable. Patent ductus arteriosus is diagnosed in 50% of children born weighing less than 1.7 kg, and 80% of children born weighing less than 1 kg. Prematurely born children often have congenital defects in the structure of the genitourinary and digestive systems. Untimely closure of the embryonic canal between the aorta and the pulmonary trunk in children born prematurely is a consequence of respiratory failure, oxygen starvation during childbirth, metabolic acidosis, constant supply of highly concentrated oxygen, and improper infusion treatment.

In children born at term, this heart defect is detected more often in areas with thin air. In certain cases, insufficient closure of the canal is associated with its incorrect structure. Causes such as genetic predisposition and infectious diseases suffered by a pregnant woman, such as rubella, also lead to the appearance of the ductus botallus.

Characteristics of blood flow with a patent ductus arteriosus

The patent ductus arteriosus in children is located in the upper part of the mediastinum, it begins along with the left subclavian artery on the wall of the aorta, its reverse end is combined with the pulmonary trunk, partially affecting the left pulmonary artery. In especially severe cases, a bilateral or right-sided defect is diagnosed. The canal can have a cylindrical, cone-shaped, fenestrated structure, its length varies from 0.3 to 2.5 cm, width - from 0.3 to 1.5 cm.

The arterial canal, as well as the open foramen ovale, is a physiological component of the embryo’s circulatory system. Blood from the right side of the heart enters the pulmonary artery, from where it is directed through the arterial duct into the underlying aorta. With the onset of pulmonary respiration after birth, pulmonary pressure decreases, and in the cardiac artery it increases, which leads to blood entering the pulmonary vessels. When inhaling, a spasm of the ductus arteriosus occurs due to contraction of muscle fibers. The duct soon stops working and becomes completely overgrown as unnecessary.

Heart defects in newborns are indicated by the continued functioning of the ductus 2 weeks after birth. PDA is classified as a pale type defect, since in this disease, oxygenated blood from the aorta is thrown into the pulmonary artery. This leads to the release of excess blood into the pulmonary vessels, their overflow and a local increase in pressure. High load on the left side of the heart leads to expansion of the ventricles and pathological thickening of their walls.

Impaired blood flow during a PDA depends on the size of the canal, its angle relative to the aorta, and the difference in pressure in the pulmonary circulation from the pressure in the systemic circulation. If the channel has a small lumen diameter and is located at an acute angle to the aorta, no serious disturbances in blood flow occur. Over time, such a defect may disappear on its own. The presence of a duct with a wide lumen leads to the reflux of large amounts of blood into the pulmonary vessels and severe disturbances in blood flow. Such channels do not heal on their own.

Classification of heart defects of this type

Depending on the level of pressure in the pulmonary arteries, anomalies in the structure of the heart muscle are divided into 4 types. With grade 1 PDA, the pressure in the pulmonary artery does not exceed 40% of arterial pressure, with grade 2 defects, the pressure ranges from 40 to 70% of arterial pressure, grade 3 is characterized by an increase in pressure to 75% of arterial pressure and preservation of the left shunt. A severe degree of the defect is characterized by an increase in pressure to arterial values ​​or exceeding these values.

In its natural course, the disease goes through 3 stages:

1. 1. At the first stage, the first symptoms of PDA appear; dangerous conditions often develop, which, if left untreated, lead to death.
2. 2. Stage 2 is characterized by relative compensation. Hypervolemia of the pulmonary circulation develops and persists for many years, and overload of the right side of the heart occurs.
3. 3. At stage 3, sclerotic changes occur in the pulmonary vessels. The further course of the disease is accompanied by adaptation of the pulmonary arteries with their subsequent gluing. Symptoms of a patent arterial canal at this stage are replaced by manifestations of pulmonary hypertension.

Clinical picture of the disease

The disease can occur in either asymptomatic or extremely severe forms. An arterial canal of small diameter, the presence of which does not lead to circulatory impairment, may remain undetected for a long time. With a wide ductus arteriosus, pronounced symptoms of the disease appear already at its first stage. The main signs of heart disease in newborns may be constant pallor of the skin, cyanosis of the nasolabial triangle during sucking, crying, and defecation. There is a lack of body weight and a lag in psychophysical development. Such children often suffer from pneumonia and bronchitis. During physical activity, shortness of breath, irregular heart rhythm, and excessive fatigue are noted.

The severity of the disease worsens during puberty, pregnancy, and after childbirth. Blueness of the skin is constantly present, which indicates regular veno-arterial discharge of blood and progressive heart failure. Severe complications arise when infective endocarditis, aneurysm and duct rupture occur. In the absence of timely surgical treatment, a patient with PDA lives no more than 30 years. Spontaneous fusion of the duct occurs in rare cases.

During the initial examination of a patient with a defect of this type, a curvature of the chest in the heart area and increased pulsation in the area of ​​the upper parts of the organ are detected. A characteristic symptom of a patent ductus arteriosus is a pronounced systole-diastolic murmur in the 2nd intercostal space. When diagnosing the disease, it is necessary to conduct an X-ray examination of the chest organs, electrocardiography, ultrasound of the heart and phonocardiography. The image reveals an increase in the heart muscle due to dilatation of the left ventricle, bulging of the pulmonary artery, a pronounced pulmonary pattern, and expansion of the pulmonary roots.

The cardiogram shows signs of dilation and overload of the left ventricle; with pulmonary hypertension, similar changes are observed in the right side of the heart. Echocardiography allows you to identify indirect symptoms of heart disease, see the open arterial canal itself and determine its size. With a high degree of pulmonary hypertension, aortography, MRI of the chest, and sounding of the right ventricle are performed. These diagnostic procedures allow us to identify concomitant pathologies. When identifying a disease, defects such as aortic septal defect, common truncus arteriosus, aortic insufficiency and venoarterial fistula should be excluded.

Methods of treating the disease

When treating low-birth-weight newborns, conservative therapy is used, which involves the administration of prostaglandin production blockers to stimulate the natural clogging of the duct. If the result of such treatment does not appear after 3 courses of drug administration, children older than a month are subjected to surgical intervention. In pediatric cardiac surgery, both abdominal and endoscopic operations are practiced. In open operations, the duct is ligated or secured with vascular clips. In some cases, the canal is cut and both ends are sutured.

Endoscopic methods include: clamping of the ductus arteriosus during thoracoscopy, catheter closure of the lumen with special devices. It is better to prevent any disease than to treat it, especially for heart defects. Even a small size of the ductus arteriosus is dangerous with the risk of death. Premature death can be caused by a decrease in the compensatory capabilities of the heart muscle, rupture of the pulmonary arteries, and the occurrence of severe complications.

After surgery, blood circulation is gradually restored, good blood flow indicators are noted, life expectancy increases and its quality improves. Deaths during and after surgery are extremely rare.

To reduce the risk of having a child with abnormalities in the structure of the heart muscle, a pregnant woman must eliminate all factors leading to the occurrence of such diseases.

During pregnancy, you must stop drinking alcohol, smoking, and taking strong medications. It is necessary to avoid stressful situations and contacts with people with infectious diseases. A woman who has had a congenital heart defect should visit a geneticist at the stage of pregnancy planning.

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General information

This congenital defect, related to the pathology of the cardiovascular system, is lack of closure of the ductus arteriosus, connecting the pulmonary artery and the baby’s aorta in the prenatal period.

What happens if a child has patent ductus arteriosus? The baby begins to form a functioning “vessel” between the indicated anatomical formations, which is unnecessary for the organism existing outside the mother’s womb, which leads to obvious disruptions in the functioning of not only the heart, but also the respiratory system.

Causes and risk factors

Knowledge of 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 promptly sound the alarm and seek medical help in case of any suspicion. This knowledge is also no less important for preventing the occurrence of PDA.

However, some factors can affect its healing. Among the main causes of patent ductus arteriosus and congenital heart defects of the newborn generally distinguish:

Types and phases of 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 pulmonary artery stenosis).

It is also customary to classify open botalls by phases of its development:

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

Considering 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 no 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 equals the systemic arterial pressure, the blood flows from right to left.

Why it’s dangerous: possible complications

• The development of endocarditis of a bacterial nature, leading to damage to the inner layer of the wall of the heart chambers, primarily in the area of ​​the valve apparatus.
• Bacterial endarteritis.
• Myocardial infarction with risk of rhythm disturbance or death.
• Heart failure of varying severity.
• Swelling of the lung tissue due to increased pressure in the pulmonary vessels, requiring extremely rapid action by medical personnel.
• Rupture of the main vessel of the human body – the aorta.

Symptoms

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

In others she progresses to extreme degrees of severity and manifests itself in the development of a “heart hump” (a convex deformation of the anterior chest wall in the area of ​​​​the projection of the heart), downward movement of the apical impulse of the heart along with the expansion of its zone, tremors of the heart in its lower and left parts, persistent shortness of breath with orthopnea and severe cyanosis.

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

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

When to see a doctor

Not in every case, parents can notice changes in the 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 your baby:

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

You should make your appeal to the local pediatrician, who, in the presence of pathological symptoms, can refer you for consultation to other specialists: pediatric cardiologist, pediatric cardiac surgeon.

Diagnostics

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

• rapid pulse;
• an increase in systolic pressure with a simultaneous decrease in diastolic pressure;
• changes from the apical impulse;
• expansion of the boundaries of cardiac dullness (borders of the heart);
• Gibson's murmur described above (systole-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 towards hypertrophy of the left parts of the heart, and in more severe stages, the right parts with deviation of the cardiac axis to the right. As the disease progresses, signs of heart rhythm disturbances appear.
2. Echocardiography. It also gives information about the expansion of the left heart cavities. If you add a Doppler study, a mosaic pattern of blood flow through the pulmonary artery is determined.
3. Radiography chest organs. Characteristic is an increase in the contours of the lung pattern, an increase in the transverse size of the heart due to the left ventricle in the initial stages of the manifestations of PDA symptoms. If hypertension of the pulmonary vessels develops, the pattern of the lungs, on the contrary, becomes poorer, the trunk of the pulmonary artery bulges, and the heart is enlarged.

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

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

Treatment

Conservative treatment is used only in premature babies and consists of administering inhibitors of prostaglandin formation in order to medically stimulate the independent closure of the duct.

The main drug in this group is Indomethacin. If there is no effect after repeated administration of the drug three times in children over three weeks of age, then surgical obliteration is performed.

Children are treated surgically at the age of 2-4 years, this is the best period for this method of therapy. In extended use is the method of ligating the ductus botallus or transversely crossing it, followed by suturing the remaining ends.

Prognosis and prevention

If the duct is not operated on, 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 young patients.

Preventive measures:

1. Avoiding smoking, alcohol abuse, and drugs.
2. Avoiding stress.
3. Mandatory medical and genetic counseling both before and during pregnancy;
4. Sanitation of foci of chronic infection.

Patent ductus arteriosus is a serious congenital pathology, which carries high mortality rates with untimely or inadequate treatment.

The debut of its clinical picture is the development of signs of pulmonary hypertension and cardiac failure. However, If this disease is diagnosed in time, its outcome is very favorable, which is confirmed by modern statistical data.

Patent ductus arteriosus (PDA) is a pathological condition of the heart in which the normal structure of its structure is disrupted, as a result of which the aorta is connected to the pulmonary artery canal.

This leads to the fact that after pushing blood through the left ventricle directly into the aorta, and from it into the artery of the lung (where the pressure on the walls increases significantly) and back into the same ventricle.

Heart pathology (PDA)

The formation of this pathology occurs at the stage of the formation of the structure of the heart and blood vessels in the fetus, even when the child is pregnant. Accordingly, it belongs to congenital heart defects.

The ductus arteriosus is necessary for feeding the fetus inside the womb, and after the baby is born, it closes during normal development.

The pathological condition entails functional abnormalities of the heart and the progression of oxygen starvation of the heart tissues.

What is OAP?

The identical name of the PDA is the duct of Botallus. The duct itself is an important structural component in the fetal circulatory system to maintain its vital functions and nutrition.

After the child is born, his breathing begins with the help of the lungs, which reduces the need for an open arterial duct to zero and it becomes overgrown.

Botall's duct

In many cases, the functional actions of the ductus arteriosus end in the first twenty hours, from the moment the child is born, and its closure occurs in a period of two to eight weeks.

According to statistics from cardiologists, patent ductus arteriosus is diagnosed in almost ten percent of children born with heart defects, and twice as many are registered in females. In many cases it is diagnosed in premature babies.

The pathological deviation can be local (only the structure of the AP is disturbed).

Narrowing of the aortic bed

Accompanied by other deviations of the structural system of the heart and blood vessels:

• Narrowing of the aortic bed;
• Narrowing of the pulmonary artery;
• Narrowing of the aorta in the isthmus region;
• Break in the aortic arch;
• A severe form of narrowing of the aorta or pulmonary artery.

At the moment, pathological changes in many cases are detected using ultrasound examinations (ultrasound). This means that incidence rates in adults are very rare.

If a patent ductus arteriosus is detected in a person of adult age, this indicates inattentive examination of doctors in childhood.

Fact! A pathological structural change in the heart, such as PDA, is exclusively a defect from birth and cannot be inherited throughout a person’s life.

Possible complications depend on the size of the PDA, the level of damage to the vessels of the pulmonary circulation, the presence of associated heart disease, and the timely effective treatment applied. In the early stages of diagnosing patent ductus arteriosus, the disease can be effectively treated.

Classification

The initial classification of patent ductus arteriosus occurs in four degrees, depending on pressure indicators.

On the walls of the pulmonary trunk:

• 1st degree. Indicators of pressure on the walls of the artery of the lung in systole do not increase by more than 40 percent of blood pressure;
• 2nd degree. An increase in the pressure limits in the pulmonary trunk, amounting to more than forty, but less than seventy percent of blood pressure;
• 3rd degree. There is an increase in pressure of over 75 percent. The ejection of blood from the left side to the right side remains;
• 4th degree. Extreme degree of increase in pressure in the pulmonary trunk. Pressure levels are equal to or exceed systemic pressure, which provokes the release of blood from the right side to the left, and circulatory disorders.

Classification of the duct of Botallus also occurs according to three stages of development of the pathological condition:

First stage	Second stage	Third stage
The identical name is primary adaptation (progresses in the first three years of a newborn’s life). Clinical manifestations of PDA are characteristic. In rare cases, serious complications occur, which, in the absence of surgical intervention, leads to a twenty percent mortality rate.	Also called the stage of relative compensation. It develops between the ages of three and twenty years. It is characterized by progression and prolonged increase in circulating blood of the pulmonary circulation, narrowing of the left atrioventricular orifice, as well as excessive load of the right ventricle.	Also called the stage of sclerotic vascular deviations. At this extreme stage, a restructuring of the capillaries in the lungs occurs, which leads to irreversible changes. With the onset of this stage, symptoms of pulmonary hypertension become increasingly apparent, while signs of patent ductus arteriosus subside.

What causes PDA?

At birth, any baby has a PDA, which in most cases ceases to function on the 3rd day of life (in the case of premature babies, a little longer).

There are no clear causes that directly lead to PDA; the disease continues to be studied. However, there are several factors that can provoke PDA.

• Chromosome disruption. The main example is Down, Marfan, Edwards syndrome. Disturbances in the formation of chromosomes can result from a pregnant woman taking narcotic drugs, drinking alcohol and cigarettes while carrying a child, or rubella at birth;
• When giving birth at high altitudes above sea level;
• Prematurity. In most cases, PDA is diagnosed in premature infants, with a rate of eight affected per thousand infants;
• Lack of vitamins, when carrying a child;
• Chronic oxygen starvation of the embryo;
• Mother's age category is more than thirty-five years old;
• The effect of chemicals on the body of the expectant mother;
• Congenital heart defects;
• The influence of drugs used when carrying a child;
• Maternal diseases carrying a child. Diabetes mellitus, hypothyroidism, etc.;
• Exposure to x-rays or gamma irradiation.

The body of a woman carrying a child is very sensitive and requires special care and attention. It is necessary to walk more in the fresh air, eat a balanced and sufficient diet, and also eliminate harmful factors.

How to identify the signs?

• Heart failure;
• Heavy breathing;
• Heart rhythm disturbances;
• Blue shade of legs.

If the disease reaches adulthood, it enters the second or third stages. In adults, a gradual increase in pressure in the blood vessels of the lungs can progress, which subsequently leads to lung failure.

This may result in the affected person being unable to perform daily activities (feeding themselves, cleaning, etc.).

What complications may arise?

The larger the size of the patent ductus arteriosus, the more severe the consequences it can provoke if left untreated.

The most dangerous of them:

• Death of heart muscle tissue (heart attack). The disease is characterized by the occurrence of foci of necrosis in the myocardial tissue. Large heart attacks can seriously threaten the patient's life. It manifests itself as pain in the heart area that does not disappear after taking Nitroglycerin, fear of death and restless state, pale skin tone and increased sweating;
• Bacterial endocarditis characterized by inflammatory processes of the inner lining of the heart, provoked by infectious agents;
• Heart failure is characterized by a failure of blood circulation in the internal organs, and appears if the patient is not provided with proper surgical care. The heart muscle cannot pump blood in full, which leads to general oxygen starvation of organs and impaired functionality of the body;
• Swelling of the lungs. The disease progresses if the fluid moves from the capillaries into the intercellular space;
• Cerebral ischemia and cerebral hemorrhages may occur due to reverse blood flow, which appears with large PDAs;
• Aortic rupture (fatal), ductus arteriosus rupture, cardiac arrest– are rare, but can progress in the absence of medical care.

Bacterial endocarditis

With timely diagnosis and effective medical care, complications of PDA can be avoided in most cases.

Diagnostics

It is not possible to determine a PDA during fetal development inside the womb, since a patent ductus arteriosus is a normal phenomenon for an embryo developing inside the mother.

The pathological condition can be detected after the baby is born if heart murmurs are heard during auscultation of the heart.

To accurately diagnose the disease, the following hardware methods are used:

Research method	Characteristic
Ultrasound examination of the heart (ultrasound)	This study provides an opportunity to visualize the work of the heart, determine the thickness of the heart muscle, and the size of the ductus arteriosus. Ultrasound examination helps to visually see defects of the heart and its blood vessels, as well as evaluate heart contractions.
	Dopplerography is effective (a complex ultrasound examination method using ultrasound of the heart and duplex scanning of blood vessels), which will help determine the width of the arterial passage and the rapid movement of blood through the aorta.
Electrocardiogram (ECG)	This type of study records the frequency of contractions. Also, an ECG can determine the increase in heart size, which is characteristic of PDA.
Chest X-ray	X-ray training is performed to obtain a visual image of the chest organs. With PDA, the results are an enlarged heart and stagnation of blood in the vessels of the lungs.
Oximetry	The study is carried out without penetration into the body. The result is a measured amount of oxygen in the blood. Using this study, it is possible to determine the reverse flow of blood through the PDA.
Aortography	A test method in which contrast fluid is injected into the heart and X-rays are taken. If the fluid stains both the aorta and the pulmonary trunk at once, this is a sign of PDA. The results are stored in the computer's memory, which allows you to study them more than once.
Cardiac catheterization	An effective diagnostic method for PDA. The diagnosis is confirmed when the probe passes quietly from the pulmonary trunk through the duct of the descending aorta.
Phonocardiography	The study helps identify heart defects and structural abnormalities between the cavities. It is performed using a graphical display of heart sounds and measuring the duration of murmurs and their frequency.

The type of examination is selected exclusively by the attending physician, after an initial examination.

Treatment

The main goal of treatment for a patent aortic duct is to close the duct, due to which the heart's performance returns to normal and complications are prevented. Treatment can be conservative, minimally invasive or through surgery.

Treatment of patent ductus arteriosus

Closure of small aortic ducts, in most cases, occurs on its own, without medical treatment. Children who have already reached the age of three months or older, but the ductus arteriosus is still open, need medical attention.

Fact! In premature babies, PDA closure occurs in 75 percent of cases.

Drug treatment

The use of drugs to treat patent ductus arteriosus is used if the size of the duct is not large enough, the symptoms are mild and there are no complications.

Drug treatment is used for children under one year of age, as well as premature babies.

If after three courses of drug therapy the ductus arteriosus remains open and the symptoms of heart failure increase, surgical intervention is necessary.

Conservative treatment methods used include:

• The affected child is prescribed a specific diet, in which fluid intake is limited;
• Prostaglandin inhibitors (Ibuprofen, Indomethacin). This group of drugs helps to activate the independent overgrowth of the duct;
• Diuretic drugs (Veroshpiron, Lasix). Used to reduce fluid levels in the body;
• ACE inhibitors (Captopril, Enalapril). Prescribed for signs of heart failure;
• Cardiac glycosides (Strophanthin, Korglykon). Also used for symptoms of heart failure;
• Antibiotics. Used to prevent inflammation of the lining of the heart and pneumonia;

Taking medications is allowed only after they have been prescribed by the attending physician. To prevent serious complications, do not self-medicate.

Minimally invasive treatment

The use of minimally invasive intervention is also called cardiac catechesis. With this type of treatment, a thin catheter is inserted through the femoral artery in the groin.

In most cases, it is used to treat adults or children who are already old enough to undergo such an intervention.

Minimally invasive treatment is used to treat small open ducts arteriosus, with the goal of preventing inflammation of the lining of the heart by infectious agents.

The procedure takes place under anesthesia. The catheter, inserted through the femoral artery, is directed into the aorta. After reaching the desired location, the doctor inserts a small-sized coil or other device through it that will block the patent ductus arteriosus.

This method of treatment does not require open surgery, which contributes to the patient’s rapid recovery. Complications after catheterization are rare and disappear quickly.

Among them:

• Infectious inflammation at the catheter insertion site;
• Displacement of the blocking device;
• Hemorrhages.

Surgical intervention

The use of surgical intervention completely eliminates the patent ductus arteriosus, as a result of which the patient’s vital activity, susceptibility to physical activity improves, and life span is significantly extended.

The surgery takes place under general anesthesia, since heart surgery is open. The open ductus arteriosus is ligated in two places, sutured and clips are applied.

What are the preventive actions?

The main method of preventive action is to eliminate factors that can provoke the disease.

Careful care of a pregnant woman and compliance with the following conditions will minimize the chance of progression to patent ductus arteriosus.

These include:

• A balanced diet for a pregnant woman, with a high content of vitamins and beneficial elements;
• Exclusion of alcoholic beverages, cigarettes and drugs;
• Avoiding contact with people affected by infectious diseases;
• Constant examination of a woman by a doctor during the period of pregnancy;
• Avoiding stressful situations and emotional stress;
• Taking medications only after a doctor’s prescription;
• In case of infection with rubella or infectious diseases, it is necessary to be carefully observed by a doctor.

If your child has already had surgery, the following recommendations should be followed:

• You need to engage in moderate physical exercise with your child;
• Give the child a massage;
• Eliminate the possibility of passive smoking;
• Provide enhanced proper nutrition;
• Monitor the child’s moderate mobility;
• Protect him from stress and emotional influences.

By adhering to the above rules, you can minimize the chance of progression of patent ductus arteriosus, as well as complications after surgery.

Life forecast

With early diagnosis and timely effective treatment, and also if patent ductus arteriosus is the only heart defect, the prognosis is quite favorable. In the case of premature infants, prognosis is based on comorbidities.

In most cases, after the ductus arteriosus closes, patients do not experience discomfort, their symptoms disappear and complications do not progress.

In the adult age category, prediction is based on the state of the structure of the vessels of the small circle, as well as the state of the heart muscle.

In case of ignoring the disease or ineffective treatment.

The mortality rate from PDA is:

• Age group under 20 years – twenty percent;
• Age group under 45 years – forty-two percent;
• Age group up to 60 years – sixty percent.