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Echocardiographic assessment of Patent D uctus Arteriosus

Echocardiographic assessment of Patent D uctus Arteriosus. Dr Sandeep Mohanan Senior resident, Cardiology GMC, Kozhikode. TOPIC OVERVIEW. PDA anatomy and classification Echocardiographic identification Echocardiographic quantification Role of Echo in corrective management

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Echocardiographic assessment of Patent D uctus Arteriosus

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  1. Echocardiographic assessment of Patent DuctusArteriosus Dr SandeepMohanan Senior resident, Cardiology GMC, Kozhikode

  2. TOPIC OVERVIEW • PDA anatomy and classification • Echocardiographic identification • Echocardiographic quantification • Role of Echo in corrective management • Role of 3D Echo and TEE

  3. Anatomy ~ 10 * 5mm 5-10mm from the L-SCA

  4. Embryology Distal part of Left 6th arch

  5. Classification – Angiographic(Krichenko et al,1989) Conical Window- like Elongated with a remote constriction Tubular Complex with multiple constrictions Krichenko et al. Angiographic classification of the isolated, persistently patent ductusarteriosus and implications for percutaneous catheter occlusion. Am J Cardiol.1989 Apr 1;63(12):877-80.

  6. Why the PDA is often difficult to Echo-image? TTE?? TEE??

  7. When should the echocardiographer look for a PDA? • All neonatal echo s • All paediatric referral for Echo • Any unexplainable cause of heart failure in adults • Unexplained central cyanosis • Any unexplained PAH, LV volume overload • Any referral for suspicion of IE

  8. TTE- PSAX view The 1st step in imaging the ductus is knowing where to look for it. Superior and leftward sweep of a routine Basal PSAX view

  9. TTE-PSAX view for PDA

  10. 1. Three-legged pant view-high left PSAX view A large PDA shunting L to R is often easily visualized However smaller PDA required help of Colour Doppler

  11. 2. Horizontal short axis view

  12. PSAX – Colour Doppler Echo -Identify the ‘central flame in the blue stream’ (red - PDA blue-LPA, RPA, DescAo) - A flow that appears to come from the left corner of the LPA origin and directed usually towards the left PV However again confusion arises in the case of a predominant R to L shunt through the PDA.

  13. Doppler echo

  14. CWD - Normal PA vs PDA

  15. 3. Ductal view – high parasternalsagittal view

  16. Ductal view with colour Doppler

  17. Echo measurement of the Pulmonary end

  18. 4. TTE- Suprasternal view

  19. The value of suprasternal view above parasternal views Zhang et al. Value of the EchocardiographicSuprasternal View for Diagnosis of Patent DuctusArteriosusSubtypes. JUM September 1, 2012vol. 31 no. 9 1421-1427

  20. PDA type characterisation by suprasternal view

  21. Measurements from the suprasternal view • -Ampulla • Adjacent aortic • diameter.

  22. PDA significance • The direction of shunting • The shunt gradient • PA pressures • Size of the PDA

  23. Direction of predominant shunting-PWD

  24. Increasing PA pressures Appearance of an early systolic R to L shunt with increasing PA pressures Widening and deepening of early systolic R to L shunt in parallel with a lesser L to R gradient.

  25. PDA-Eisenmenger • Very difficult to demonstrate the Doppler flow • Corroborative evidence and clinical picture should guide suspicion : Septal flattening, RVH, dilated PA, high velocity PR etc • Contrast Echo : reveal bubbles in the descending aorta and not in the ascending aorta

  26. PDA with suprasystemic pressures

  27. PDA shunt quantifcation • LA/ Aorta ratio -- >1.5 – moderate to large PDA (Sens -79%, Spec-95%)1 • LV dimensions • LV output • Qp/Qs • PDA pressure gradient • Colour Doppler ductal diameter • Diastolic flow reversal in descending aorta 1. Re-evaluation of the left atrial to aortic root ratio as a marker of patent ductusarteriosus. Archives of Disease in Childhood 1994; 70: Fl 12-Fl 17

  28. Qp/Qs in PDA vs ASD/VSD • In VSD Qs- Qp = shunt • In ASD Qs - Qp = shunt Any output from LV goes to the systemic circulation ... So, Qs= LV output Any output from RV goes only to pulm circulation ie, Qp = RV output So Qp/Qs = RV output/ LV output for ASD & VSD --- Continuity equation ) • However in PDA the shunt is extracardiac Therefore, Qp≠ RV output (will be more) and Qs ≠ Lv output (will be less)

  29. Qp/Qs in PDA • Counterintuitively ,Qs = RV output & Qp = LV output • Thus, Qp/Qs = LV output / RV output ..... FOR AN ISOLATED PDA However, for most neonates this is unusual. Coexisting L to R shunts makes simple ventricular output ratios unreliable

  30. Colour Doppler ductal diameter • Optimal gain settings • (not too high) • Maximum Doppler • scale settings • Duct should be imaged • along its entire length Colour Doppler diameter > 2mm ~ Qp/Qs >2:1 in neonates Evans N, Iyer P. Assessment of ductusarteriosus shunt in preterm infants supported by mechanical ventilation: effect of interatrial shunting. J Pediatr.1994;125:778–785

  31. Diastolic flow reversal in Descending Ao PWD in PDA NORMAL FLOW Retrograde diastolic flow –VTId/VTIs >30% ~ QP/Qs>1.6

  32. Increased diastolic flow in branch PAs

  33. PDA in a Right aortic arch • The PDA is commonly left in origin

  34. Ductal aneurysm • ~8% • May present at any age • In adults may present as a thoracic mass or with cardiovocal syndrome • In children may spontaneously resolve • Requires surgical excision / covered stent placement

  35. Infective endocarditis TEE image showing vegetations on the MPA wall at the pulmonary end of PDA

  36. Use of 2D Echo in pre-interventional work up • Minimum diameter (A) • Length (B) • Ampulla diameter (C) • PDA type

  37. Use of 2D Echo in pre-interventional work up • Echo classification corresponding to Krichenko’s A- Conical with a narrow pulmonary end B- Short with narrow aortic end C- Tubular without constriction D- Multiple constrictions E- Long and tortuous requiring >1 echo plane for complete imaging Comprehensive Assessment of Patent DuctusArteriosus by Echocardiography Before Transcatheter Closure. J Am Soc Echocardiogr 2002;15:1154-9.

  38. Important to define the Ampulla • Adequate Ampulla: Length of PDA> Narrowest portion of the PDA (usually at pulm end)

  39. Inadequate ampulla: Short PDA - Worst example : WINDOW type (Type B)

  40. Tubular ductus: Same diameter from aorta to pulmonary end

  41. Echo classification • CONICAL DUCT ( common) • WINDOW DUCT • TUBULAR DUCT

  42. Correlation of 2D echo and Angio • Wong et al found poor correlation between colour Doppler and angiographic measurements1 • 2DE imaging overestimates the minimal diameter in comparison with angiography but in the majority difference was <1mm2 • In ~14% there is discrepancy in classification type2 • Ampulla and length measurement were the most discordant Wong et al. Validation of colorDoppler measurements of minimum patent ductusarteriosusdiameters: significance for coil embolization. Am Heart J 1998;136:714-7. Comprehensive Assessment of Patent DuctusArteriosus by Echocardiography Before Transcatheter Closure. J Am Soc Echocardiogr 2002;15:1154-9.

  43. TEE for PDA • TEE is not that popular among the PDA cohort in its incremental benefit in echo diangnosis, compared to ASD, VSD and complex congenital heart disease • Inherent difficulties in imaging

  44. TEE imaging -In high esophageal position (~20-35cm), probe rotated completely backward to image decending aorta in the short axis (0 deg).... -Then slowly rotated to around 60 to 80 deg will help visualize the PDA to PA connection

  45. Doppler TEE of PDA Evaluation of Shunt Flow by MultiplaneTransesophageal Echocardiography in Adult Patients with Isolated Patent DuctusArteriosus. JASE 2002.

  46. TEE vs TTE • 40 patients with PDA • Gold standard--- angiography TEE sensitivity –97% vs 42% and TEE NPV 98% vs 68%, ; p<0.001) for confirming the presence of PDA For PDA Eisenmenger's syndrome, thesensitivityof TEE in confirming diagnosis of PDA was 100% vs 12% (p<0.01), Diagnostic Accuracy of TransesophagealEchocardiography for Detecting Patent DuctusArteriosus in Adolescents and Adults. CHEST 1995; 108:1201-05

  47. 3D echo for PDA Full volume 3D acquisition from a modified parasternal short-axis view, cropped so as to show the entrance of the PDA into the left pulmonary artery

  48. 3D vs 2D echo for PDA • 42 patients with PDA (mean ~3 years) • - 3D was better than 2D for type, length, • ampulla as well as constrictions • - Both 2D & 3 D Echo overestimated Type A • Type C was overdiagnosed by Echo • Type D is poorly defined in echo • Both underestimated Type E Roushdy et al. Visualization of patent ductusarteriosus using real-time three-dimensional echocardiogram: Comparative study with 2D echocardiogram and angiography. J Saudi Heart Assoc 2012;24:177–186

  49. 3D TEE

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