Parasternal short-axis

view of the patent

ductus arteriosus
(PDA) (arrow)
connection between
the main pulmonary
artery (MPA) and
descending aorta
(DAo). Ao, aorta; LA,
left atrium; RV, right
ventricle.
Visualization of
patent ductus
arteriosus in short
axis view
(SAX). (A) 2D SAX
moved
anteriorly, (B) same
picture with color
Doppler, (C) Doppler
in the main
pulmonary artery by
closed duct,
and (D) Doppler in
the main pulmonary
artery by patent duct.
Diagram of suprasternal notch two-dimensional echo
views.
Visualization of patent ductus arteriosus (PDA) in suprasternal view. (A) Normal suprasternal
view of the aortic arch, (B) suprasternal sagittal view with pulmonary artery and descending
aorta, and (C) color Doppler in a sagittal suprasternal view with PDA in red.
Visualization of patent ductus arteriosus in long axis view (LAX). (A) 2D classical LAX, (B) LAX slightly
tilted anteriorly toward the pulmonary artery, and (C) main pulmonary artery with pulmonary
branches. RV, right ventricle; LV, left ventricle; AV, aortic valve; PV, pulmonary valve; MPA, main
pulmonary artery; RPA, right pulmonary artery; LPA, left pulmonary artery
Ductal sizing The most accurate view
for measuring the size of the DA is
the high left parasternal short axis
window, also called “ductal view.”

To obtain this view, the transducer is

positioned between the suprasternal
notch and the standard parasternal region
in the left infraclavicular region. The plane
of transducer is directed similar to the
suprasternal long-axis views through the
left pulmonary artery. In this view, the PDA
can be seen between the origin of left
pulmonary artery and the descending
aorta
The DA should be measured at its
narrowest point, before its entry into
the main pulmonary artery
With slight rotation of the transducer to
obtain the long-axis view of the aorta, the
entire length of the PDA can be visualized)
.
It is not recommended to use the color
Doppler, which can exaggerate the size.

SAX should not be chosen to measure

ductal size because it is not always
possible to differentiate the left pulmonary
artery from the DA.
high-left parasternal
short-axis view (ductal
view) of a large patent
ductus arteriosus (PDA)
between the origin of
left pulmonary artery
(LPA) and descending
aorta (DAo)

The DA should be
measured at its
narrowest point,
before its entry into
the main pulmonary
artery
High
parasternal
view (ductal
view) using
color Doppler
demonstrating
all right-to-left
flow across the
patent ductus
arteriosus
(PDA). LPA, Left
pulmonary
artery; RPA,
right pulmonary
artery.
• PDA is considered small at <1.5 mm,
moderate when it ranges between 1.5 and 3
mm, and large if the dimension exceeds 3
mm.
• When the pulmonary vascular resistance falls, the shunt
will be bidirectional with a flow above the baseline during
the systole and below the baseline during the
diastole Velocities are usually low and suggest equal
..
pressure in the pulmonary artery and the descending
aorta. Color Doppler shows alternating red and blue. Once
the pulmonary pressure drops further, the shunt will be left
to right and appears red on color Doppler. On pulsed or
continuous wave Doppler, maximal velocities during systole
and diastole can be measured,
• The pictures below contrast three preterm ductal ultrasound assessments. (A)
is closed with no ductal shunt apparent on colour Doppler. (B) is well
constricted at less than 1.0 mm diameter. Constriction has failed in (C) which is
over 2.0 mm in diameter and has a large left to right shunt draining blood from
the systemic circulation
Color Doppler imaging
in the PSAX showing a
high-velocity,
turbulent jet across a
small (PDA) into MPA
in a patient with
normal pulmonary
artery pressure. This
high-velocity Doppler
flow is indicative of a
large pressure gradient
between the aorta and
the pulmonary artery
Direction of shunt
Lt TO Rt
Parasternal
short-axis view
with color
Doppler showing
continuous flow
(red) from the
patent ductus
arteriosus (PDA)
into the main
pulmonary
artery
(MPA). Ao, aorta;
RV, right
ventricle.
• left to right and appears red on color Doppler.
A right-to-left shunt across the PDA is more difficult to see: color Doppler will show a
flow going from the pulmonary artery toward the descending aorta. Thus, both great
arteries and the DA will appear blue on color Doppler because the blood moves away
from the transducer. Placing pulsed wave Doppler over the DA shows a Doppler wave
below the baseline, usually during systole. Less often, a continuous flow during systole
and diastole can be observed, representing a pure right-to-left shun
the shunt may be bidirectional with a flow above the baseline during the systole and below the baseline
during the diastole
Velocities are usually low and suggest equal pressure in the pulmonary artery and the descending aorta.
Color Doppler shows alternating red and blue
Bidirectional Shunt Bidirectional Predominately L to R
• Color Doppler demonstrates a right-to-left shunt in systole (blue
color flow) and a left-to-right shunt in diastole (red color flow) . On
spectral Doppler, a negative deflection arising from the right-to-left
shunt signifies flow from the pulmonary artery to aorta in mid-to-
late systole, whereas a positive deflection arising from left-to-right
shunt represents flow from the aorta to pulmonary artery in late
systole with extension into late diastole . One should be cautious to
differentiate the negative deflection from a right-to-left ductal
shunt from a negative deflection caused by flow within the left
pulmonary artery. Spectral Doppler from the left pulmonary artery
begins at the onset of systole and peaks early, while the right-to-left
shunt across a PDA begins later in systole and peaks in mid to late
systole.
• In assessing peak Doppler velocities across a PDA to
obtain pressure gradients, it is important to remember
that for a left-to-right shunt the sample volume should
be positioned at the pulmonary end of the PDA.
Conversely, for a right-to-left shunt, the sample volume
should be positioned at the aortic end of the PDA.
Doppler estimation of pulmonary artery pressure using
the PDA velocity may not always be accurate and can
be limited by the position of the sample volume,
interference from signals from adjacent structures such
as the left pulmonary artery, and the unusual shape,
tortuosity, and size of the PDA.
 ECHO CRITRIA OF SIGNIFICANT
PDA

• LA to Aortic root dimension > 1.4

• A duct diameter > 1.4 mm/kg wt
• LVE
• Diastolic flow reversal
• B type naturtic peptide N terminal proBNP
elevated
 Is the PDA Hemodynamically Significant?

Enlargement of the left atrium with a left atrium to aortic valve (LA:Ao) ratio of ≥1.5,
absent or retrograde
diastolic flow in the
descending aorta
. In order to visualize this, the
transducer has to be placed in the
postductal descending aorta; the
pulsed wave Doppler is used.

Suprasternal view: (A) color Doppler of

the postductal descending aorta
with (B) normal anterograde
flow, (C) absent end diastolic flow,
and (D) pandiastolic retrograde flow.
Absent or retrograde
diastolic flow in the
mesenteric superior
artery and/or in the
anterior cerebral artery
Subcostal view of the
descending aorta
abdominalis with
visualization of the
truncus coeliacus and
superior mesenteric
artery, (A) on 2D, (B) on
color Doppler, (C) with
anterograde
flow, (D) with absent
end diastolic flow,
and (E) with retrograde
flow. TC, truncus
coeliacus; SMA,
superior mesenteric
artery.
Continuous-wave Doppler
tracing obtained from the
parasternal short-axis view in
a patient with a restrictive
small (PDA) and normal
pulmonary artery
pressure. There is continuous
left-to-right shunting across
the PDA in systole and
diastole, with a peak Doppler
velocity obtained in late
systole. The high-velocity of
the jet (4 m/s) across the PDA
indicates normal pulmonary
artery pressure.
Spectral Doppler of a large PDA with an unrestricted left-to-right shunt will have
a pulsatile flow pattern with the highest velocity at end-systole and a very low
peak velocity at end-diastole. This is because the relative pulmonary and aortic
pressures are equal at end-diastole in large PDAs
.
 Transductal flow on Doppler in short axis view or suprasternal
view: (A,B) unrestrictive pulsatile flow and (C) restrictive continuous flow

large hsPDA unrestrictive pulsatile transductal flow”

the maximal end-diastolic velocity is below 1 m/s
unrestrictive pulsatile transductal flow
If the PDA is moderately hemodynamically significant, the Doppler flow pattern has a maximal diastolic
velocity of less than 2 m/s “.”
restrictive continuous transductal flow Non-hemodynamically significant PDA has a high flow velocity
during systole and diastole with a maximal velocity above 2 m/s at the end of the diastole;

.
• it is also possible to measure the ratio
between the systolic and diastolic velocities. If
the peak diastolic velocity is more than 50% of
the peak systolic velocity, the flow pattern is
restrictive. If this ratio is less than 50%, the
flow pattern is pulsatile suggesting
hemodynamically significant PDA.
• Pulmonary blood flow and thus Qp:Qs can be
difficult to calculate accurately because of
differences in right/left PA blood flow caused
by the flow from the PDA.
Pulmonary Artery Flow (A) Normal flow in the left pulmonary
artery. In the absence of a significant duct there is usually no
flow in the diastolic phase. (B) Turbulent flow with a
significant end diastolic velocity, a sign of a large PDA
The presence of forward pulmonary flow in diastole in the
left pulmonary artery (LPA) has been described as a sign of
significant left to right shunt through the PDA. Using pulsed
wave Doppler in the LPA mean and end-diastolic velocity
can be measured and cut-off points of 0.42 and 0.20 m/s,
respectively, have been described as indicative of significant
ductal shunt
Exercise testing should be performed in
patients with PAH to
exclude desaturation of lower limbs.
Cardiac catheterization is required in the case of non-invasive signs
of PAP elevation (calculated systolic PAP >40 mmHg or indirect
signs when PAP cannot be estimated) to determine PVR.
Measurement
of pulmonary blood flow is challenging in this setting.
Measurement of oxygen saturation in both left and right PA is
mandatory.
Lateral left ventriculogram in a patient
with tetralogy of Fallot. This image
shows opacification of both the right
ventricle (RV) and the left ventricle
(LV). The pulmonary artery ( white
open arrow) is small and partly fills
from a long-segment, downward-
pointing patent ductus arteriosus (
solid black arrow). DAo = descending
aorta.
Presentations of adult patients with PDA include:
• Small duct with no LV volume overload (normal LV) and
normal
PAP (generally asymptomatic).
• Moderate PDA with predominant LV volume overload: large
LV
with normal or reduced function (may present with left heart
failure).
• Moderate PDA with predominant PAH: pressure-overloaded
RV
(may present with right heart failure).
• Large PDA: Eisenmenger physiology with differential
hypoxaemia and differential cyanosis (lower extremities
cyanotic, sometimes left arm too); .
Aneurysm formation of the duct is a very rare complication.
Natural history :

• Preterm: may close

• Full term: no spontaneous closure.
• Large PDA: recurrent pneumonia, CHF.
• Pulmonary hypertension , PVOD with Diff
Cyanosis
• Ductal calcification
• Ductal aneurysm
Significant complications of the PDA are well-described and
are largely due to significant shunting of oxygenated blood
from the aorta, through the PDA away from vital end organs to
the pulmonary artery resulting in a combination of systemic
hypoperfusion, pulmonary over circulation, and pulmonary
hypertension throughout the neonatal period. This results
directly or indirectly in end-organ damage manifested by a
higher incidence of
necrotizing enterocolitis (NEC),
bronchopulmonary dysplasia (BPD),
neonatal chronic lung disease (CLD),
retinopathy of prematurity (ROP),
intraventricular hemorrhage (IVH), and risk of mortality.
BPD The condition results from damage to the lungs,
usually caused by mechanical ventilation (respirator)
and long-term use of oxygen.
 1. Diagram showing impact of
significant left to right shunt across
ductal arteriosus (DA) leading to
pulmonary over-circulation and
systemic hypoperfusion. Spectrum
of clinical features in preterm
infants depends upon magnitude of
ductal shunt, which depends upon
DA size and balance between
systemic and pulmonary vascular
resistance, and inability of
immature myocardium to adpat to
circulatory disturbance. PDA,
patent ductus arteriosus; SVR,
systemic vascular resistance; PVR,
pulmonary vascular resistance.
BPD The condition results from damage to the lungs,
usually caused by mechanical ventilation (respirator)
and long-term use of oxygen.
 1. Diagram showing impact of
significant left to right shunt across
ductal arteriosus (DA) leading to
pulmonary over-circulation and
systemic hypoperfusion. Spectrum
of clinical features in preterm
infants depends upon magnitude of
ductal shunt, which depends upon
DA size and balance between
systemic and pulmonary vascular
resistance, and inability of
immature myocardium to adpat to
circulatory disturbance. PDA,
patent ductus arteriosus; SVR,
systemic vascular resistance; PVR,
pulmonary vascular resistance.