Echocardiographic Evaluation of Patent Ductus Arteriosus Neonatologists Perspective - Dr. Ahmad Kautsar, Sp.A

Echocardiographic Evaluation of Patent
Ductus Arteriosus : Neonatologist’s

Perspective
Ahmad Kautsar
Department of Child Health
Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo Hospital
INDONESIAN PICU NICU UPDATE – 2020/2021

Disclosure
The goal of Neonatologist Performed Echocardiography (NPE) is to
assess functional measures in structurally normal hearts
A good collaboration with pediatric cardiologist should be done in

every echo particularly if there is any concern of anatomical defect
or doubtful results

OBJECTIVES
• The importance of echo as supporting tool to
establish diagnosis of PDA
• What is hsPDA (hemodynamically significant PDA)
• How to assess PDA (functional echo perspective)

Ductus Arteriosus
Vascular structure that connects

the main pulmonary artery
(MPA) (at its junction with the
left pulmonary artery [LPA]) with
the descending thoracic aorta at
the level of left subclavian artery
Courtesy of Satyan Lakshminrusimha

NATURAL HISTORY IN PRETERM
Median time for ductal closure :
• < 26 weeks 71 days
• 26 - 27+ 6 weeks 13 days
• 28 - 29 + 6 weeks 8 days
• ≥ 30 weeks 6 days
50%-70% of infants <28

weeks of gestation persist
in having a moderate-to-
large PDA shunt for weeks
after birth
Semberova J, et al.Pediatrics. 2017

Hemodynamically Significant PDA
Teixiera, et al. Acta Paed. 2006

PDA Consequences in Preterm
1-3 days 1-3 weeks 4 weeks

PIVH NEC Chronic
Pulmonary PVL Lung
Hemorrhage ROP Disease
Hypotension
Evans N. Semin Fetal Neonatal Med. 2015

Shepherd JL. Noori S. Congenit Heart Dis. 2018
Ruoss JL. Semin Fetal Neonatal Med. 2020

Clinical Clues
Increased Pulmonary blood flow Decreased systemic blood flow Increased volume load on heart
leading to CHF
Systolic murmur at thel left upper Systolic and diastolic hypotension Hyperactive cardiac impulse
sternal border
Accentuated pulmonary component of Increased pulse pressure (bounding Tachycardia
second heart sound peripheral pulses)
Loud third heart sound Palpable pulses at the palm of the Cardiomegaly
Mid-diastolic flow murmur at the apex hands
Tachypnea at baseline with episodes of Metabolic acidosis Hepatomegaly
apnea
Respiratory distress Left and/or right ventricular
enlargement
Need for assisted ventilation Rales in the lung fields
Poor weight gain
Difficulty with oral feeds
Naidu DP, et al. Assissted Neonatal Ventilation. 2020
Benitz,W. Pediatrics. 2016

Clinical Exam to Assess hsPDA
DOL 1 2 3 4 5 6 7
Murmur
Sensitivity (%) 0 30 44 67 78 80 100
Specificity (%) 0 90 91 84 91 86 78
Precordium
Sensitivity (%) 50 70 78 78 78 80 100
Specificity (%) 73 65 55 66 82 86 78
Pulses
Sensitivity (%) 10 40 78 78 78 100 100
Specificity (%) 70 73 61 66 76 83 76
Clinical Signs Poorly detect significant PDA in first 4 days of life

Diagnosis by echo precedes clinical exam by 2 days
Skelton et al. J Paed Child Health. 1994

Definition of hsPDA : The Evidence
Numerous criteria and various cut-off used
Most used criteria from systematic review :
• Clinical
• Murmur
• Hyperdynamic precordium
• Ultrasound
• Left atrium to aorta ratio (LA/Ao)
No universal definition of hsPDA in that era
Zonnenberg I, Waal K. Acta Pediatrica.2012

Typical PDA Echo Report
• PDA diameter
• LA/Ao
• LV systolic function
Preterm infants > 7 days, ductal
diameter (DD) had weak correlations
with other markers of shunt volume
Need Comprehensive Assessment
Martins FDF,et al. J Pediatr. 2018

Variability of Ductal Diameter in Relation to PDA
Morphology
When measuring 3D structure in 2D there is a

variation in measurement Courtesy of Patrick McNamara
Phillip R, et al. Catheter Cardiovascular Inter. 2015

PDA Morphology in Preterm Infants
• Children born prematurely have relatively

larger and longer PDA
• Type F = Hockey stick
• Long, mild curve at entrance to PA,
constricts minimally at PA end
Phillip R, et al. Catheter Cardiovascular Inter. 2015

Shunt Volume and Poiseuille’s Law
“At a constant driving pressure the
flow rate of liquid through a tube is
directly proportional to the fourth
power of the radius of the tube and
inversely proportional to the length
and viscosity of the tube”
PDA :
• Vessel Length
• Pressure gradient
Shunt volume is not just influenced by • Blood viscosity
diameter. Difference of pressure gradient • Diameter of vessel
between SVR and PVR is more important Smith A,et al. Semin Fetal Neonatal Med. 2018

What Determines Hemodynamic Significance
Evidence of increased
pulmonary blood flow
Evidence of hypoperfusion
Clinical clues + Ultrasound
PDA
How the heart handle the
shunt
Gestational age, chronologic

age, sepsis, antenatal steroid,
Antenatal/neonatal factors
growth restriction, asphyxia,
pre-eclampsia Sankar MN, et al. Congenit Heart Dis. 2019
Laere D, et al. Pediatr Res. 2018

NPE PDA Assessment Reference
Van Laere D, et al. Pediatr Res. 2018

Echocardiographic Indicators of HsPDA
Diameter
Shunt Size
Flow Pattern
LA: Ao
Volume Overload
LVO
Pulmonary overflow LPA
Desc Aorta Flow

Systemic
hypoperfusion Organ Flow
Sepherd JL, Noori S. Cong Heart Dis. 2018

Comprehensive PDA Evaluation – Shunt Volume
Ductal Evaluation Measurement View
PDA – size, flow direction and PDA Characteristics
quantity
Diameter (mm) High Parasternal ductal view
Pulmonary Overcirculation Flow direction PWD at ductal view
LA:Ao, E/A ratio, IVRT Pulmonary overcirculation
ASD size and flow LVO (ml/kg/min) 5 chamber and PLAX view
LPA diastolic flow Left heart volume loading
Pulmonary Venous Vmax La:Ao, PLAX
Systemic Hypoperfusion LPA diastolic velocity (m/s) Ductal view

Indices of systemic shunt effect
LVO or LVO:SVC flow
Desc Aorta Doppler Aorta descendant Suprasternal aortic
End-organ Doppler flow Celiac trunk/SMA Subcostal sagittal
(MCA, celiac, renal) Anterior cerebral artery HUS sagittal

Giesinger RE, Klein JM, Mcnamara PJ. Protocol for echocardiographic screening. for extremely
low birth weight infants in the transitional period
Ultrasound Window
El-Khuffash A. Neonatologist performed echocardiography teaching manual. 2019

Suprasternal View
Evans N, Malcom G. Practical cardiac ultrasound for neonatologist part 2

El-khuffash A. NPE Teaching Manual. 2019
Suryawanshi P, et al. Point of care neonatal ultrasound neonatal cardiology. 2016

PDA Visualization (1)
Suprasternal Ductal View


PDA Visualization (2)
High Left Parasternal
The probe is positioned in a complete sagittal fashion along the left Evans N, Malcom G. Practical cardiac ultrasound for neonatologist part 2
border of the sternum, with the marker pointing towards the head. El-khuffash A. NPE Teaching Manual. 2019

PDA View
The PDA diameter should be obtained in 2D from

the at the narrowest point usually at pulmonary end

How big is big?
Ductal Characteristics
Small Moderate Large
Absolute diameter <1.5 1.5-2.0 ≥ 2 mm
(mm)
PDA to LPA ratio <0.5 0.5-1 ≥1

PDA diameter to ≥ 1.4
body weight mm/kg
Van Laere D, et al Pediatr Res. 2018

de Boode WP, et al. Semin Fetal Neonatal Med. 2018
Flow Pattern at PDA
L
Pulsatile or Closing or
Pure R to L Bidirectional nonrestrictive restrictive
with RtoL < 30% Vsys: Vdia ≥ 2 Vsys: Vdia < 2
Evans N. Practical cardiac ultrasound part 2
de Boode WP, et al. 2018. Semin Fetal Neonatal Med
El-Khuffash A. Hemodynamic and cardiology Neonatology questions and controversies. 2019

Flow Pattern at PDA (2)
L to R flow R to L flow
Harm Benefit
Pulsatile flow pattern : ratio between peak systolic and end-diastolic velocity is >2 Singh Y, et al. Front Pediatr. 2020
Condo M, et al. Arch Dis Child Fetal Neonatal Ed. 2012
Restrictive flow pattern : ratio between peak systolic and end-diastolic velocity of <2 Smith A, et al. Arch Dis Child Fetal Neonatal Ed. 2018
El-Khuffash A. NPE teaching manual. 2019
Suryawanshi P, et al. Point of care neonatal ultrasound neonatal
cardiology. 2016
Left Pulmonary Artery Velocity
Mild Moderate Severe

End diastolic LPA flow <0.2 0.2-0.5 >0.5
velocity (m/s)
Evans N. Practical cardiac ultrasound
Apical 4 chamber
Evans N. Practical Cardiac Ultrasound

El-Khuffash A, Mcnmara PJ. Tnecho.com

Left Heart Dilation
Qualitative assessment
Volume overload may lead dilatation of left

atrium, ventricle and pulmonary veins
El-khuffash A, Mcnamara P. TnEcho.com
Apical 5 chamber
This view is used to measure Left Ventricular output
Siassi B, Noori S. Practical neonatal echocardiography. 2019

De Boode WP, et al. 2018. Semin Fetal Neonatal Med
El-Khuffash A, Mcnamara P. Tnecho.com
Evans N. Practical cardiac ultrasound
Left Ventricular Output

Increase pulmonary venous return will elevate LVO LVO <200 200-300 >300
LVO measurement using following formula : (ml/kg/min
De Boode WP, et al. Semin Fetal Neonatal Med. 2018
Parasternal Long Axis View
This view is used to measure aortic

diameter in LVO calculation

Left Atrium to Aorta Ratio
• Increased pulmonary venous return

→ left atrial preload → left atrial
dilation
• The degree of LA dilation is indexed
to aortic root diameter
• High inter and intraindividual
variability
• May potentially influenced by
Mild Moderate Severe interatrial LtoR shunt
LA/Ao ratio <1.5 1.5-2 >2 Siassi B, Noori S. Practical neonatal echocardiography. 2019

Subcostal Long Axis View
When the left atrium becomes more dilated, it may stretch the PFO
El Khuffash A, Mcnamara P. Tnecho.com

Systemic Steal-Descending Aorta

Descending aorta Forward Absent Reversed De Boode WP, et al. Semin Fetal Neonatal Med. 2018

Subcostal View
Abdominal Aorta Sagital View
El Khuffash A, Mcnamara P. Tnecho.com


Abdominal Aorta and Cerebral Artery Flow Pattern

Middle cerebral artery Forward Forward Absent De Boode WP, et al. Semin Fetal Neonatal Med. 2018
Celiac artery Forward Absent Reversed Suryawanshi P, et al. Point of care neonatal ultrasound neonatal
cardiology. 2016
Trans-mitral Flow E/A ratio
Immature babies have “stiffer” heart

which make active filling more
pronounced (inherent diastolic
dysfunction)

Mitral E/A <1 1 >1
ratio
Two-phase of ventricular filling:
• E (early), passive diastolic phase
• A (atrial), active contraction phase Siassi B, Noori S.. Practical neonatal echocardiography. 2019
IVRT (Isovolumetric Relaxation Time)
• Time between closure of the aortic valve

and opening of the mitral valve
• Prolonged in premature neonate
• Decrease in neonates with a significant
PDA due to early pressure related valve
closure/opening
LV-IVRT <40 30-40 <30
(ms)
Pulmonary Vein Doppler
A systolic ‘S” wave is followed by a diastolic “d”

wave due to opening of the mitral valve and
reduction in left atrial pressure
Higher pulmonary vein velocity in neonates with hsPDA

Pulmonary <0.3 0.3-0.5 >0.5
vein d wave
velocity
(m/s)

PDA Scoring (1) Iowa’s Scoring System
• PDA diameter (mm)

• Maximum velocity across PDA shunt Start treatment :
(m/s) 1. Ductal diameter 1.5 mm, AND
• LVO (ml/kg/min) 2. Predominant (>90%) LtoR transductal
• LV diastolic function measured as an a’ flow, AND
wave using TDI (cm/s) 3. PDA shunt volume score ≥ 6
El-Khuffash A, et al. J Pediatr. 2015

Giesinger RE, Klein JM, Mcnamara PJ. Protocol of echocardiography screening for extremely low birth weight infant in transitional period
PDA scoring (2)
This scoring facilitate triaging and

case prioritization for PDA ligation
Since its introduction, the number

of PDA reduced by over 50%
Mcnamara P, Sehgal A. 2007. Arch Dis Child

What is essential?
Measurement View
PDA Characteristics
Diameter (mm) High Parasternal ductal view • PDA characteristics
Flow direction PWD at ductal view • Indices of pulmonary
Pulmonary overcirculation
LVO (ml/kg/min) 5 chamber and PLAX view
overcirculation :
Left heart volume loading • LVO + ( one-parameter
La:Ao, LVEDD (mm) PLAX left-sided volume loading
LPA diastolic velocity (m/s) Ductal view
Indices of systemic shunt effect
OR left heart-pressure
loading)
Aorta descendant
Celiac trunk/SMA
Suprasternal aortic
Subcostal sagittal
• Systemic shunt effect
Anterior cerebral artery HUS sagittal

Echo Parameter Wrap Up
De Boode PW, et al. Semin Fetal Neonatal Med. 2018

Conclusion
• In extremely preterm infants, PDA screening should be done
early
• Clinical clues may not be apparent in the first week of life
• Ductal diameter is not the only parameter to define hsPDA
• Establishing protocol for PDA screen is necessary

Any Question ?

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Echocardiographic Evaluation of Patent

Ductus Arteriosus : Neonatologist’s

INDONESIAN PICU NICU UPDATE – 2020/2021

A good collaboration with pediatric cardiologist should be done in

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Vascular structure that connects

Courtesy of Satyan Lakshminrusimha

INDONESIAN PICU NICU UPDATE – 2020/2021

50%-70% of infants <28

INDONESIAN PICU NICU UPDATE – 2020/2021

Teixiera, et al. Acta Paed. 2006

INDONESIAN PICU NICU UPDATE – 2020/2021

1-3 days 1-3 weeks 4 weeks

Evans N. Semin Fetal Neonatal Med. 2015

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Clinical Signs Poorly detect significant PDA in first 4 days of life

INDONESIAN PICU NICU UPDATE – 2020/2021

No universal definition of hsPDA in that era

Zonnenberg I, Waal K. Acta Pediatrica.2012

INDONESIAN PICU NICU UPDATE – 2020/2021

Need Comprehensive Assessment

Martins FDF,et al. J Pediatr. 2018

INDONESIAN PICU NICU UPDATE – 2020/2021

When measuring 3D structure in 2D there is a

INDONESIAN PICU NICU UPDATE – 2020/2021

• Children born prematurely have relatively

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Gestational age, chronologic

INDONESIAN PICU NICU UPDATE – 2020/2021

Van Laere D, et al. Pediatr Res. 2018

INDONESIAN PICU NICU UPDATE – 2020/2021

Pulmonary overflow LPA

Desc Aorta Flow

Sepherd JL, Noori S. Cong Heart Dis. 2018

INDONESIAN PICU NICU UPDATE – 2020/2021

Systemic Hypoperfusion LPA diastolic velocity (m/s) Ductal view

(MCA, celiac, renal) Anterior cerebral artery HUS sagittal

El-Khuffash A. Neonatologist performed echocardiography teaching manual. 2019

INDONESIAN PICU NICU UPDATE – 2020/2021

Evans N, Malcom G. Practical cardiac ultrasound for neonatologist part 2

INDONESIAN PICU NICU UPDATE – 2020/2021

Evans N, Malcom G. Practical cardiac ultrasound for neonatologist part 2

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

The PDA diameter should be obtained in 2D from

INDONESIAN PICU NICU UPDATE – 2020/2021

PDA to LPA ratio <0.5 0.5-1 ≥1

Van Laere D, et al Pediatr Res. 2018

INDONESIAN PICU NICU UPDATE – 2020/2021

Mild Moderate Severe

Evans N. Practical Cardiac Ultrasound

INDONESIAN PICU NICU UPDATE – 2020/2021

Volume overload may lead dilatation of left

Siassi B, Noori S. Practical neonatal echocardiography. 2019

Mild Moderate Severe

This view is used to measure aortic

INDONESIAN PICU NICU UPDATE – 2020/2021

• Increased pulmonary venous return

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021