Patent ductus arteriosus physical examination

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Patent Ductus Arteriosus Microchapters


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Priyamvada Singh, M.B.B.S. [2], Cafer Zorkun, M.D., Ph.D. [3], Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Physical Examination

Vital Signs


Blood Pressure


Small PDA

Moderate PDA

  • Pulmonary to systemic flow ratio between 1.5 and 2.2 to 1
  • As a result of the runoff from the aorta, there are bounding pulses, and the pulse pressure widens.
  • A continuous thrill may be present in the first or second left intercostal space.
  • Displaced apex (indicating left ventricular overload)
  • Continuous murmur (may be grade 2,3 and occasionally 4)
  • The features of murmur are very similar to that seen with small ducts, however, they are louder than that associated with small PDA.

Large PDA

  • Pulmonary to systemic flow ratio >2.2 to 1
  • Dynamic left ventricular impulse
  • Left ventricular thrill
  • S1 is normal, S2 may be split with an accentuated pulmonary component. The continuous machinery murmurs with similar features as seen in moderate and small sized ducts but with louder intensity (4/6 grade) could be heard.
  • An apical diastolic rumble due to increased flow across the mitral valve may be present.
  • A third heart sound may be present.
  • If there is no reduction in the size of ductus, after age 2, progressive obstructive disease develops in these patients:
    • Signs of heart failure develop
    • The JVP may be elevated due to RV failure. Prominent "a wave" due to diminished RV compliance and RVH.
    • Signs of pulmonary hypertension associated with right-to-left shunt start appearing.
    • As the pulmonary hypertension increases, left to right flow across the duct decreases and there is no audible murmur. A murmur of pulmonic insufficiency may be noted (Graham-Steell murmur) due to dilation of the pulmonic valve ring resulting from pulmonary hypertension. Flow into a dilated pulmonary trunk causes a pulmonic ejection sound and pulmonic ejection murmur. The second pulmonic heart sound is closely split or not split.