A Case of Patent Ductus Arteriosus with Congestive Heart Failure in a 80-Year-Old Man
A 80-year-old man visited the emergency room (ER) due to aggravation of dyspnea for a week. He had diagnosed with hypertension nine years ago and blood pressure had been controlled well. He complained of dyspnea of New York Heart Association (NYHA) IV classification at the time of ER visitation. Though he had a smoking history of 50 pack/years, his pulmonary function test which performed three weeks previously for an orthopedics operation showed normal range of lung function without any evidence of obstructive lung disease. He denied any history of cardiorespiratory problems, but stated that he had suffered dyspnea on exertion for a decade without any functional limitations in his routine activities.\nInitial blood pressure was 100/60 mm Hg, heart rate was 90/minute, respiratory rate was 22/minute and body temperature was 37.1℃. During checking of review of systems, he noted dyspnea and sputum but denied fever, cough, chest pain, and nocturnal dyspnea. Upon physical examination, grade II/VI systolic murmur best heard at the left upper sternal border in second intercostal space and the second heart sound was physiologically split, suggesting an absence of significant pulmonary hypertension. Pulses seemed normal, with no evidence of pulse deficit. No diastolic murmurs were heard. Rales and wheezing sounds could be heard in both lung fields but pretibial pitting edema wasn't obvious. Pro-B-type natriuretic peptide was 5603 pg/mL.\nChest X-ray showed cardiomegaly {cardiothoracic (CT) ratio=0.59} and both pulmonary edema without pleural effusion (). As a part of his evaluation, a transthoracic echocardiogram (TTE) was performed and found visualized retrograde jet flow at main pulmonary artery, indicating presence of PDA. TTE also showed severe diastolic dysfunction and moderate pulmonary hypertension (right ventricular systolic pressure=57.3 mm Hg) but preserved left ventricular function (ejection fraction of left ventricle=52.6%). End-diastolic volume in M-mode with TTE was 59.2 mm. CT scan of aorta also suggested PDA ().\nCardiac catheterization and aortic angiogram were done to confirm and check accurately the state of the PDA, proving the presence of a connection between left pulmonary artery and distal aortic arch sized up to 3.1 mm (). Cardiac catheterization implied PDA, showing a step up from right pulmonary artery to right ventricle (78.7% to 72.9%). Measured Qp/Qs through oxygen saturation was 1.504.\nThe option of a transcatheter occlusion of PDA had been suggested to the patient to relieve left to right shunt and improve heart failure. Occlusion of PDA with an Amplatzer duct occlusion device was done and no shunt flow was seen in post-procedure aortogram (). After the procedure, CT ratio (0.47) was decreased in the chest X-ray () and a follow-up echocardiogram showed no visualized jet flow at the main pulmonary artery indicating successful closure of the PDA. Three days after the closure, a follow-up echocardiogram was done. The end-diastolic dimension was 55.0 mm in M-mode while the right ventricular systolic pressure was 46.0 mm Hg, indicating improvement of heart failure and pulmonary hypertension after the procedure. The patient continues to do well and has no symptom of heart failure or functional limitations without medication including diuretics.