Infantile aneurysm of the ductus arteriosus. Diagnosis, incidence, pathogenesis, and prognosis

Ductus arteriosus and fetal echocardiography: Implications for practice

The ductus arteriosus (DA) is a crucial part of the fetal circulation, both in the normal fetus and in critical congenital heart disease (CHD). It allows shunting between the pulmonary and systemic circulations. In physiological prenatal conditions, the DA lets the majority of right ventricular output bypass the fluid-filled, high-resistance lungs. The DA can cause hemodynamic compromise in the fetus and neonate when constricted or absent (in isolation or in patients with CHD) and may lead to pre- or postnatal sequelae within other systems when forming part of a vascular ring. In CHD, the DA can be interrogated by fetal echocardiography to infer information regarding severity of pulmonary outflow tract obstruction, adequacy of the sub-pulmonary ventricle to supply pulmonary blood flow, and to predict the likelihood of atrial septum restriction in transposition of the great arteries. A good understanding of the DA is crucial for fetal cardiologists.

A case of isolated congenital ductus arteriosus aneurysm detected by fetal echocardiography at 38 weeks of gestation

A 30 year-old pregnant woman (G1P0) was diagnosed with fetal ductus arteriosus aneurysm (DAA) at 38 weeks of gestation. The three-vessel view of the heart and the sagittal view of the ductal arch showed a 12-mm fusiform dilatation of the ductus arteriosus. Turbulent flow was detected in it by color Doppler. DAA was confirmed by postnatal echocardiography within 24 hours after birth and it spontaneously closed in the neonatal period. Congenital DAA, usually developed in the third trimester, is potentially fatal due to the possible complications such as spontaneous rupture, dissection, and thromboembolism.

Isolated ductus arteriosus aneurysm in the fetus and infant: a multi-institutional experience

OBJECTIVES

The purpose of this study was to describe the clinical characteristics and outcome and to elucidate the pathogenesis of ductus arteriosus aneurysm (DAA).

BACKGROUND

Ductus arteriosus aneurysm is a rare lesion that can be associated with severe complications including thromboembolism, rupture and death.

METHOD

We reviewed the clinical records, diagnostic imaging studies and available histology of 24 cases of DAA, diagnosed postnatally (PD) in 15 and antenatally (AD) in 9 encountered in five institutions.

RESULTS

Of PD cases, 13 presented at <2 months, and all AD cases were detected incidentally after 33 weeks of gestation during a late trimester fetal ultrasound study. Of the 24, only 4 had DAA-related symptoms and 6 had associated syndromes: Marfan, Smith-Lemli-Opitz, trisomies 21 and 13 and one possible Ehlers-Danlos. Three had complications related to the DAA: thrombus extension into the pulmonary artery, spontaneous rupture, and asymptomatic cerebral infarction. Six underwent uncomplicated DAA resection for ductal patency, DAA size or extension of thrombus. In the four examined, there was histologic evidence of reduced intimal cushions in two and abnormal elastin expression in two. Five of the 24 died, with only one death due to DAA. Of 19 survivors, all but one remain clinically asymptomatic at a median follow-up of 35 months; however, two have developed other cardiac lesions that suggest Marfan syndrome. A review of 200 consecutive third trimester fetal ultrasounds suggests an incidence of DAA of 1.5%.

CONCLUSIONS

Ductus arteriosus aneurysm likely develops in the third trimester perhaps due to abnormal intimal cushion formation or elastin expression. Although it can be associated with syndromes and severe complications, many affected infants have a benign course. Given the potential for development of other cardiac lesions associated with connective tissue disease, follow-up is warranted.

Spontaneous closure and thrombosis of a ductal aneurysm in a neonate

The natural history of a ductal aneurysm detected prenatally is presented. Neurologic concerns in the neonate and absence of cardio-respiratory compromise permitted serial echo demonstration of constriction, thickening and subsequent closure with formation of thrombus in the aneurysm.

Aneurysm of the ductus arteriosus

Two neonates with aneurysms of the ductus arteriosus were seen. One suffered a fatal spontaneous rupture of the aneurysm, and the second (in which it was an incidental finding) the aneurysm was monitored by echocardiography, and seemed to resolve spontaneously.

A ruptured large aneurysm of the ductus arteriosus

A 60 year old man was admitted with acute back pain followed by hoarseness. An aneurysm of the ductus arteriosus Botalli was diagnosed and an operation was recommended because of the high risk of complications such as rupture, embolism, or infection. The patient and his family refused surgery, however. The patient died suddenly of a rupture of the aneurysm a year later; necropsy confirmed the diagnosis. Several diagnostic methods were used and enhanced computed tomography gave the best representation of the aneurysm as it was seen at necropsy. This case indicates that enhanced computed tomography is probably the most useful investigation in patients with this type of aneurysm and it confirms the importance of an aneurysmectomy.

Ductus arteriosus aneurysm presenting as pulmonary artery obstruction: diagnosis and management

The occurrence of pulmonary artery obstruction in an 8 day old infant as a complication of an aneurysm of a nonpatent ductus arteriosus is reported, together with the echocardiographic and angiographic findings. To relieve the obstruction, the aneurysm and an intrapulmonary thrombus were successfully removed with the use of cardiopulmonary bypass when the infant was 3 months old.

Aneurysm of the nonpatent ductus arteriosus in the newborn

Aneurysm of the nonpatent ductus arteriosus in the newborn is a rare, but potentially fatal condition. Of reported ductal aneurysm up to 1969, diagnosis was made at autopsy only. We report here to our knowledge for the first time on a two week old infant with correct preoperative angiographic diagnosis followed by a successful surgical cure.