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Murmur of Persistent Ductus Arteriosus in Premature Infants K Arch Dis Child: first published as 10.1136/adc.47.255.725 on 1 October 1972. Downloaded from Archives of Disease in Childhood, 1972, 47, 725. Murmur of Persistent Ductus Arteriosus in Premature Infants K. A. HALLIDIE-SMITH From the Department of Medicine (Clinical Cardiology), Royal Postgraduate Medical School, London Hallidie-Smith, K. A. (1972). Archives of Disease in Childhood, 47, 725. Murmur of persistent ductus arteriosus in premature infants. A long- term survey of the repeated clinical examination of premature newborn infants is reported. There were 52 infants in whom there was well-documented clinical and phono- cardiographic evidence of delayed closure of the ductus arteriosus. The ductus is believed to have closed spontaneously in 47 of them before 6 months of age and to have persisted in 5. Nine infants developed heart failure and all were treated medically. 8 recovered and the ductus subsequently closed spontaneously. The ninth (birthweight 1132 g) died in heart failure with a widely patent ductus. The characteristics of the various murmurs ascribed to the persistent ductus arteriosus are described and discussed. Extreme lability of the factors determining flow through the duct is suggested by the rapidly changing characteristics of the murmurs recorded. copyright. The characteristic features of a persistent reviews a 15-year experience of the clinical cardio- ductus arteriosus presenting in children and adults vascular examination of premature infants, des- are well known and accepted as diagnostic cribing the cardiac murmurs which were thought to proof without further confirmation. The charac- be diagnostic of a persistent ductus arteriosus, teristic continuous murmur has been reported as their possible haemodynamic significance, and occurring transiently in normal full-term infants their differential diagnosis. during the first few days of life (Burnard, 1958; http://adc.bmj.com/ Braudo and Rowe, 1961), and in premature infants Material and Methods in the first few weeks of life (Powell, 1963; Auld, The material was provided by over 700 newborn 1966; Danilowicz, Rudolph, and Hoffman, 1966), infants born over the past 15 years and admitted to and is thought to be evidence of functional patency special care neonatal units. These infants all weighed of the ductus before its spontaneous closure. less than 2 5 kg at birth and the majority were of less However, it is well known that a widely persistent than 37 weeks' gestation. They were examined in an ductus may be silent or a systolic murmur only attempt to compare the clinical cardiovascular findings may be recorded in young infants with persistent of premature infants with those already described in on September 29, 2021 by guest. Protected ductus proven by cardiac catheterization (Rudolph term infants (Hallidie-Smith, 1960). 50 of these et al., 1958). Rowe and Lowe (1964) described infants were examined within the first 24 hours of birth, three types of murmurs heard in infants with then daily until their discharge or for a maximum of 6 proven ducts and felt that the two 'atypical' ones weeks and at subsequent follow-up visits until 1 year of age. In one year the majority of 229 premature were in fact diagnostically characteristic. and sick infants admitted to a neonatal special care unit Delayed spontaneous closure of the ductus in a were examined at least twice weekly. The other infants small number of premature infants has been were examined on one or more occasions or were then reported (Auld, 1966; Danilowicz et al., 1966). specially referred by the paediatric house physician A recent report has confirmed this and drawn on account of a cardiac murmur. Once a cardiac attention to some of the possible determining murmur was heard, the infant was followed up until factors (Girling and Hallidie-Smith, 1971), and to either it had disappeared or had been adequately the factors which may influence this. This paper explained. When possible any murmur heard clinically was documented by a phonocardiographic record. Received 25 February 1972. Electrocardiograms and chest x-rays were taken on the 725 Arch Dis Child: first published as 10.1136/adc.47.255.725 on 1 October 1972. Downloaded from 726 K. A. Hallidie-Smith PATIENT NUMBER 1_ 2 _ 3 *4 ------71 *5 6 8 - -=-==20 wk. 9 10 LIa _ P DA 11 12 13 * 14 rPDA_nnA Died10n.'V/52. o- 15 16 17 PDA 18s l Died 4112 19 20 21 E M, 22 I 23 * 24 0 ---4~~o23 wk 25 * 26 27 _3 28 Died /12 29 E _11.119,911MIA _-.16 wk 30 ~- =&16 wk. 31 32 -V 33 18wk. 34 * 35 36 37 PDA copyright. 38 39 * 40 wler, 41 r- 42 1- 43 44 45 SHIA 46 r :1 47 48 * 49 I _-.20 wk 50 http://adc.bmj.com/ 51 52 Immummom= I, , 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 AGE IN WEEKS HEART MURMURS on September 29, 2021 by guest. Protected = Ejection systolic - Systolic, continuing * Heart tailure into early diastole. Pan systolic Continuous FIG. 1.-Dturation and characteristics of murmurs ascribed to a persistent ductus arteriosus in 52 premature infants. majority of infants in whom a ductus murmur was paratively common within the first week of life. suspected and in all infants in whom such a murmur 52 infants, examined at birth and subsequently persisted for more than a week. at frequent intervals, presented with murmurs Results persisting to a persistent ductus arteriosus. The auscultatory Transient continuous murmurs and other mur- findings, amplified by phonocardiographic records murs attributed to a ductus arteriosus were com- in all cases, are shown in Fig. 1. Arch Dis Child: first published as 10.1136/adc.47.255.725 on 1 October 1972. Downloaded from Murmur of Persistent Ductus Arteriosis in Premature Infants 727 copyright. FIG. 2.-Typical ductus murmurs in a premature infant (No. 5). (A) Ejection systolic murmur (aged 4 days); (B) ejection systolic murmur and delayed diastolic murmur, best heard at apex (aged 4k weeks); (C) continuous murmur http://adc.bmj.com/ (aged 3 weeks); (D) systolic murmur continuous into early diastole (aged 5 weeks); (E) pansystolic murmur (aged 8 days); and (F) ejection systolic murmur (aged 9 weeks). P. Area, pulmonary area; HF, high frequency; LLSE, lower left sternal edge; MF, medium frequency. Four types of murmur were most commonly 2 A-F), but also from hour to hour (Fig. 3a, b) heard, characteristically maximal in the pulmonary and sometimes even from one cardiac cycle to the area. First, a high pitched ejection systolic mur- mur, sometimes maximal lower down the left on September 29, 2021 by guest. Protected sternal edge; second, a long crescendo systolic murmur; third, a murmur continuous through systole into early diastole; and fourth, a continuous murmur. When there was evidence of an appre- ciable left-to-right shunt as judged by a hyper- dynamic cardiac impulse and jerky arterial pulses, a low pitched apical diastolic murmur and a low pitched ejection systolic murmur, maximal at the lower left sternal edge and transmitted to the aortic area, were heard. This latter murmur was some- times heard in the absence of other murmurs. FIG. 3.-Phonocardiograms taken at an interval of 45 The murmurs heard varied in their characteristics, minutes in a 2-week-old infant (a) pansystolic murmur; not only from week to week or day to day (Fig. (b) continuous murmur. Arch Dis Child: first published as 10.1136/adc.47.255.725 on 1 October 1972. Downloaded from 728 K. A. Hallidie-Smith next. The changing character of the murmur was two months later and a widely patent ductus was particularly noticeable during the first week of found at necropsy but no other intracardiac life, when there might be brief periods when no defect. murmur was heard. Clearly, these rapid changes could not be documented exactly in the analysis Unrelated deaths. Two infants died after of these murmurs (Fig. 1) and only the murmur their duct was considered to have closed spon- most commonly heard over a period of days or taneously. Infant 18 died suddenly at home at weeks has been given. It will be seen that a 4 months of age and no cause of death was found continuous murmur was the first 'established' at necropsy; the duct was closed. Various charac- murmur in only 2 infants, though it was documented teristic duct murmurs had been heard from the more than transiently in 22 other infants. The first week until the eighth week and she had had a ejection systolic murmur was the first murmur brief episode of heart failure at 1 month, respond- heard in 15 of the babies, and such a murmur ing to medical treatment. Another infant (No. 28) invariably directly preceded the final disappearance died of pneumonia at 3 months. At necropsy the of all murmurs. Any of the four main types of duct was closed and there was no intracardiac murmur described might be heard at a time when abnormality. A continuous murmur had been an appreciable left-to-right shunt was detected in first heard at 4 weeks, followed by an ejection combination with an apical diastolic murmur and/or systolic murmur persisting for a further 10 days. an aortic ejection systolic murmur. Electrocardiograms and chest x-rays. Cardiac failure. Cardiac failure developed in Electrocardiograms and chest x-rays were carried 12 infants included in the complete survey, 9 of out on the 52 patients and a proportion of the other whom were included in the 52 fully documented infants surveyed. The electrocardiogram was infants (Nos. 4, 5, 14, 18, 24, 26, 35, 40, and 49). normal in all those infants in whom the ductus closed The heart failure was treated medically and 11 of spontaneously.
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