3/29/2017 PatentDuctusArteriosus(PDA):Background,Anatomy,Pathophysiology

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PatentDuctusArteriosus(PDA)
Updated:Dec26,2016
Author:LukeKKim,MDChiefEditor:StuartBerger,MDmore...

OVERVIEW

Background
Patentductusarteriosus(PDA),inwhichthereisapersistentcommunicationbetweenthe
descendingthoracicaortaandthepulmonaryarterythatresultsfromfailureofnormalphysiologic
closureofthefetalductus(seeimagebelow),isoneofthemorecommoncongenitalheartdefects.

Schematicdiagramofalefttorightshuntofbloodflowfromthedescendingaortaviathepatentductus
arteriosus(PDA)tothemainpulmonaryartery.
ViewMediaGallery

Thepatientpresentationofpatentductusarteriosus(PDA)varieswidely.Althoughfrequently
diagnosedininfants,thediscoveryofthisconditionmaybedelayeduntilchildhoodoreven
adulthood.Inisolatedpatentductusarteriosus(PDA),signsandsymptomsareconsistentwithleft
torightshunting.Theshuntvolumeisdeterminedbythesizeoftheopencommunicationandthe
pulmonaryvascularresistance(PVR).

Patentductusarteriosus(PDA)mayalsoexistwithothercardiacanomalies,whichmustbe
consideredatthetimeofdiagnosis.Inmanycases,thediagnosisandtreatmentofapatentductus
arteriosus(PDA)iscriticalforsurvivalinneonateswithsevereobstructivelesionstoeithertheright
orleftsideoftheheart.

Historicalinformation
Galeninitiallydescribedtheductusarteriosusintheearlyfirstcentury.Harveyundertookfurther
physiologicstudyinfetalcirculation.However,itwasnotuntil1888thatMunroconductedthe
dissectionandligationoftheductusarteriosusinaninfantcadaver,anditwouldbeanother50
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yearsbeforeRobertE.Grosssuccessfullyligatedapatentductusarteriosus(PDA)ina7yearold
child.[1]Thiswasalandmarkeventinthehistoryofsurgeryandheraldedthetruebeginningofthe
fieldofcongenitalheartsurgery.Catheterbasedclosureofthestructurewasfirstperformedin
1971.

SeealsoPediatricPatentDuctusArteriosusSurgeryandPediatricEisenmengerSyndromeand
PulmonaryHypertension.

Anatomy
Duringfetallife,theductusarteriosusisanormalstructurethatallowsmostofthebloodleaving
therightventricletobypassthepulmonarycirculationandpassintothedescendingaorta.
Typically,onlyabout10%oftherightventricularoutputpassesthroughthepulmonaryvascular
bed.

Theductusarteriosusisaremnantofthedistalsixthaorticarchandconnectsthepulmonaryartery
atthejunctionofthemainpulmonaryarteryandtheoriginoftheleftpulmonaryarterytothe
proximaldescendingaortajustaftertheoriginoftheleftsubclavianartery.Itpassesfromthe
anterioraspectofthepulmonaryarterytotheposterioraspectoftheaorta.Typically,theductus
hasaconicalshapewithalargeaorticendtaperingintothesmallpulmonaryconnection.The
ductusmaytakemanyshapesandforms,fromshortandtubulartolongandtortuous.

Ananatomicmarkeroftheductusistherecurrentlaryngealnerve,whichnervetypicallyarises
fromthevagusnervejustanteriorandcaudaltotheductusandloopsposteriorlyaroundthe
ductustoascendbehindtheaortaenroutetothelarynx.Itisthemostcommonlyinjuredanatomic
structureinductalligation.Otherlesscommonlyinjuredstructuresincludethephrenicnerveand
thethoracicduct.

Mosttypically,thepatentductusarteriosus(PDA)isaleftaorticremnanthowever,itcanberight
sidedoronboththeleftsideandrightside.Althoughaleftductusarteriosusisanormalstructure
duringnormalfetaldevelopment,thepresenceofarightductusarteriosusisusuallyassociated
withothercongenitalabnormalitiesofthecardiovascularsystem,mosttypicallyinvolvingtheaortic
archorconotruncaldevelopment.

TheKrichenkoclassificationofPDAisbasedonangiographyandincludestypeA(conical),typeB
(window),typeC(tubular),typeD(complex),andtypeE(elongated)PDA.

Inthepresenceofcomplexcongenitalheartdefects,theusualanatomyoftheductusmaynotbe
present.Anatomicabnormalitiescanvarywidelyandarecommoninconjunctionwithcomplex
aorticarchanomalies.Structuresthathavebeenmistakenforthepatentductusarteriosus(PDA)
insurgicalproceduresincludetheaorta,thepulmonaryartery,andthecarotidartery.

Pathophysiology
Theductusarteriosusisnormallypatentduringfetallifeitisanimportantstructureinfetal
developmentasitcontributestotheflowofbloodtotherestofthefetalorgansandstructure.From
the6thweekoffetallifeonwards,theductusisresponsibleformostoftherightventricularoutflow,
anditcontributesto60%ofthetotalcardiacoutputthroughoutthefetallife.Onlyabout510%of
itsoutflowpassesthroughthelungs.

ThispatencyispromotedbycontinualproductionofprostaglandinE2(PGE2)bytheductus.
Closureoftheductusbeforebirthmayleadtorightheartfailure.Prostaglandinantagonism,such
asmaternaluseofnonsteroidalantiinflammatorymedications(NSAIDs),cancausefetalclosure
oftheductusarteriosus.

Thus,apatentductusarteriosus(PDA)producesalefttorightshunt.Inotherwords,itallows
bloodtogofromthesystemiccirculationtothepulmonarycirculation.Therefore,pulmonaryblood
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flowisexcessive(seetheimagebelow).Pulmonaryengorgementresultswithdecreased
pulmonarycompliance.Thereactionofthepulmonaryvasculaturetotheincreasedbloodflowis
unpredictable.

Schematicdiagramofalefttorightshuntofbloodflowfromthedescendingaortaviathepatentductus
arteriosus(PDA)tothemainpulmonaryartery.
ViewMediaGallery

Themagnitudeoftheexcesspulmonarybloodflowdependsonrelativelyfewfactors.Thelarger
theinternaldiameterofthemostnarrowportionoftheductusarteriosus,thelargerthelefttoright
shunt.Iftheductusarteriosusisrestrictive,thenthelengthofthenarrowedareaalsoaffectsthe
magnitudeoftheshunt.Alongerductusisassociatedwithasmallershunt.Finally,themagnitude
ofthelefttorightshuntispartiallycontrolledbytherelationshipofthepulmonaryvascular
resistance(PVR)tothesystemicvascularresistance(SVR).

IftheSVRishighand/orthePVRislow,theflowthroughtheductusarteriosusispotentiallylarge.
Beginningattheductusarteriosus,thecourseofbloodflow(throughsystoleanddiastole)ina
typicalpatentductusarteriosus(PDA)withpulmonaryovercirculationisasfollows:patentductus
arteriosus(PDA),pulmonaryarteries,pulmonarycapillaries,pulmonaryveins,leftatrium,left
ventricle,aorta,patentductusarteriosus(PDA).Therefore,alargelefttorightshuntthrougha
patentductusarteriosus(PDA)resultsinleftatrialandleftventricularenlargement.Thepulmonary
veinsandtheascendingaortacanalsobedilatedwithasufficientlylargepatentductusarteriosus
(PDA).Inaddition,iflittleornorestrictionispresentatthelevelofthepatentductusarteriosus
(PDA),pulmonaryhypertensionresults.

Functionalandanatomicclosure
Inthefetus,theoxygentensionisrelativelylow,becausethepulmonarysystemisnonfunctional.
Coupledwithhighlevelsofcirculatingprostaglandins,thisactstokeeptheductusopen.Thehigh
levelsofprostaglandinsresultfromthelittleamountofpulmonarycirculationandthehighlevelsof
productionintheplacenta.

Atbirth,theplacentaisremoved,eliminatingamajorsourceofprostaglandinproduction,andthe
lungsexpand,activatingtheorganinwhichmostprostaglandinsaremetabolized.Inaddition,with
theonsetofnormalrespiration,oxygentensioninthebloodmarkedlyincreases.Pulmonary
vascularresistancedecreaseswiththisactivity.

Normally,functionalclosureoftheductusarteriosusoccursbyabout15hoursoflifeinhealthy
infantsbornatterm.Thisoccursbyabruptcontractionofthemuscularwalloftheductus
arteriosus,whichisassociatedwithincreasesinthepartialpressureofoxygen(PO2)coincident
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withthefirstbreath.Apreferentialshiftofbloodflowoccursthebloodmovesawayfromthe
ductusanddirectlyfromtherightventricleintothelungs.Untilfunctionalclosureiscompleteand
PVRislowerthanSVR,someresiduallefttorightflowoccursfromtheaortathroughtheductus
andintothepulmonaryarteries.

Thiswasfirstdemonstratedbymultipleexperimentsinthe1940sandhasbeensubsequently
confirmed.Althoughtheneonatalductusappearstobehighlysensitivetochangesinarterial
oxygentension,theactualreasonsforclosureorpersistentpatencyarecomplexandinvolve
manipulationbytheautonomicnervoussystem,chemicalmediators,andtheductalmusculature.

Abalanceoffactorsthatcauserelaxationandcontractiondeterminethevasculartoneofthe
ductus.Majorfactorscausingrelaxationarethehighprostaglandinlevels,hypoxemia,andnitric
oxideproductionintheductus.Factorsresultingincontractionincludedecreasedprostaglandin
levels,increasedPO2,increasedendothelin1,norepinephrine,acetylcholine,bradykinin,and
decreasedPGEreceptors.Increasedprostaglandinsensitivity,inconjunctionwithpulmonary
immaturityleadingtohypoxia,contributestotheincreasedfrequencyofpatentductusarteriosus
(PDA)inprematureneonates.

Althoughfunctionalclosureusuallyoccursinthefirstfewhoursoflife,trueanatomicclosure,in
whichtheductuslosestheabilitytoreopen,maytakeseveralweeks.Asecondstageofclosure
relatedtofibrousproliferationoftheintimaiscompletein23weeks.

Casselsetaldefinedtruepersistenceoftheductusarteriosusasapatentductusarteriosus(PDA)
presentininfantsolderthan3months.[2]Thus,patencyafter3monthsisconsideredabnormal,
andtreatmentshouldbeconsideredatthisjuncture,althoughurgencyisseldomnecessary.Some
caninebreeds,suchascertainstrainsofpoodle,havealargeprevalenceofpatentductus
arteriosus(PDA).

Spontaneousclosureafter5monthsisrareinthefullterminfant.Leftuntreated,patientswitha
largepatentductusarteriosus(PDA)areatrisktodevelopEisenmengerSyndrome,inwhichthe
PVRcanexceedSVR,andtheusuallefttorightshuntingreversestoarighttoleftdirection.At
thisstage,thePVRisirreversible,closureofthepatentductusarteriosus(PDA)iscontraindicated,
andlungtransplantationmaybetheonlyhopeforlongtermsurvival.

Failureofductusarteriosustocontract
Failureofductusarteriosuscontractioninpretermneonateshasbeensuggestedtobeduetopoor
prostaglandinmetabolismbecauseofimmaturelungs.Furthermore,highreactivitytoprostaglandin
andreducedcalciumsensitivitytooxygeninvascularsmoothmusclecellscontributetocontraction
oftheductus.Theabsenceofductusarteriosuscontractioninfulltermneonatesmightbedueto
failedprostaglandinmetabolismmostlikelycausedbyhypoxemia,asphyxia,orincreased
pulmonarybloodflow,renalfailure,andrespiratorydisorders.

Cyclooxygenase(COX)2(anisoformofCOXproducingprostaglandins)inductionandexpression
mightalsopreventductalclosure.TheactivationofGproteincoupledreceptorsEP4byPGE2,the
primaryprostaglandinregulatingductaltoneleadstoductalsmoothmusclerelaxation.

Duringlategestation,thedecreaseinprostaglandinlevelsresultsinconstrictionoftheductus
arteriosus.Thus,theintimalcushionscomeintocontactandoccludetheductuslumen.

Volumepressurerelationships

Furtherprogressionofdiseaseisdependentonvolumeandpressurerelationships,asfollows:

Volume=pressure/resistance
Highvolumeyieldsincreasingpulmonaryarterypressures,eventuallyproducingendothelial
andmuscularchangesinthevesselwall

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Thesechangesmayeventuallyleadtopulmonaryvascularobstructivedisease(PVOD),a
conditionofresistancetopulmonarybloodflowthatmaybeirreversibleandwillpreclude
definitiverepair

Etiology
Genetics
Familialcasesofpatentductusarteriosus(PDA)havebeenrecorded,butageneticcausehasnot
beendetermined.Ininfantsbornattermwhohaveapersistentpatentductusarteriosus(PDA),the
recurrencerateamongsiblingsis5%.Someearlyevidencesuggeststhatasmanyasonethirdof
casesarecausedbyarecessivetraitlabeledPDA1,locatedonchromosome12,atleastinsome
populations.

Chromosomalabnormalities

Severalchromosomalabnormalitiesareassociatedwithpersistentpatencyoftheductus
arteriosus.Implicatedteratogensincludecongenitalrubellainfectioninthefirsttrimesterof
pregnancy,particularlythrough4weeks'gestation(associatedwithpatentductusarteriosus[PDA]
andpulmonaryarterybranchstenosis),fetalalcoholsyndrome,maternalamphetamineuse,and
maternalphenytoinuse.

Prematurity
Prematurityorimmaturityoftheinfantatthetimeofdeliverycontributestothepatencyofthe
ductus.Severalfactorsareinvolved,includingimmaturityofthesmoothmusclewithinthestructure
ortheinabilityoftheimmaturelungstoclearthecirculatingprostaglandinsthatremainfrom
gestation.Thesemechanismsarenotfullyunderstood.Conditionsthatcontributetolowoxygen
tensionintheblood,suchasimmaturelungs,coexistingcongenitalheartdefects,andhigh
altitude,areassociatedwithpersistentpatencyoftheductus.

Other

Othercausesincludelowbirthweight(LBW),prostaglandins,highaltitudeandlowatmospheric
oxygentension,andhypoxia.

Epidemiology
Theestimatedincidenceofpatentductusarteriosus(PDA)inUSchildrenbornattermisbetween
0.02%and0.006%oflivebirths.Thisincidenceisincreasedinchildrenwhoarebornprematurely
(20%inprematureinfants>32weeks'gestationupto60%inthose<28weeks'gestation),
childrenwithahistoryofperinatalasphyxia,and,possibly,childrenbornathighaltitude.In
addition,upto30%oflowbirthweightinfants(<2500g)developapatentductusarteriosus(PDA).
Siblingsalsohaveanincreasedincidence.Perinatalasphyxiausuallyonlydelaystheclosureof
theductus,and,overtime,theductustypicallycloseswithoutspecifictherapy.

Asanisolatedlesion,patentductusarteriosus(PDA)represents510%ofallcongenitalheart
lesions.Itoccursinapproximately0.008%ofliveprematurebirths.

Nodatasupportaracepredilection.However,thereisafemalepreponderance(femaletomale
ratio,2:1)ifthepatentductusarteriosus(PDA)isnotassociatedwithotherriskfactors.Inpatients
inwhomthepatentductusarteriosus(PDA)isassociatedwithaspecificteratogenicexposure,
suchascongenitalrubella,theincidenceisequalbetweenthesexes.

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Occasionally,anolderchildisreferredwiththelatediscoveryofatypicalductusarteriosusmurmur
(eg,machineryorcontinuousmurmur).

Prognosis
Theprognosisisgenerallyconsideredexcellentinpatientsinwhomthepatentductusarteriosus
(PDA)istheonlyproblem.Inprematureinfantswhohaveothersequelaeofprematurity,these
sequelaetendtodictateprognosisofpatentductusarteriosus(PDA).

Typically,followingpatentductusarteriosus(PDA)closure,patientsexperiencenofurther
symptomsandhavenofurthercardiacsequelae.Prematureinfantswhohadasignificantpatent
ductusarteriosus(PDA)aremorelikelytodevelopbronchopulmonarydysplasia.

Spontaneousclosureinthoseolderthan3monthsisrare.Inthoseyoungerthan3months,
spontaneousclosureinprematureinfantsis7275%.Inaddition,28%ofchildrenwithpatent
ductusarteriosus(PDA)whowereconservativelytreated(withprophylacticibuprofen)reporteda
94%closurerate.Thisratecomparedwellwithratesreportedinliteraturefollowingmedical
treatment(8092%).

Intheadultpatient,theprognosisismoredependentontheconditionofthepulmonaryvasculature
andthestatusofthemyocardiumifcongestivecardiomyopathywaspresentbeforeductalclosure.
Patientswithminimalorreactivepulmonaryhypertensionandlimitedmyocardialchangesmay
haveanormallifeexpectancy.

Morbidity
Morbidityandmortalityratesaredirectlyrelatedtotheflowvolumethroughtheductusarteriosus.
Alargepatentductusarteriosus(PDA)maycausecongestiveheartfailure(CHF)ifleftuntreated
foralongperiod,pulmonaryhypertensionmaydevelop.Occasionally,theductusarteriosus
patencycanbeintermittent.

Lowbirthweightprematureinfants

Asmanyas20%ofneonateswithrespiratorydistresssyndromehavepatentductusarteriosus
(PDA).Inbabieswhoarelessthan1500gatbirth,manystudiesshowtheincidenceofapatent
ductusarteriosus(PDA)toexceed30%.Theincreasedpatencyinthesegroupsisthoughttobe
duetobothhypoxiainbabieswithrespiratorydistressandimmatureductalclosuremechanismsin
prematurebabies.

Prematurebabies,particularlylowbirthweightneonates,aremorelikelytohaveproblemsrelated
topatentductusarteriosus(PDA).Spontaneousclosureofthepatentductusarteriosus(PDA)in
prematureneonatesiscommon,butrespiratorydistressandimpairedsystemicoxygendelivery
(CHF)oftendrivetheneedfortherapytoeffectductalclosureinthisgroup.Lowbirthweight
neonateswithapatentductusarteriosus(PDA)aremorelikelytodevelopchroniclungdisease.

Mortality

Nofirmstatisticsexist,butsurvivalratesaredecreasedinpatientswithlargeshunts.Thesurgical
mortalityrateinprematureinfantsrangesfrom20%to41%.Withtheavailabilityofantibioticsto
treatendocarditisandlowrisksurgeryandcathetertechniquestoobliteratethepatentductus
arteriosus(PDA),themortalityrateappearstobequitelowexceptintheextremelypremature
infant.

Itisestimatedthatleftuntreated,themortalityrateforpatentductusarteriosus(PDA)is20%by
age20years,42%byage45years,and60%mortalityratebyage60years.Anestimated0.6%
peryearundergoesspontaneousclosure.

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ClinicalPresentation

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MediaGallery

Schematicdiagramofalefttorightshuntofbloodflowfromthedescendingaortaviathe
patentductusarteriosus(PDA)tothemainpulmonaryartery.
Diagramillustratingthepatentductusarteriosus.
Diagramillustratingligationofthepatentductusarteriosus.
Diagramillustratingdivisionandoversewingofthepatentductusarteriosus.
Diagramillustratingpatchclosureofthepatentductusarteriosus.

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Author

LukeKKim,MDAssistantProfessorofMedicine,DepartmentofInternalMedicine,Divisionof
Cardiology,NewYorkPresbyterianHospital,WeillCornellMedicalCenter

Disclosure:Nothingtodisclose.

Coauthor(s)

JeffreyCMilliken,MDChief,DivisionofCardiothoracicSurgery,UniversityofCaliforniaatIrvine
MedicalCenterClinicalProfessor,DepartmentofSurgery,UniversityofCalifornia,Irvine,School
ofMedicine

JeffreyCMilliken,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAssociationforThoracicSurgery,AmericanCollegeofCardiology,AmericanCollegeof
ChestPhysicians,AmericanCollegeofSurgeons,AmericanHeartAssociation,AmericanSociety
forArtificialInternalOrgans,CaliforniaMedicalAssociation,InternationalSocietyforHeartand
LungTransplantation,PhiBetaKappa,SocietyofThoracicSurgeons,SWOG,WesternSurgical
http://emedicine.medscape.com/article/891096overview 9/12
3/29/2017 PatentDuctusArteriosus(PDA):Background,Anatomy,Pathophysiology

Association

Disclosure:Nothingtodisclose.

ChiefEditor

StuartBerger,MDMedicalDirectorofTheHeartCenter,Children'sHospitalofWisconsin
AssociateProfessor,DepartmentofPediatrics,SectionofPediatricCardiology,MedicalCollegeof
Wisconsin

StuartBerger,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Pediatrics,AmericanCollegeofCardiology,AmericanCollegeofChestPhysicians,American
HeartAssociation,SocietyforCardiovascularAngiographyandInterventions

Disclosure:Nothingtodisclose.

Acknowledgements

HughDAllen,MDProfessor,DepartmentofPediatrics,DivisionofPediatricCardiologyand
DepartmentofInternalMedicine,OhioStateUniversityCollegeofMedicine

HughDAllen,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Pediatrics,AmericanCollegeofCardiology,AmericanHeartAssociation,AmericanPediatric
Society,AmericanSocietyofEchocardiography,SocietyforPediatricResearch,Societyof
PediatricEchocardiography,andWesternSocietyforPediatricResearch

Disclosure:Nothingtodisclose.

DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedical
SchoolViceChair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital

DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysiciansandSocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

StevenJCompton,MD,FACC,FACPDirectorofCardiacElectrophysiology,AlaskaHeart
Institute,ProvidenceandAlaskaRegionalHospitals

StevenJCompton,MD,FACC,FACPisamemberofthefollowingmedicalsocieties:AlaskaState
MedicalAssociation,AmericanCollegeofCardiology,AmericanCollegeofPhysicians,American
HeartAssociation,AmericanMedicalAssociation,andHeartRhythmSociety

Disclosure:Nothingtodisclose.

ChristopherIDoty,MD,FACEP,FAAEMAssistantProfessorofEmergencyMedicine,Residency
ProgramDirector,DepartmentofEmergencyMedicine,KingsCountyHospitalCenter,State
UniversityofNewYorkDownstateMedicalCenter

ChristopherIDoty,MD,FACEP,FAAEMisamemberofthefollowingmedicalsocieties:American
AcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedical
Association,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademic
EmergencyMedicine

Disclosure:Nothingtodisclose.

GehaanD'Souza,MDUniversityofCaliforniaIrvineSchoolofMedicine

Disclosure:Nothingtodisclose.

http://emedicine.medscape.com/article/891096overview 10/12
3/29/2017 PatentDuctusArteriosus(PDA):Background,Anatomy,Pathophysiology

JustinGalovich,MDResidentPhysician,DepartmentofSurgery,UniversityofCalifornia,Irvine,
SchoolofMedicine

JustinGalovich,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons

Disclosure:Nothingtodisclose.

ChristopherJohnsrude,MD,MSChief,DivisionofPediatricCardiology,UniversityofLouisville
SchoolofMedicineDirector,CongenitalHeartCenter,KosairChildren'sHospital

ChristopherJohnsrude,MD,MSisamemberofthefollowingmedicalsocieties:American
AcademyofPediatricsandAmericanCollegeofCardiology

Disclosure:StJudeMedicalHonorariaSpeakingandteaching

StevenRNeish,MD,SMDirectorofPediatricCardiologyFellowshipProgram,Associate
Professor,DepartmentofPediatrics,BaylorCollegeofMedicine

StevenRNeish,MD,SMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Pediatrics,AmericanCollegeofCardiology,andAmericanHeartAssociation

Disclosure:Nothingtodisclose.

GirishSethuraman,MD,MPHAssistantProfessor,UniversityofMarylandSchoolofMedicine

GirishSethuraman,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanAcademy
ofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedical
Association,AmericanPublicHealthAssociation,andSocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

GarySetnik,MDChair,DepartmentofEmergencyMedicine,MountAuburnHospitalAssistant
Professor,DivisionofEmergencyMedicine,HarvardMedicalSchool

GarySetnik,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,NationalAssociationofEMSPhysicians,andSocietyforAcademicEmergency
Medicine

Disclosure:SironaHealthSalaryManagementpositionSouthMiddlesexEMSConsortiumSalary
ManagementpositionProceduresConsult.comRoyaltyOther

MarkSSlabinski,MD,FACEP,FAAEMVicePresident,EMPMedicalGroup

MarkSSlabinski,MD,FACEP,FAAEMisamemberofthefollowingmedicalsocieties:Alpha
OmegaAlpha,AmericanAcademyofEmergencyMedicine,AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,andOhioStateMedicalAssociation

Disclosure:Nothingtodisclose.

FranciscoTalavera,PharmD,PhD,AdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeReferenceSalaryEmployment

ParkWWillisIV,MDSarahGrahamDistinguishedProfessorofMedicineandPediatrics,
UniversityofNorthCarolinaatChapelHillSchoolofMedicine

ParkWWillisIV,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyof
Echocardiography

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3/29/2017 PatentDuctusArteriosus(PDA):Background,Anatomy,Pathophysiology

Disclosure:Nothingtodisclose.

MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:Nothingtodisclose.

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