Aust. N.Z. J. Med. (1979), 9, pp. 174 176

Patent Ductus Arteriosus in Malaysia K. T. Singham' and H. 0. Wong'c From the Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Summary: Patent ductus arteriosus in Malaysia. K . T. Singham and H. 0. Wong, Aust. N . Z . J . Med., 1979, 9, pp. 174-176.

Findings are reviewed of isolated Patent Ductus Arteriosus after infancy as seen in 181 patients studied at the University Hospital, Kuala Lumpur, during the period 1967 to 1975. The ages of patients ranged from nine months to 54 years. Eighty-two patients underwent cardiac catheterization. More than 50% of patients were above ten years of age; the sex ratio was 1 male: 2.9 3 females. Thirty-two per cent of the patients had significant effort dyspnoea or were in heart failure. The complications noted were elevated pulmonary vascular resistance, Eisenmenger syndrome, bacterial endocarditis and cardiac failure.

This review was undertaken to determine the clinical pattern of isolated Patent Ductus Arteriosus as seen at the University Hospital in Malaysia. There is no compulsory medical examination on children in the pre-school or school-going age. Hence, patients with asymptomatic patent ductus are not diagnosed until some illness occurs or a pre-employment medical examination is conducted; the majority of our patients were diagnosed after the first decade. In such a community it is possible to study to a certain extent the natural history of the disease with particular reference to the development of pulmonary vascular disease, the occurrence of bacterial endocarditis and heart failure.

monary hypertension or who did not have the classical continuous murmur, electrocardiographic or radiological changes were submitted to cardiac catheterization. These comprised 82 subjects. Pulmonary vascular disease was said to exist when the pulmonary vascular resistance (PVR) was greater than 160 dynes/sec;cm5 or the total pulmonary vascular resistance (TPVR) exceeded 240 dynes/secicm5. These parameters were defined as follows: P A - L A o r .P A W-. .

PVR

=

TPVR

PA = -:

T

QP PA = mean pulmonary artery pressure,

LA = mean left atrial pressure. PAW = mean pulmonary arterial wedge pressure, QP = pulmonary blood flow. Eisenmenger's syndrome referred to all those with severe pulmonary vascular disease where reversal of the shunt was demonstrated by oximetry

Results

Age and Sex Distribution Table 1 shows the age and sex distribution. There were 46 males and 135 females with a male to female ratio of 1:2.93. Of the 83 subjects seen in the first decade, only two patients were seen during infancy. Over the age of 40 years there were only three subjects. Clinical Feu tures The majority of subjects were discovered on routine medical examination or when examined TABLE 1 Age and sex distribution

No. of cases

M a t e r i a l and M e t h o d All patients seen at the University Hospital from 1968 to 1975 with the clinical diagnosis of patent ductus arteriosus were admitted into the study. There were altogether 181 subjects. Only those who clinically were suspected of having pul'Lecturer in Medicine. tProfessor of Medicine. Correspondence: Dr. K. T. Singham, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lurnpur 22-11, Ma Iaysi a Accepted for publication: 23 October, 1978

OP

Age (years)

Male

Female

Under 1 1-10 1 1-20 21-30 3140 4 1-50 51 -60

0 22 13 8 2 1 0

2 59 40 26 6 1 1

Total

46

135

Total (%) 1.1

44.8 29.3 18.7 4.4 1.1

0.6

APRIL

1979

175 -

PATENT DUCTUS AKTERIOSTS 13 MALAYSIA

______

~-

TABLE 2

TABLE 4

Functional classification (NYHA*) ~

Class

N o dEca\es

I TI

123

111 IV

51 1

6

Age distribution of subjects with pulmonary vascular disease ____________ w o ot Elevated Eisenmenger Age cdses syndrome PVR* or TPVR? (years)

~~~~

‘lo

67 28 0 3

9 2 6 3

*New York Heart Association.

for respiratory infections. Table 2 shows the functional classification of the subjects according to the criteria of the New York Heart Association. The analysis of symptoms are shown in Table 3. TABLE 3 Symptoms at initial assessment ~

Symptoms Dyspnoea Recurrent respiratory infection Palpitation Failure to thrive Fever ____

No. of cases

‘J

54

29 8

55

30 8 1 0

15 2 1

4

3 1

6

Of the 181 subjects 86.27; had the typical continuous murmur and 19.82%;had only a systolic murmur. Mitral diastolic murmurs were recorded in 18.7”,,. Routine electrocardiography showed left ventricular hypertrophy in S6.9:;, right ventricular hypertrophy in 8.8“;) and biventricular hypertrophy in 11%. Normal electrocardiograms were recorded in 24.3%. Pulmonary vascular disease was the most frequent complication (Table 4). Of the 44 subjects (24.3%) with this complication 14 had shunt reversal and form 7 7% of all cases. One of these patients died suddenly during the period of this study. The age distribution of those with Eisenmenger syndrome are shown in Table 4. Other complications noted were bacterial endocarditis 5 * S%, heart failure 3.17; and massive collapse of left lung in one subject. Discussion

This study throws some light on the natural history of patent ductus arteriosus after infancy in Malaysia. Information regarding the disease in

-3

Under 1 1 10 11-20 21-30 31 4 0 41-50 51-60

81 53 34 8 2 1

Total

181

0 20 16 6

0

1

0 0 0

3

8 3

1 0 ..

44

14

*Pulmonary Vascular Resistance. ?Total Pulmonary Vascular Resistance

infancy is however lacking. Owing to the lack of a comprehensive school health programme the majority of our cases are detected only after the first decade of life when they are examined prior to employment or for unrelated illnesses. The important complications we have noted are pulmonary vascular disease, bacterial endocarditis and heart failure. Pulmonary pressure measurements in patent ductus arteriosus were not done in a previous study of the disease in Malaysia.’ Loh2 from Singapore reported an overall incidence of 24-2”,; of pulmonary hypertension in a series of 136 cases, which is comparable to that seen in our patients. This percentage is higher than that reported by Keith3 or Cleland rt but is much lower than that reported by Espino-Vela and Zamora’ from Mexico City where altitude may have aggravated the pulmonary arterial pressures. The occurrence of bacterial endocarditis and its complications have varied in the various reports. In the ten patients of this study one died while the others had successful ductal interruption after adequate antibiotic therapy. Abbot6, Bullock el u1.’ and Keys and Shapiro8 reported bacterial endocarditis as the most common cause of death. Cosh’ reported bacterial endocarditis in eight of his 69 patients; of these six patients died. In the Hammersmith Hospital series eight patients out of 165 patients had bacterial endocarditis: Espino-Vela and Zamora’ reported this complication in 38 of 1433 patients. With the use of more potent and specific antibiotics directed to the sensitivity of

176

SINGHAM A S D WONG

the actual organisms. death from bacterial endocarditis has declined. In addition surgical treatment at earlier ages has contributed significantly to this fall in mortality. In three of our patients a rare complication of mycotic aneurysm of the left pulmonary artery occurred as a result of bacterial endocarditis. Two of these had the aneurysms successfully resected at the time of ductal interruption. The other patient perforated his aortic valve, developed gross aortic incompetence and died." Aneurysm of the ductus itself was not seen. Cardiac failure occurred in six of the 181 patients giving an incidence of 3. Is