WordNet

obtain a patent for; "Should I patent this invention?"
an official document granting a right or privilege (同)letters_patent
a document granting an inventor sole rights to an invention (同)patent of invention
(of a bodily tube or passageway) open; affording free passage; "patent ductus arteriosus"
grant rights to; grant a patent for
make open to sight or notice; "His behavior has patented an embarrassing fact about him"
a continuous tube formed by a row of elongated cells lacking intervening end walls
an enclosed conduit for a fluid
a bodily passage or tube lined with epithelial cells and conveying a secretion or other substance; "the tear duct was obstructed"; "the alimentary canal"; "poison is released through a channel in the snakes fangs" (同)epithelial duct, canal, channel
the top of the head (同)poll, crown
liver or meat or fowl finely minced or ground and variously seasoned
(of devices and processes) protected by patent; "they are patented inventions"

PrepTutorEJDIC

『特許』,特許権,パテント / 『専売特許品』,特許となっている製法 / 専売特許証 / (一般に特権などを授ける)公式証書 / 《名詞の前にのみ用いて》専売特許の / 《名詞の前にのみ用いて》《英話》賢い,独特な,まねのできない / 明白な / …‘の'特許[権]を取る / …‘に'特許[権]を与える
送水管;(建物・船などの)通気管;(地下ケーブルなどの)ダクト / (体液を運ぶ)導管,(植物が水・空気を運ぶ)導管
頭,脳天;頭脳
パテ,肉パイ(レバー肉・魚などを小麦粉で練った菓子)
パテナ(聖体祭儀のときパンをのせる金属製の皿)

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/08/28 19:59:50」(JST)

wiki en

Patent ductus arteriosus (PDA) is a congenital disorder in the heart wherein a neonate's ductus arteriosus fails to close after birth. Early symptoms are uncommon, but in the first year of life include increased work of breathing and poor weight gain. With age, the PDA may lead to congestive heart failure if left uncorrected. The ductus arteriosus is a normal fetal blood vessel that closes soon after birth. In a PDA, the vessel does not close and remains "patent" (open) resulting in irregular transmission of blood between two of the most important arteries close to the heart, the aorta and the pulmonary artery. PDA is common in neonates with persistent respiratory problems such as hypoxia, and has a high occurrence in premature children. In hypoxic newborns, too little oxygen reaches the lungs to produce sufficient levels of bradykinin and subsequent closing of the DA. Premature children are more likely to be hypoxic and thus have PDA because of their underdeveloped heart and lungs.

A PDA allows a portion of the oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta (which has higher pressure) to the pulmonary artery. If this shunt is substantial, the neonate becomes short of breath: the additional fluid returning to the lungs increases lung pressure to the point that the neonate has greater difficulty inflating the lungs. This uses more calories than normal and often interferes with feeding in infancy. This condition, as a constellation of findings, is called congestive heart failure.

In some cases, such as in transposition of the great vessels (the pulmonary artery and the aorta), a PDA may need to remain open. In this cardiovascular condition, the PDA is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the DA open.

Signs and symptoms

While some cases of PDA are asymptomatic, common symptoms include:

tachycardia
respiratory problems
dyspnea – shortness of breath
continuous machine-like heart murmur (to-and-fro murmur, systolic from aorta to pulmonar and diastolic from pulmonar to aorta)
cardiomegaly - enlarged heart, reflecting ventricular dilation and volume overload
left subclavicular thrill
bounding pulse
widened pulse pressure
patients typically present in good health, with normal respirations and heart rate. If the ductus is moderate or large, widened pulse pressure and bounding peripheral pulses are frequently present, reflecting increased left ventricular stroke volume and diastolic runoff of blood into the initially lower-resistant pulmonary vascular bed. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume.
poor growth^[1]
differential cyanosis, i.e. cyanosis of the lower extremities but not of the upper body.

Adult PDA

Since PDA is usually identified in infants, it is less common in adults. But it can have serious consequences, and is usually corrected surgically if it is diagnosed.

Diagnosis

Phonocardiograms from normal and abnormal heart sounds

PDA is usually diagnosed using non-invasive techniques. Echocardiography, in which sound waves are used to capture the motion of the heart, and associated Doppler studies are the primary methods of detecting PDA. Electrocardiography (ECG), in which electrodes are used to record the electrical activity of the heart, is not particularly helpful as there are no specific rhythms or ECG patterns which can be used to detect PDA.^{[citation needed]}

A chest X-ray may be taken, which reveals the overall size of neonate's heart (as a reflection of the combined mass of the cardiac chambers) and the appearance of the blood flow to the lungs. A small PDA most often shows a normal sized heart and normal blood flow to the lungs. A large PDA generally shows an enlarged cardiac silhouette and increased blood flow to the lungs.

Normal anatomy

In the developing fetus, the DA is the vascular connection between the pulmonary artery and the aortic arch that allows most of the blood from the right ventricle to bypass the fetus' fluid-filled compressed lungs. During fetal development, this shunt protects the right ventricle from pumping against the high resistance in the lungs, which can lead to right ventricular failure if the DA closes in-utero.

When the newborn takes its first breath, the lungs open and pulmonary vascular resistance decreases. After birth, the lungs release bradykinin to constrict the smooth muscle wall of the DA and reduce bloodflow through the DA as it narrows and completely closes, usually within the first few weeks of life. In most newborns with a patent ductus arteriosus the blood flow is reversed from that of in utero flow, i.e. the blood flow is from the higher pressure aorta to the now lower pressure pulmonary arteries.

In normal newborns, the DA is substantially closed within 12–24 hours after birth, and is completely sealed after three weeks. The primary stimulus for the closure of the ductus is the increase in neonatal blood oxygen content. Withdrawal from maternal circulating prostaglandins also contributes to ductal closure. The residual scar tissue from the fibrotic remnants of DA, called the ligamentum arteriosum, remains in the normal adult heart.

Treatment

Neonates without adverse symptoms may simply be monitored as outpatients, while symptomatic PDA can be treated with both surgical and non-surgical methods.^[2] Surgically, the DA may be closed by ligation (though support in premature infants is mixed),^[3] wherein the DA is manually tied shut, or with intravascular coils or plugs that leads to formation of a thrombus in the DA. This was first performed in humans by Robert E. Gross.^{[citation needed]}

Because Prostaglandin E1 is responsible for keeping the ductus patent, NSAIDS (inhibitors of prostaglandin synthesis) such as indomethacin or a special form of ibuprofen have been used to help close a PDA.^[1]^[4] This is an especially viable alternative for premature infants.^{[citation needed]}

In certain cases it may be beneficial to the neonate to prevent closure of the ductus arteriosus^{[citation needed]}. For example, in transposition of the great vessels, a PDA may prolong the newborn's life until surgical correction is possible. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs such as alprostadil or misoprostol (prostaglandin E₁ analogs)^{[citation needed]}.

More recently, PDAs can be closed by percutaneous interventional method.^{[citation needed]} Via the femoral vein or femoral artery, a platinum coil can be deployed via a catheter, which induces thrombosis (coil embolization). Alternatively, a PDA occluder device (AGA Medical)^{[citation needed]}, composed of nitinol mesh, is deployed from the pulmonary artery through the PDA. The larger skirt of the device sits on the aortic side while the ampulla of the device hugs the walls of the PDA, with care taken to avoid occlusion of the pulmonary arterial lumen by the device^{[citation needed]}. These methods permit closure without open heart surgery.

Prevention

There is evidence to suggest that giving indomethacin on the first day of life, prophylactically to all preterm infants (less than 37 weeks gestation) reduces the risk of developing a PDA (relative risk 0.29 95% CI 0.22, 0.38) and the complications associated with PDA. There is also a decreased need for surgical intervention to treat PDA in premature infants prophylactically treated with indomethacin (relative risk of 0.51 95%CI 0.37, 0.71). Complications of PDA include intraventricular hemorrhage which can lead to severe brain damage. There is not evidence however to show that giving indomethacin prophylactically improves survival for these infants (RR 0.96; 95% CI 0.81, 1.12). There is also no significant evidence to suggest prophylactic indomethacin decreases long-term disability (cerebral palsy, visual impairment, hearing impairment, decreased cognitive performance) rates.^[5]

Etiology

A PDA can be idiopathic (i.e. without an identifiable cause), or secondary to another condition. Some common contributing factors in humans include:

Preterm birth
Congenital rubella syndrome
Chromosomal abnormalities such as Down syndrome

Prognosis

Without treatments, the disease may progress from left-to-right (noncyanotic heart) shunt to right-to-left shunt (cyanotic heart) called Eisenmenger's syndrome. Also, a long-term effect would be pulmonary hypertension, which can lead to needing a heart and/or lung transplant.

History

Robert E. Gross, MD performed the first successful ligation of a patent ductus arteriosus on an eight year old girl at Children's Hospital Boston in 1938.

Additional images

Illustration of Patent Ductus Arteriosus
patent ductus arteriosus
An echocardiogram of a stented persisting ductus arteriosus. One can see the aortic arch and the stent leaving. Pulmonary artery not seen.
An echocardiogram of a coiled persisting ductus arteriosus. One can see the aortic arch,the pulmonary artery and the coil between them.

References

^ ^a ^b MedlinePlus > Patent ductus arteriosus Update Date: 21 December 2009
^ Zahaka, KG and Patel, CR. "Congenital defects'". Fanaroff, AA and Martin, RJ (eds.). Neonatal-perinatal medicine: Diseases of the fetus and infant. 7th ed. (2002):1120-1139. St. Louis: Mosby.
^ Mosalli R, Alfaleh K, Paes B (July 2009). "Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice". Ann Pediatr Cardiol 2 (2): 120–6. doi:10.4103/0974-2069.58313. PMC 2922659. PMID 20808624.
^ MayoClinic > Patent ductus arteriosus (PDA) Dec. 22, 2009
^ Fowlie, PW; Davis PG; McGuire W (19 May 2010). "Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants (Review)". The Cochrane Database of Systematic Reviews (7). doi:10.1002/14651858. |accessdate= requires |url= (help)

^ Long-Term Neurological Outcomes Following Neonatal Heart Surgery: Implications for Cerebral Protections in Adults. Sandra Bellezza MD. March 2, 2011

External links

Patent Ductus Arteriosus information from Seattle Children's Hospital Heart Center
Patent Ductus Arteriosus Causes from US Department of Health and Human Services
Patent Ductus Arteriosus from Merck
Fetal Circulation at berkeley.edu
Information about PDA - The Hospital for Sick Children
Down's Heart Group Easy to understand diagram and explanation of PDA.
PDA Occluder Amplatzer PDA occluder device used for percutaneous closure of PDAs.
Children's Hospital Boston Archives
Patent ductus arteriosus information for parents.

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 動脈管開存症の臨床症状および診断 clinical manifestations and diagnosis of patent ductus arteriosus
2. 動脈管開存症のマネージメント management of patent ductus arteriosus
3. 早産児における動脈管開存症の病態生理、臨床症状、および診断 pathophysiology clinical manifestations and diagnosis of patent ductus arteriosus in premature infants
4. 早産児における動脈管開存症のマネージメント management of patent ductus arteriosus in premature infants
5. 乳幼児および小児における心不全の病因および診断 etiology and diagnosis of heart failure in infants and children

English Journal

Patent ductus arteriosus: time to grasp the nettle?

Smith CL, Kissack CM.SourceCorrespondence to Christopher M Kissack, Neonatal Unit, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK; chris.kissack @luht.scot.nhs.uk.
Archives of disease in childhood. Fetal and neonatal edition.Arch Dis Child Fetal Neonatal Ed.2013 May;98(3):F269-71. doi: 10.1136/fetalneonatal-2011-301129. Epub 2012 Feb 28.
The management of patent ductus arteriosus is controversial, and there are diverse approaches to treatment, ranging from very conservative management through to early and aggressive securing of ductus closure, either pharmacologically or surgically. This lack of consensus on best management reflects
PMID 22375021

Neonatal outcome of preterm infants born to mothers with abnormal genital tract colonisation and chorioamnionitis: A cohort study.

Seliga-Siwecka JP, Kornacka MK.SourceDepartment of Neonatology and Neonatal Intensive Care Warsaw Medical University, Poland. Electronic address: seliga.joanna@gmail.com.
Early human development.Early Hum Dev.2013 May;89(5):271-5. doi: 10.1016/j.earlhumdev.2012.10.003. Epub 2012 Nov 14.
PURPOSE: We hypothesised that abnormal genital tract colonisation leading to an in utero inflammation/infection process, contributes to the risk of respiratory distress syndrome (RDS), patent ductus arteriosus (PDA), intra ventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy
PMID 23158015

Japanese Journal

死亡保障保険における先天性心疾患の検討

青田浩司,尾関全,吉丸昌秀
日本保険医学会誌 111(2), 115-121, 2013-06-28
当社における死亡保障保険の申込みと(成立した)新契約を対象として心房中隔欠損症,心室中隔欠損症,動脈管開存症などの先天性心疾患について調査した。先天性心疾患の新契約数は近年増加しており,10年前の2.3倍(322件/年)になった。手術治療後の先天性心疾患の場合は,心雑音や心電図異常を認めても経過が良好であれば特別保険料を加算した条件体契約として締結している。しかしこの集団は心疾患による死亡が多く, …
NAID 110009615538

インドメタシン投与が有効であったがその後に動脈管再開通を認めた極低出生体重児の臨床的特徴と再開通危険因子の検討

内山温,中西秀彦,戸津五月,増本健一,鷲尾洋介,首里京子,今井憲,石田宗司,杉田依里,楠田聡,UCHIYAMA Atsushi,NAKANISHI Hidehiko,TOTSU Satsuki,MASUMOTO Kenichi,WASHIO Yosuke,SHURI Kyoko,IMAI Ken,ISHIDA Shuji,SUGITA Eri,KUSUDA Satoshi
東京女子医科大学雑誌 83(E1), E125-E130, 2013-01-31
背景: 未熟児動脈管開存症は極低出生体重児によく見られる合併症の1つで、治療薬としてインドメタシンが使用される。また近年インドメタシンの予防投与が脳室内出血の予防に有効であることも明らかにされており、その投与方法も変わりつつある。インドメタシン投与によって非症候化した症例の中には、再び症候化する症例、すなわち再開通症例が存在する。しかしながら、動脈管が再開通した症例の臨床的特徴についてはあまり知ら …
NAID 110009559360

重症左心不全に対し，バルーン心房中隔裂開術を施行し救命し得た新生児心筋炎の1 例

平岩明子,齋藤和由,伊吹圭二郎,渡辺一洋,小澤綾佳,市田蕗子,宮脇利男,芳村直樹,小浦詩,藤田修平,二谷武,畑崎喜芳
Pediatric Cardiology and Cardiac Surgery 29(3), 149-155, 2013
　新生児期の心筋炎は極めて予後不良であり，救命のため体外補助循環の装着を必要とすることがある．コクサッキーB4 ウイルス性心筋炎による重症左心不全に対し，体外補助循環の代わりに，バルーン心房中隔裂開術（Balloon atrial septostomy 以下BAS）を施行し，救命しえた新生児例を経験した．この新生児では，肺うっ血と重症僧帽弁逆流を伴った重症左心不全に対して，内科的治療のみでは血行動 …
NAID 130003380031

Related Pictures

★リンクテーブル★

リンク元	「血圧」「動脈管開存症」「PDA」
拡張検索	「patent ductus arteriosus due to prematurity」「patent ductus arteriosus in premature infants」
関連記事	「patent」「duct」「ductus」「arteriosus」

「血圧」

Patent ductus arteriosus
	Classification and external resources
	Heart cross-section with PDA
ICD-10	Q25.0
ICD-9	747.0
OMIM	607411
DiseasesDB	9706
MedlinePlus	001560
eMedicine	emerg/358
MeSH	C14.240.400.340

　　[★]

英: blood pressure, BP
同: 動脈圧 arterial pressure AP
関: 血圧測定

成人の血圧

至適血圧：＜120mmHg　かつ　＜80mmHg
正常血圧：130mmHg　かつ　85mmHg
正常高値血圧：130～139mmHg　または　85～89mmHg
I度高血圧(軽症)：140～159mmHg　または　90～99mmHg
II度高血圧(中等症)：160～179mmHg　または　100～109mmHg
III度高血圧(重症)：≧180mmHg　または　≧110mmHg
収縮期高血圧：≧140mmHg　かつ　＜90mmHg

糖尿病性腎症

管理目標： 130/80 mmHg
尿蛋白1g/日以上：125/75 mmHg

冠血管と血圧

In the normal state, autoregulatory mechanisms adjust coronary tone tomatch myocardial oxygen supply with oxygen requirements. In the absence of obstructive coronary disease, thesemechanisms maintain fairly constant rate of coronary flow, as long as the aortic perfusion pressure is approximately 60 mmHg or greater.

血圧の異常

血圧の上肢における左右差

大動脈炎症候群、大動脈縮窄症、解離性大動脈瘤、胸郭出口症候群、動脈硬化による一側の血管の狭窄

大動脈炎症候群：腕頭動脈、鎖骨下動脈の狭窄・閉塞を生じる
動脈硬化：鎖骨下動脈領域の病変があるとき、左右の脈拍差や皮膚温の違いを生じる

血圧の上下肢の差（下肢＞上肢）

1. 生理的：下肢の方が20 mmHg高い。
2. 病的　：大動脈炎症候群、大動脈解離(解離性大動脈瘤)、大動脈閉鎖不全症

大動脈炎症候群：大動脈弓部が冒されやすいが、鎖骨下動脈が冒された場合に上肢の血圧が低下。
解離性大動脈瘤：解離腔に生じた血腫が鎖骨下動脈を圧迫すると、上肢の血圧が低下
大動脈閉鎖不全症：Hill徴候

収縮期血圧のみ高い。拡張期血圧は高くない

拡張期に動脈血流が減少する病態(血流が体循環に押し出されないか、心収縮力のみ上昇している状態？(体循環の血管抵抗が上がっていない？))

脈圧が上昇する

1. 大動脈基部の血流が逆流やシャントにより減少する場合

2.高心拍出量状態 hyperdynamic state

3. その他

大動脈弾性低下(老人性高血圧症)
完全AV block

ショック

収縮期血圧 90 mmHg以下

非侵襲的な血圧測定法による血圧の上肢・下肢の差

血圧を測定するために駆血帯で血流を遮断する必要がある。このとき、下肢の動脈の方が深部を走行しているため上肢より強く駆血帯で圧迫する必要がある。強く圧迫を要する分だけ下肢の血圧が高く測定されてしまう。

心血管とその周囲の血圧 YN.C-29

臓器移植における脳死判定の除外

脳死判定#脳死判定の除外規定、臓器の移植に関する法律施行規則#第二条第四項

収縮期血圧が以下で定められる数値未満の場合には脳死判定ができない。

1歳未満の者　65
1歳以上13歳未満の者　年齢x2+65
13歳以上の者　90

国試

101B032

「動脈管開存症」

　　[★]

英: patent ductus arteriosus, PDA
関: 心室中隔欠損症、心房中隔欠損症; 動脈管、動脈管索

まとめ

出生後72時間以内に閉鎖するはずの動脈管が残存することが本疾患の本態である。多くの症例では無症状であり、2LSBに連続性雑音を聴取することで診断されうる。動脈管開存の程度が大きい場合、左心系負荷、左心不全、あるいは肺高血圧によりアイゼンメンゲル症候群を来しうる(この場合のチアノーゼは下半身に起こる)。また、動脈管の圧迫により左反回神経麻痺を起こしうる。治療は動脈管結紮切離術、コイル塞栓法、(未熟児に対しては)インドメタシン投与により行う。(YN.C-123 SSUR.360)

概念

病因

疫学

先天性心疾患の約5-10% (YN.C-123)
男女比 = 1:2-3 (YN.C-123)

病態

肥大部位 PHD.380-

	RA	RV	LA	LV
ASD	○	○
VSD		○	○	○
PDA			○	○

症候

左心房肥大、左心室肥大
左心不全
(次第に)肺高血圧
(肺高血圧からアイゼンメンゲル化した症例)下半身のチアノーゼ

身体所見

脈拍

(動脈管の開存度が大きい場合)速脈・脈圧↑

聴診

シャント量によって所見が変化する。

新生児期(つまり病初期)には収縮期雑音。　→　拡張期雑音が出現し連続性雑音となる(拡張期雑音は高まった動脈圧によりdriveされる動脈管から肺動脈への血流を反映。よってII音でピークとなる)。　→　肺高血圧の進行により、収縮期雑音のみとなり、IIp音が亢進。

2LSB(胸骨左縁上部)に連続性雑音

検査

胸部単純X線写真

左第一弓↑、左第三弓↑、左第四弓↑
左第二弓↑(SPE.449)
肺血管陰影増強

心エコー

動脈管での左右シャント

心カテーテル検査

カテーテルの肺動脈から大動脈弓への到達
肺動脈血の酸素飽和度上昇
肺動脈圧上昇

心電図

左室肥大、V5-V6に目立つq波 (SPE.449)

治療

生後半年を過ぎると動脈管自然閉鎖はまれである

方針

ガイドライン1

細い動脈管で心雑音のない場合(silent PDA)について治療適応かどうかは統一見解がない。
治療適応は連続性雑音が見られる場合であり、肺血管抵抗が高くなり右左短絡が主体で高度の肺高血圧が見られる例、あるいはEisenmenger化した例については治療適応がない。
治療法の選択は形態と太さによる。心エコーで評価できなければ造影CTやMRIを施行する。
経皮的コイル塞栓術は最小内径が2.5mm以下の場合に第一選択となり、狭窄部がない筒型や、最小内径が4mm以上の場合にはコイル塞栓症は適応とならない。窿形成を伴っている場合や、動脈管の長さが短いwindowsタイプではステントグラフト内挿術や外科手術が適応となる。

↓これは出典不明

シャント量が小さい場合でも感染性心膜炎のリスクとなるため、全例で手術適応。

未熟児～乳児期に心不全を認める例：早期手術
その他：待機的に3-6歳での手術

手術療法

適応：肺高血圧合併症例、易感染性や発育不全を認める症例。(SPE.450)
手術法：動脈管の結紮切離

interventional radiography

コイル塞栓法

内科的治療

未熟児の場合、動脈管が閉鎖しにくいため、インドメタシンを投与

ガイドライン

1. 先天性心疾患の診断、病態把握、治療選択のための検査法の選択ガイドライン

http://www.j-circ.or.jp/guideline/pdf/JCS2010_hamaoka_h.pdf

「PDA」

　　[★]

「patent ductus arteriosus due to prematurity」

　　[★] 未熟児動脈管開存症

「patent ductus arteriosus in premature infants」