Patency of the ductus arteriosus in adults

T

HE first successful ligat,ion of a patent ductlls arteriosns was reported by Gross and Hubbard,“” in 1939. Since that, date. numerous additional successes, and some failnrcs, have stimulated much int crest in the subject. Gras@ (1941) has now operated on thirty paticnts with only two fatalities. The record of .Jonesd2is almost as impressive : twent,ysix operations with two failures. WC now have records on 134 operations to ligate the ducks; nearly half of these have not beru reported except by personal correspondence to ihc authors. The analysis of t,hosc operations will he reported elsewhere I Am. .J. X. SC., in press 1. Pat,ency of the ductus arkriosus is apparcntl>- much more common than was previously helicvccl. WC hav(>porsonallyi studied. with sonic cart, fifty-one paGents with this contlit ion in Ilie Minneapolis and St. Paul area. Jones, I~ollcy, an<1 Bullock’” Ilit\-C xvi almlt sixty-five cases in the LOS i4ngeles :trpil. Rongh c;~lelllnI ion rno~dd suggest, that, there arc at least 20,000 persons with a patent tlnctiis arteriosiis in the Trnited States at t.he present, time. Thwca is clearly- a ncctl for careful ronsideration as to what, should 1~ done with these people. Apart from cdonsideration of t,he immcdiatc rcsult~ oi’ oI)Cration, thcrc~ is the cluestion as to what rrentually happrns to persons with pat cncy of Itick ductiis arteriosns in the ordinary course of c~vc~ls. J<:vitl(>nc*c is oht.ainf?cl on this point i’rOJn it caonsideration of 011r own patitant s, Illany of whom have ~KYW followed for years (several for ciglitcc>n ycxars ra& ). In addition, there arc Ilic scattered reports in the literature whitah have never hren satisfactoril)c;ollected and analp,cd. This paptar is a report on patency of the ductus in adults; adults are dcfinctl as Ibcrsons 17 ~P;IIY of ag:c and older. Further, we shall confine ourselves primarily to cases in which iIllt0psiW were performed. I’or this analysis WC hart clinic*al and post-mortem records of sixty-seven paticntn in the) literature ;In~l follr patkits fro?i~ our own series. of these, sixty-onrb patients had IIO other important al)llormalities and map 132consider~cl tyl)iPill. Laboratory of Physiological Hygiene. Univ~*wit\- of Minnesota, nml tllv Cardiac Clinic nf the c7ity of Minneapolis. was aided by a grant from the University of Minncsuta Graduate School and by assistancefrom the Work Projects Administration as part of Subproject 380, University of Minnesota, Project No. X760, Official Project No. 565-l-71-336. Read at the Eighteenth Meeting of thr American Heart AssoCiati0n. Atlantic City. S. J., June 5, 1942. Received for publication Juls- 31, 1942. Since this paper was written. O~P r,f our patients who Ilad been under ohse~‘\‘~tion for ten years developed subacutr. bacterial endarteritis and was dead Wit;;; three months. We were not informnl of her condition until after her death. was a sixteen-year-old girl who ~1 NS xpparently in good health until the endarteritis signs of patmcy of thr ductua developed. Physical examination rrvwlvd typical Surgical Shr tml t>?l,l no synl!>tonls. mteriosus. The brwrt was of no~nnl aiacx. J’wt-mortm~ examination treatment had been wlvised pwviously. but was wfused. The heart revealed ELmidrl>- p;\t~nt ductus, wittl suprrimwsed bacteriiL1 mdartrritis. Five‘ :~
Ii\

I
ASD

SHAPIRO

:

I’.\TKKCY

OF

DL7CTLlS

~\RTERIOSCS

IS

.\D171~‘1’S

15D

Reports I+o~)L tttc Litej*rrture.-The first ease of typical patency of the ductus arteriosus in an adult, with clinical and post-mortem observations, was reported by Chever$’ in 1845. The patient, an adult woman, war; said to have died of tuberculosis, but., from the meager history and postmortem report, it appears possible that death may actually have bee11 caused by subacute bacterial endarteritis. Brief notes on the cases from the literature are given in Appendix ~1 to this article. Before considering the salient characteristics of thcNv cases, we shall report the adult patients of our own who came to autopsy.

Fig. In.-Stethocardiogram and simultaneous pulse.wave record hefore operation. Stethophone in second left intercostal space,. pulse hrachial arterv. Fig. lb.-&me as Fig. lrc. but four days after operation. Note flcation was used as in Fig. lcr.

on patient No. 1 recorder on rig),{ that

same

am~)li-

KEYS

AND

SHAPIRO:

P.\TESCT

OF

DIJCTVS

.\RTERIOSUS

IS

161

ADTJI,TS

About 150 c.c. of slightly bloodtinged purulmt fluit wrre found in the pericardial cavity. A fine, plastic, readily broken rsudatr united the prricardium with tlw St~rptocowus viritlnns was cultured from thr ant,erior surface of the left rentriclr. pcricnrtlial material. There wrre five i~ysterectm~ cl:~m~~s in the region of the Ilnctus arteriosus.

Fig.

3.-Anterior

view

01 the

heart

and

great

vessels

of

patimt

No.

2.

Heart weight, GX grams; generalized hypertrophy, more on right than the left side. Marked right-sided cardiac dilatation. All valves and chambers normal; marked hypertrophy of the papillary muscles of tricuspid and mitral valves. Length of the ductus arteriows. 3 mm. on the cardiac side, and 7 or .Y mm. on the lateral side. The aortic orifice was about 8 mm. in diameter, the pulmonary orifice, B mm. Minimal atherosclerosis in the aorta, none in the pulmomarg artery. The left lung was completely atelectatic, with no ernboli, infarcts, or abscesses. The upper lobe of the right lung showed moderate edema; most of the lower right lobe was atelectatic. There was a sterile abscess, 2 cm. in diameter. in the head of the pancreas. There was nothing else of importance.

16”

.\3Ib‘Hl(‘.\S

III~:.\I:‘I’

.I(l171iS.\l.

.s

Fig.

4.-Opened aorta endothelium.

and pulmonary artery of patient No. 2. Note normal with atheromutous patch at the orifice of the ductus.

pulnllal:rI’>

kEYS

AND

Autopsy

(Abstract).-Body

or cyanosis; three

large

The trophied.

heart

this

the

edema

decubital

ulcers

region

of

valves artery

were was

the

ductus.

of

but

was

in the

great

vessels

The

liver

weighed

Fig.

5.-Anterior

otherwise and

the

150

ankles.

on the back,

(and great vessels) The duct,us arterioaus

orifice

OF

length,

slight

myocardium, and of the pulmonary of

PATENCY

SHAPIRO:

ARTERIOSUS

IS

ADULTS

cm.; weight, 140 pounds. Btelectasis and crepitation

marked

dilatation

weighetl 33j grams, tvns very short, but The pulmonary normal.

of the large am1 both widely conus

Atherosclerotic

minimal

grams,

in the

and

showed

163

No jaundice of the lungs, bowel.

ventricles

were

hyper-

patent. The chambers, was dilated; the intima

smooth and normal except for thickening The aortic wall showed moderate normal.

were

1,850

DUCTUS

changes

were

in the region calcification in generally

absent

coronaries. pigmentation,

congestion,

and

central

atrophy.

Diagnoses (3) hydrothorax, of the duc.tus passive

view

of the

heart

and

great

vessels

of

patient

(Abstract).-(l) Carciuoma of the stomach, removed (3) pulmonary edema, (4) paralytic ileus (colon), arteriosus, (6) cardiac hypertrophy and dilatation, and congestion of liver.

No.

3.

surgically, (5) patency (7)

chronic

16-l

.\MKRIC.\K

I IK\B’l’

.JOTlRS.\I.

CASE 3.-This l&year-old woman was :ttlmitted to the hospital July 29. 1941, and died August 7. Her entering c+orupl:~ints were dyspnea, nausea and vomiting. anorexia, and pains in the feet, all of Tvlli(sll had grnduallv inc~W:ts~d in severity fol seTera weeks.

Fig.

B.-Posterior

view

of the

heart

and

great

vessels

History.-Since the age of 5 years, she had known and had always led a somewhat sheltered but otherwise medical and family history were unimportant.

of patient

tllat she normal

had life.

No. heart Her

3. trouble, general

Physical Bzaminution.-She was well developed and moderately obese. There were generalized anasarea, moderate ascites, and moderate cyanosis. The heart was greatly enlarged to the right and left, ant1 the contour was that of congenital or mitral The pulmonary artery was markedly enlarged, and the hilar shadows much disease. enlarged. The heart sounds lvere rapid and regular, with no murmurs; there were Ales in both bases. There was no fever or petechia.e. The blood pressure was 14?/40.

KEYS

AKD

PATENCY

SHAPIRO:

OF

DUCTUS

ARTERIOSUS

IX

165

ADULTS

Urinalysis.-Sp. gr., 1,030; albumin, t t t; occasional bacteria and 6 to 8 leucocytes per microscopic field. Diagnosis.-Congestive heart failure and congenital heart disease (interauricular septal defect 9). Course.-The patient grew worse rapidly and died of heart failure.

L. carotid L.subcl.a.

Fig.

7.--Opened

Fig.

aorta

K-Opened

Autopsy (Abstract).-No length, 157.5 cm. The costal margin.

of patient

porn.

No. 3. Note numerous orifice of the ductus.

pulmonary

liver

a. I

artery

edema, extended

of patient

cyanosis, or (i cm. below

a.

atheromata

No.

3.

Note

jaundice. the xiphoid

and

slight

fold

at

atheromata. Weight, 1% pound and 0 cm. below t

Is. 1,;

166

AMERICAS

The heart weighed some left ventricular 2 cm. long and 1.5 monsry artery were were no septal defects. the coronary orifices root of the aorta, the The

liver

weighed

JOURKAL

700 Gm.; it drowc~l marked right PIWI I it*ul:tr hgpertlophy xn11 hypertrophy. Thea tlwtus artrriosua was fbatcwt and was about cm. wide. Tht? plllIll0ll:l~y COUUS ilIld IlIt, f)r:lnc~ll~s of the pulmarkedly enlargc~tl. :\I1 of the valves w(xw normal, and thrw There wts minirmtl atherosclerosis of the wronxry artcrier; were normal. Therc~ w:Ls nmrketl intirird :~th~~ros~~lrr~wis of the ductus arteriosua, an11 the pulmonary >rrt~~r~. 1,425

Microscopic examination There pulmonary artery. the pulmonary artery.

Fig.

I-II&YRT

!I--Anterior

Din~noses.-(1) Patency trophy and dilat:ltion, (S) teriosclerosi r, am1 (5 ) mild

Gm.

and

sl~owc~l

modcrate

longestion.

rerraletl marke11 :~rteriosc~lntwis was a large ante-mortem (-lot in

view

of

heart

and

great

vessels

of tlrr

all right

of patient

brawIles of the main branc~h ot

No.

4

( 2 ) right vcmtricd:tl~ hypwof tlw tlwtus nrteriosus, thrombosis or embolism, (4) pulmonary :lrpulmonary ~~hr~,nit~ passirc~ congestion of tll(s liver.

Conzm&.-ThP l:rr$$! p’~tcw~y 01’ t 111, ,lwtus artrriosus :dlowt~d 46 years of rno~lThe tliagnosis was erately normal lift but ultimatc~ly 1~~1 to right rrnt+ul:tr failuw. It is possible that the murmur was audible impossible because there was no murmur. hnntomically, tlwe :~p~)e:~re~l to bc no rc~son why before the onset of failure. ligation could not have heen pcrformetl successfully.

KEYS

AND

SHAPIRO:

PATENCY

OF

DUCTUS

ARTERIOSUS

IN

ADULTS

167

CASE 4.-This 53-year-old woman was first admitted to the hospital September 2, 1941, and died February 5, 1942. Her entering complaints were headaches, nausea, vomiting, and fever, beginning about August 27, 1941.

History.-She year of age. A of 12 years. She physical activity. At the age of 19

had been told her heart disease was discovered before she was one definite diagnosis of congenital heart disease was made at the age had never been incapacitated but was always :forced to restrict her At no time did she have complaints suggesting cardiac failure. she had received digitalis for a time (reason unknown).

Fig.

lo.--Opened

aorta

Fig.

Il.-Opened

pulmonary

of patient

artery

No.

4. Note

of patient

atheromata

No.

4.

and

Note

fold

heavy

at orifice

patch

of ductus.

of atheromata.

Physical ~‘zami~wztion.-She was ~~11 developed and nourished. There was no cyanosis or clubbing. A systolic thrill was palpable in the second left intercostal space, ant1 a machinery murmur, typical of patency of the ductus arteriosus, was heard over this region. The systolic phase of the murmur was transmitted upwards and to

the back. were rrilrs

She had a Corrigan pulse ancl n capillary pulse in the finger tips. There in both bases. Roth the liver :~ud spleeu were ~~llpablc, but nut: tender. There were no petechiae. The blood pressure in the arm was 140/G, and in tile Her temperature ranged from 98” to 1trno F. ,‘;frcptococcu.s rchlmts leg, 170/96. was recovered from the blooll wltuw in 48 IIOU~S. The hemoglobin ~vvas 74 to 80 per rent. The heart was enlarged to tile left :tml right. There WCI’P marked enlargruwn t of the puln~onxry arterv and increxsctl sl~;~~lows of hilar vessels. ~rinn2y,si.s.~l’r:1(~I~ of albumin; $1’. g:“,. l.(W to 1.018: I,,, r~:ists 01’ c~r~throc~trs; 1. to ri leucocytes. nicr!//losi.s.-P:lten(,?of thus ,lwtus :Lrteriosus, wit11 superirnpose(l subwut (* ICIP tcrial endarteritis. Cowse.-Several rourses of sulfathiaxole, sulfanilamide. am1 sulfxdiaxine were ineffective. Repeated blooll transfusions increased the hemoglobin level from 5.5 per writ to 89 per (Tent. The temperature was normal during the last tllree weeks in hospital. Arrangement s were made to attempt to ligate tlw Ilwtus, but the patient, cxPirrt1 after twenty minutes of anesthesia i cgyc-lopropane intratracheally) before the operation was started. .l~top~q (.Ihst~crct ).-No edema, petechiae, or jaundice : marked cyanosis. Body length 1.58 cm. ; weight, 110 pounds. The liver was 11 cm. below the xiphoid process in the midline, but, even with the costal margins on the right ant1 left. slight, hypertrophy of the right ventricle The heart weighed 190 Gm. ; it showed and more marked hypertrophy of the kft ventricle. The aorti(>, pulmonary, and tricuspid valves were normal. The mitr:tl valve showed some old thickening and tlvo recent vegetation> on the medial leaflet. The l’oronary orifices were normal. The ductus arteriosus was patent and measuretl 1 2 mm. in external tliameter ; its smallest bore was about, 2 mm. in the contracted specimen. Vegetations and sever4 atheromata were present, in the pulmonary artery. There was an infawt, 1 em. in (liamcter, in the upper lobe of tlle left lung, anrl another, 1: vm. in diarrwt~~l~, in the lvft lower lobe. The spleen was firm, deep red in sect ion, and weighed S520 grams. The liver shomcd long-standing passive congestion, and weiF;hed 1,720 grxms. IIin~/~~sc.u.(1) Subacute bacterial endartcritis, (21 p:\‘cn*~~- of the t1uctus :,I’(,? ) (,hronic llassive c~ongestion of liver, tel,ilwus, (Z) infawts of lung, (4) awitw, (,8) left \-ontricwlar h>-pertrophy, and (6 j septic splenitis, (i) uterine myumat:t, (II) dilatation of left auricle and ~cntric~h~. ComnLent.-The correct diagnosis was not made by the original attending physician. The physical condition of the patient at this time, some months after the onset of the infection, made her a poor operat,ive risk. ANALYSIS

OF

60

CASES

IN

ADULTS

In an analysis of I)athologic changes and cause of death it is not justifiable to include our own Case 1, so that we have in our series a total of 60 adults with typical, simple patency of the ductus. There were 14 men and 46 women ; ‘i6.‘i per cent, w’crc women. The preponderance of females with patency of the ductns arteriosus is, if anything, more marked in adults than it is in series of all ages and of children previously summarized in the literature. For example, in Maude Abbott’s’ series of 97 cases in which the average age was 21.2 years at death, the females comprised 63 per cent of the total. The average age at death of the 14 men in t.he present series was 38.9 years; that of the 46 women was 35.5 years. The oldest man died at 58, and the oldest woman, at 66 years. We can estimate the reduction in

KlWS

AND

SHAPIRO

:

PATESCY

OF

DKCTUS

I\RTERIOSUS

IX

.\DUI,TS

16%

length of life by comparison with the average life expectancy of the Properly, this comparison should be made for each general population. individual in this series, using the life tables for the year of death and for the country of residence. Such exact comparison is impossible, hut a reasonable estimate can bc made. Since the life expectancy of adults is not greatly different in the Vnited States, England, and the northern European countries in which the rest of the patients resided, we can refer to the United States TAife Tables with no great error. Further, the life cspectancy of adults has shown a fairly constant,, slow increase in these countries for many years. The chronological mid-point of the present series is close to 1910; that is, roughly, half of the patients died previous to that time. Accordingly, it appears desirable to use the tables for that year. By this means we can say that the presence of patency of the ductus arteriosus in t,he persons in the present series coincided with an average reduct,ion in life expectancy of about 23 years in the men and 28 years in the women. Expressed in another way, we can say that these people, who were alive at the age of li, had a life cspcrtancy which averaged about half that of the population as a whole. The interpretation of these figures will be treated fnrt,her in the TXscussion. The cause of death in these cases is shown in Table I. Subacute bacterial endarteritis accounted for more than 40 per cent, and congestive heart failure for nearly 30 per cent. The two deaths from rupture of aneurysms of the pulmonary artery (Nos. 26 and 41) also must surely be ascribed to the condition of the dnctus. Roughly, 4 out, of 5 of these persons eventually succumbed to the effects of patency of the ductus. This is the more striking when we note t,hat the majority of these persons lived many years, during which they wcrc apparentl)- well adjusted to the defect. T.\BLE Car:ss NO. pj

OF DEATH

GO AUULTS

28.3 3.3 3.3 1.7 1.7

IYITH

CAUSE

%

-41.7 17 2 2 1 1

IN

Subacute

bact.

art. Cong. failure

end-

Rupt. pulm. aneurysm Cerebrovascular Ca. of stomach Suicide

I PATEX~P NO. --.A&-

OF THIS DUVTUS

ARTERIOWS CAUSE

subacute bact. endart.

”

3 .::

Prob.

D ”

5 3.3

Tuberculosis Rupt. aortic aneurysm Pneumonia Yellow atrophy Questionable

i

1 3

1.7 1.7 5

It is generally stated t,hat hppertrophy of the right side of the heart is characteristic of patency of the ductus arteriosus, and this is said Table II to be the result of increased pressure in the pulmonary artery. summarizes the observations in the present series. It is clear that hypertrophy of the right side of the heart is frequent, but, in many cases both sides were equally hypertrophied, and cases of predominantly left-sided heart hypertrophy are not rare. In some cases neither side was hypertrophied.

Dilatation of the pulmonary arter? is, of course, frequently associated with patency of t,he ductns arteriosus. It is not uncommon. howcrer, IO find that such dilatat,ion is not demonstrable ~~oe~ltgcnologieall~. We believe that this dilatation is, in fart,, nearly always present in adults, for it occurred in the majority of the patients in the prestlnt series. 1n ten cases, actual aneurysms 01’ the pulmonary artery were present. There may be some argument, as to 111~definition of’ “ aneu~~ystn”; CYJYtainly many fusiform dilatations oE the pulmonary arterv do not merit t,he term. When the dilatation is profound and well cGrcumscribcd, how ever, wit,h degenerative changes in Ihe walls, such an appellation seems justified. We have noted that spontaneous rnpturc oi’ such ant~arystns resulted in two deaths. The presence of atheromat,a and calcareous plaques in the pulmo~~an~y artery has been noted many times before and was prominent in all of our cases (cf. Figs. 4, 5, 11). This is so frequent t,hat, it, is the rule in adults. Exceptions occur, however, notably the 6%Fear-old patient oi White.g1 The fact tha.t these wthcromatn and plaques occur with almost, equal frequency in the aorlas of these patients has not been stwssd I)t’eviously. The length of the ductus is of interest in view ol’ t,hc prtisenl. possibilities of ligation. In general, the tluctus is short in adults, and cases in which it is a centimeter or more in length are rather rare (Appendix A Nos. 24, 27 40 46 52, 53). Cases are not uncommon in which the dietus is extre&el$ yli:rt, or even reduced to a mere fistula-like opening between the aorta and pulmonary- artery. Iii the present, series, ~aases of this type, rcpresentin, v very difficult or frankly inoperable ~otiditions, comprised 17 per cent of the total (10 out of 60 WWS, et’. Appcntlix A. it wsc of this cases 2, 4, 10, IS, 19, 25, 33, 37, 4s. 5%). lienz;‘” reported t,ype in an adult, wit11 calcificat,ion of tlw point oi’ .iunction 01 tlltl aortti and pulmonary artery; we hazrc hem unable to obtain the paper in which this is reported, 90 that WC have not included the pase in the I)rrsent series. The frequent>- of this condition appears to be considerably greater in adults t,han in infants and children, although it may occw in very young infants (LediberdePi . It would he of much interest, to compare the size of the lumen of the ductus with the severit>- of the cardiac disability and cause of death in these cases, but this is not I>ossiblt because of the absence of quanti-

KEYS

AND

SHAPIRO:

PATENCY

OF

DUCTUS

ARTERIOSUS

IN

ADULTS

171

tative data on the bore of the ductus. Even if post-mortem measurements were available, accurate comparison would be difficult because of the fact that the size of t,he bore in the post-mort,em contracted specimen may bc quite different from what it was in life, when the vessel was distended with blood under arterial pres+sure. We might expect that congestive failure would be more frequent when the communication is very large, but no real proof of this exists. The diagnostic signs in the present, series clearly pointed to patency of t,hc ductus artcriosus in most of the cases, and, except in the earlier cases, the diagnosis was made correctly in the majority of instances. In several instances, however, the diagnosis could not be made because there was no murmur. This was true in the case of Duroziez22 and in one of our own cases (Case 1). FoulisZ5 found that the murmur in his case disappeared entirely twenty-six days before death. All of these three patients died of congestive failure. The history in Motzfeldt’@ first case (Appendix A, No. 31) was incomplete, but the diagnosis was not made, and it is explicitly stated that there was no mention of any murmur. In addition, in two instances only faint. atypical murmurs were heard (Appendix A, Nos. 36, 39). Sternberg’” stated that there is always a characteristic shape and form of the patent ductus arteriosug, in that the opening of t,he ductus into the aorta is funnel-shaped, and at the pulmonary orifice there is some sign of a membrane or ridge. Jores43 agreed that this condition is very frequent, but also recognized several other types : (1) Extreme shortening, In the present (2) aneurysmal ductus, and (3) cylindrical ductus. series we have already noted the extremely short ductus type. Cases in which the aortic orifice of the ductus was considerab1.v larger than the pulmonary orifice are frequent (Appendix A, Xos. 12, 17, 22, 23, 27, 29, 30, 36, 37, 39, 46, 53). In at least one case, however, the pulmonary orifice was larger than the aortic orifice (Appendix 9, No. 24). The membrane or ridge referred to by Sternberg has been extensively discussed since Strassmann’sT7 publication of his theory of closure. In adults, at least, such a condition is occasionally seen (Wells;“O cf. F’igs. 7 and lo), but does not appear to have any important significance; a fold of the wall may occur at both orifices,j” but tends to occur at the aortic orifice because of the acute angle of insertion of the ductus into the aorta (cf. RoederG8). COMPLICATED

AND

ATYPIC.4L

PATESCY

OF

THE

DUCTUS

Patency of the ductus art,eriosns is peculiar among congenital defects in that it so frequently occurs without associated abnormalities. Ill Maude Abbott’s” series of 1,000 casm of congenital heart disease at all ages, simple patency of the ductus occurred in 92 instances, and, in 150 instances, patency of the ductus complicated other defects. Most of the latter patients died in infancy or at an early age, and we suspect that

1 hC

relative

prOportion

of

sinrplc

1 );rl vn(dy

to

w~x1 p!ic~;~t.tq]

(*())lc{it

iojls

is

considerably greater in adults. WC hare colleet4 data on t(~n adults, with post-mortem oI)servations, in whom patency of the ductus was 111~most prominent abnorm;~lil.~-, but in whom the patency was not typival or somr othvr defect was prvscnt. These arc listed, with brief rrol~, in Appen(Tix T< of this I);~pt~~‘. This list collld 1~ easily enlar& 1)~ including cast’s of tyarlc;position of the great vessels, septal dcfcets. puln1onary atresia. and so 011, lmt tll(:s(L 1laW been exrlnded in the beli(xI that it is not a concern of this inquiry lo examine situations in which patt~ny~ of the dnctus is secondary to other defects. Tt if; of intcrcst to note that, in Ihis series, nine of ten of the patients were men. Tn four instancrs there was associated coarctation of the aorta (Appendix H, Nos. 1, 3. M, ant1 9). In thrW inst.;lncvs the dlletlls WiIS anrnrysmal Rlltl filled with illI organized or l)ilrtl!01 ~ganized clot (Nos. 2, ti, 10). The e?rperic>nce of Graham2” is illnminatirl~. Hr tried to w mow a mediast inal lumor and tliswvcwd. post mortw. that th tmnol~ was in reality an aneurysm of lhe tluct us artcriosus. Shortly afterward hc encountered a similar case surgically-, hl \ViIS iIhlC to r*ctrcwt befor~c it

was

too

1at.c..

arc ruriositivs. Zn each inThe tWO CZ+X reIX)rted 11~ W~~~C’nCP” stanec the ductus was open lo the p’nlmonur~- arlcry, but the orifice of the latter was closed 1)~ a firm mcmhrane. This mcmbrancl was pierced hy a single pinhole in one patient u11cl1,~ two such pinholes in the other. As on(l would expect, lhrre was no cardiac disability in cithcr PilS(‘. DIS~:l-SSIOY

I

The application of autopsy results to clinical propnost ication is always tlificnlt because of the question of selection of cases. This was recognized Iy Bullock, Jones, and Dollc~y,” who included many- of the present cases in their discussion of cause of tleath in patency of the ductus artcriosns. Specifically, t,he chief possibilities 1hn1 the present series is not rcprcsentative seem to be : (1) Remarkable and pecnlia L’ eases telld t.o hc reoi 11-w ct11ct11s ported more frcqnently thall typicill PUSC’S. (2) E’ilterlc~~ map be unrecognized ;\ntl thcrei’oi*(~ unreported, when paCents die of noncardiac conditions. \yit,h regard to the first point, it will be agr~tl that rcamarkable cakes Patency of the duc+trls in the adult is ;ii*c more frequently reported. ;lud has be(ln generally considered ;I rather remarkable abnormality, If anything, \\‘e should expect that rtlga Idless of the cause of death. aLltl~()rs wonld compete to report the oldest patients and those cases in which a m;lrkp(l lesion was well tolerated. In other WOOS, we might, ]jelit?\~p t&l tlr(l pwwnt, seric5 worlld invliKtr t.hv ohleSt paCents, aS Well ;ls

1110~~

ews
this

were

true,

the

disabling

ill

\vlliyll the

alld

itlr

analysis lethal

cariiiac* of

effcet

lenioll

Ihe of

llad

l)resent

piik!TWy

110

IY~liltiOll

would

series of

t.hC

dUCl

US.

t0

dt%tll.

nndere&ilnate

II’

KEYS

ASD

SHAI’IRO

:

PATESCT

OF

DUCTIJS

ARTERIOSUS

IN

-1DIJLTS

173

It is certain that many autopsies on persons with patency of the dnctus fail to disclose the lesion because of the frequent use of the method of removing the heart in which the aorta and pulmonary artery are severed proximal to the ductus. This error would tend to be more frequent in cases of noncardiac death, and hence there would be a tendency to ovcrestimate the disabling and lethal effect of patency of the ductus. One important question may be asked: Where are the adult, living patient.s with patencv pf the dnctus 1 In any large city it is possible to find a few cases of patency of the dnctus, but, in our experience, these are almost always in children. Further, it should be emphasized that,, when we are dealing with adults, at least, there is no reason why persons with patency of the ductus who djc in the second and third decades should be discovered more readily or reported more often than those who die lat,er. Many of the patients in our own clinical series have been observed for years, and fully half of them for periods of four l-o eighteen years. With the exception of the patient who died rifler operation, only one of them exhibited any very marked change of status during all this time. (In Cases 3 and 4 in the series presented in this paper the patients were not seen prior to the beginning of the final illness.) In general, they live fairly normal lives, go to Bchool, or earn a living. One patient, a man of 35 years, is a playground supervisor. Another patient, a woman of 19 years, wishes to study physical education in the University. A third patient, a man of 28 years, has been rejected by the Army but works steadily at heavy manual work and has remarkable muscular development. Among the adults, only one, a prostitute of 31 years, shows signs of impending, serious, cardiac emba.rrassment. These facts could be taken as evidence that most patients with patency of the ductus arteriosns need not have the ductus ligated. Our patients are still quite young, however, and the fact that they keep in excellent condition, even for a good many years, does not mean t,hat they have any security against eventual subacute bacterial endarteritis or cardiac failure. It is striking in our own experience, and in the cases listed in Appendix A, that patients with patency of the ductus arteriosus: do not, in general, have long and repeated periods of failure or great cardiac dis.. abilit>- before the final illness. Ahnost none of them are “cardiac cripples. ’ ’ It is the rule that they maintain good compensation until either subacute bacterial endarteritis or cardiac failure intervenes. Very few survive once they develop failure; in this respect, these patients are in marked contrast to patients with mitral disease. Subacute bacterial cndarteritis is just as fatal in cases of patency of the ductus arteriosus as in other types. There is a record of one case in which a patient with a patent ductus developed subacute bacterial endarteritis and finally recovered completely after several years ;I’ tbc treatment in this case was entirely symptomatic.

The diagnosis of patency of ihc cl\lc+lls artoriosrls in lrc~murl~~ \vit!l great certainly, as shown b)- ihc Cilcl 1ila! we know 0C olrly two tliil~llc)st ici errors among 131 paticnls who were operated ul1011. \vc r;11011ll1note that,, in general, patients al)olll. wllom there is iIll?- clllcstion 01’ cliagnosis will not, 1)e subjccl c(l to sllrgical CX~~lO?‘ilt ion. (‘c>rlainly wc know, as \vits observed earlier in this paper! that anatomically t!-lbical l)atency 0I’ the ductus can exist with only an ent,ii*cl,v alypical systolic murmur or cv(‘n with no murmur at, all. Those conditions seem ty occur most I’rcqncnt ly in the final stages of failure and may represent. only a terminal at)normalit,y of blood prcssurc relationships in the prcat vessels. Very rarely it may ha.ppen that a murmur and other signs typical of patency of the dnctus arteriosus will exist for years and then disappear, leaving the patient apparently normal. We l?ilVChad two ems of this type, and several others, not very well anlilenticated, have been recorded in the older lit-erature. Rc are discussing these apparcntlJ spontaneous closures clsewhcrc, but here it is enough lo indicate that the phenomenon may occur, but is certainly very rare, and prob;lbly need not be considered in any practical analysis of the crvcntual outlook $01 patients with patency of the ductus. The natural history of patency of the ductus in the adult indicates a prognosis that is good t,o the extent that) the patient, may usually expect to live a considerable number of years with relativclp slight disability. On the other hand, every patient- is faced with the constant threat of Moreover, we can at best do no better subacute bacterial endarteritis. than say that life will probably 1~ short. As far as can be seen, there is no reason to place these patients on any particularly restricted regime ; patients who are voluntarily quite active seem to get along as well as the patients who are constant 1~ prevented from the slightest exertion. The present discussion can hardly close without some statement as to the desirabi1it.y of ligation of the cluct,us. Elsewhere we shall present an analysis of 134 operations; the salietlt, features are lo\\, mortality and Such patients a high percentage of what seem to he comI~let,t~ WIYS. should be freed of the possibility of developing congestive failure. It is not yet certain that these pat,ienls are completely insured against SdJIn adnlls, at least, it is probable that there acute bacterial endarteritis. are some atl1eromat.a in the great. vessels, and these might present, focal points for infection. JYe cannot say whether these atheromata will eventually regress. In any event, the orifices of IIP cllWtns in the aorta and the pulmonary artery will represent, crypts which might afford lodging for infection. The remarkable SUCCESS of Tonroff, et a1.,81,X2and Bourne, Keele, and Tubbs’” with ligation in the presence of subacute bacterial endarteritis may he taken as an indication that it is unlikely that patients with a ligated dudus will be likely t.o develop subacut,e bacterial endarteritis in the region of the ductus.

KEYS

AND

SHAPIRO:

PATENCY

OF

DUCTUS

ARTERIOSUS

IN

ADULTS

175

SUMMARY

1. Brief notes are given on 57 adults, with post-mortem examinations, who bad simple, typical patency of the ductus arteriosus. A few data are presented on 10 adults with at,yical patency of the ductus arteriosus. 2. Case reports are presented on four adult patients, with post-mortem examinations, who had simple patcncv of the duct,us arteriosus. 3. In simple patency of the ductus arteriosus the cause of death was subacute bacterial endarterit,is in over 40 per cent of the cases; 28 per Death resulted from rupture of a pulcent died of congestive failure. monary aneurysm in two cases (3.3 per cent). 4. After the age of 17 years, patency of the ductus arteriosus was associated with an average reduction of life expectancy of about 25 years; this is about half the life expectancy of the general population. In the majority of cases the paGent’s life is fairly normal while it lasts. 5. Both right- and left-sided cardiac hypertrophy occurred in these cases, but there was no enlargement in at least 10 per cent. Pulmonary aneurysms occurred in about 15 per cent. Atheromata and calcareous plaques occurred frequently, and the aorta was involved almost as often as the pulmonary artery. 6. In these adults the ductus was usually short, and, in some cases, was represented by a Gtula-like communication between the aorta and pulmonary artery. Difficult or even inoperable conditions occurred in about 17 per cent of the cases. The aortic orifice is usually larger than the pulmonary orifice. 7. A correct diagnosis of patency of the ductus can generally be made without great difficulty, but in some cases the condition cannot be recognized because of the complete absence of any murmur. 8. Among adults with simple patency of the ductus arteriosus, women predominate, representing about three-fourths of the cases. In atypical patency, however, this sex ratio seems to be reversed. 9. From analysis of the available data it is concluded that an attempt at ligation of the duetus is justifiable in spite of the absence of signs of decreasing adjustment to the defect. It must be expected that, in adults, difficult or impossible operative conditions will occur frequently. REFERENCES

On the Incidence of Bacterial Inflammatory Processes in 1. Abbott, M. E.: Cardiovascular Defects and on Malformed Semilunar Cusps, Ann. Clin. Med. 4: 189, 1925. 2. Abbott, M. E.: Atlas of Congenital Cardiac Disease, Am. Heart Assoc., N. Y., 1936. 3. Almagro, M.: etude clinique et anatomo-pathologique sur la persistance du canal artkriel, Paris, 1862, No. 63, 160 pp. Thesis. 4. Babington, B. G.: Cyanosis Dependent on Patent Ductus Arteriosus With Disease of the Aortic Valve, etc., London, Trans. Path. Soe. 1: 55, 1847. (Abstr. Jrf. Kinderkrank. 11: 137.) 5. Balfour: Clinical Lectures on Diseases of the Heart and Aorta, ed. 3, 1898, p. 243. 6. Bareroft, J.: The Brain and Its Environment, New Haven, 1938. Yale University Press.

9. Boldero, H. E. A., and Bedford, D. I<.: Infective Endocarditis in Congenital Heart Disease Involving the Pulmonary Artery, Laneet 2: 747, 1924. 10. Bourne, G., Keele, K. D.. or111 Tubl,s, 0. S.: Ligation and Chemotherapy fol Infection of Pat,ent Ductns Arieriosus, T>ancet 2: 444, 1941. II. Brady, J. G., :LII~ Rand&, A.: Patt,nt Dnctus Arterinsns, Ohio Rtate 1\T. ,T. 31: 599, 193Y. 1”I. Buchwald A.: Aneurysma des St:~lllmes cler Arteria Pulmonaiis, l>ruts;ch~~ med. Gchnschr. 4: 13, 25, 187s. 13. Bullock, L. T.: Personal communication, 1942. 1-i. Bullock, L. T., Jones, J. C., and Dolloy, F. S.: The Diagnosis and the Effects of Ligation of the Patent Ductus Arteriosus. A Report of Eleven (‘ascs, J. P&at. 15: 786, 1939. 15. Caylor, H. D.: Patent Ductus Arteriosus and Saccular Aneurysm of the Aorta, Tr. Chicago Path. Sot. 10: 296, 1918. 16. Chester, W.: Patent Ductus Botalli With Subacute Ha?terial Endocarclitis an@1 Recovery, AM. HEART J. 13: 492, 1937. Ii. C’hevers, N.: Permanence of the Ductus Arteriosus and Constriction of the Thoracic Aorta, London M. Gaz. n.s. 36: 187, 1845. 18. Dar&, J.: Persistanre du canal artbrie chez une femme de 51 ans., Rull. 8oc. Anat. Paris 40: 55, 1586. 19. D’Aunoy, R., and von Hamm, E.: Aneurysm of Pulmonary Artery With Patent Ductus Arteriosus (Batallo’s Duct) ; Report of 2 Cases and Review of Literature, 5. Path. and Bact. 38: 39, 1934. 20. Drasehe, A.: Ueher einen Fall +-on fersistenz des Ductus Arteriosus Botalli, Wien. klin. Wchnschr. 11: 1193, 1398. A C’ase of Dissecting Aneurysm of the Yul21. Durno, L., and Brown, W. L.: monary Artery: Patent Ductus Arteriosus; Rupture Into the Pericardium, Lancet 1: 1693, 1908. Mt?moire sur la persistance du canal arterie saris autre com22. Duroziez, P.: munication anormale, Gaz. mLd. de Paris (Ann&= X) 3: (XVIII): -LLl; Compt. rend. tioc. de Biol. 14: Bi9-2!C, IS62. 43. Fagge, C. H.: A Case of Patent Ductus Arteriusuh Sttended With a Peculiar Diastolic Murmur, London, Guy’s Hosp. Rep. 18: 23, 1873. BI.: Mykotix.he Endocarditis und Endarteritis der 24. Fischer, R., and Schur, Art,eria Pulmonalis Itci offenem Ductus Botalli. Klin. Wchnsrhr. 11: 114, 1932. 25. Foulis, J.: On a Case of Patent Ductus Arteriosus With Aneurysm of the Pulmonary Artery; Edinburgh 31. .I. 29: 1117; 30: 17, 1884. 26. Garipuy: Pkrsistan& du canal-artErie n ‘ayant entrafne aueun trouble pendant 28 am. Mort rapide B l’ocnasion d’un accouchement, Bull. et. m6m. Sot. Anat.

82:

179,

1907.

Lecture I. PerG. A.: Clinical Lectures ou (‘irculatory Affections. s‘)7. Gihtin, sistence of t,he Arterial Duct. and Tts Diagnosis, Edinllurgh M. J. ?Few Ser. 8: 1, 1900. Aneurysm of the Ductus Srteriosus With Consideration of 28. Graham, E. A.: Its Importance to Thorscie Surgeons, Arch. Surg. 41: 324, 194 :O. Endocardite. maligne develop& 29. Grenet, I?., Levent, R., and Joly; I’., et al.: SUP une cardiopathie eongCnitals (persistance du c:lnal a.rt&iel), Arch. de m&d. d. enf. 42: 449, 1939. Surgical Ligation of a Patent Ductus 30. Gross, R. E., and Hubbard, J. Y.: Report of First Successful Case, J. A. 11. A. 112: 729, 1939. Arteriosus: 31. Gross, R. E.: Surgical Closure of the Patent Ductus Arterioaus, Mod. Carlcepts Cardiovase. Dis. 10: No. 12, 1941. 32. Hall. E. M.: Healed Dissectincr Aneurysm of Aorta: Report of Case With P&tent Ductus Arteriosus and-Enormois Hppertrophy of-Heart, Arch. Path. and Lab. Med. 2: 41, 1926. 33. Hamilton, W. F., and Abbott, M. E.: Patent Ductus Arteriosus With Acute Trans. Assoc. Amer. Physic. 29: 294. Infective Pulmonary Endartrritis, 308, 1914. Sneury-sma des Ductus arteriosus 34. Hammerschlag, E.: Ein Fall x .on wahren Botalli, Virchow’s Arch. 258: 1, 1929. 35. Hart, C.: BeitrLge zur Pathologie des GefYtssystems. II. Uleeriixe Endokarditis mit Beteiligung des offenen Ductus Botalli, Virchow ‘s Arch. f. path. Anat. 177: 218, 1904.

KEYS

36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63.

ASD

SHAPIRO:

PATENCY

OF

DUCTUS

ARTERIOSIJS

IN

ADULTS

177

Hebb, R. G.: Aneurvsm of Ductus Srteriosus, London, Trans. Path. Sot. 44: 45; 1893. Patent Ductus Arteriosus Complicated by Hines, D. C., and Wood, D. A.: Endocarditis and Hemorrhaaic Neuhritis: Case- AM. HEART J. 10: 974. 1933. Hochhaus, H.: Beitrlge zur-Pathoiogie des Herzens, 1. Ueber das ‘Offenbleiben des Ductus Botalli, Deutsches Arch. f. klin. Med. 51: 1, 1893. Horder. T. J.: Infective Endocarditis. Quart. J. Med. 2: 289, 1909. Hubeny, M. J.: Roentgen Diagnosis ‘of Patent Ductus Arteriosus; With Report of a Case Complicated bv Presence of Sarcular Aneurvam, ilm. J. koentgenol. 7: 23, 1920. Jacobi, A. : Discussion of Paper by Hamilton and Sbbott, Trans. Assoc. Amer. Phys. 29: 308, 1914. Jones, J. C.: Personal communication, 1942. Jores, L.: Arterien. A Missbildungen und Hypoplasien. III. Offenen Ductus arteriosus Botalli, In Handb. d. spez. pathol. Anat. u. Histol. ed. Henke and Lubarsch, Vol. II, 1924, Herz u. Gefssse, pp. 614-619. Ductus Botalli nebat Atherom. in den dnten der Josefson, A. : Offenstehender Arteria nulmonalis. Nord. Med. Arkir. n.s. 7: 1. 1897. (Abstr. in Zbl. inn. Med. 19’ 634, 1898:) Kasakoff, P. T.: Zur Semiotik des Nichtverschlusses des Ductus Botalli, Wien. klin. Wochenschrift 42: 2, 1661, 1929. Kennedy, J. A., and Clark, S. L.: Observations on the Ductus Arteriosus of the Guinea Pig in Relation to Its Method of Closure, Anat. Rec. 79: 349, 1941. Keys, A.: Estimation by the Foreign-Gas Method of the Net (Systemic) Cardiac Output in Conditions Where There Is Recirculation Through the Lungs, Amer. J. Phpsiol. 134: 268, 1941. Keys, A., Friedell, H. L., Garland, L. H., Madrazo, M. F., and Rigler, L. G.: The Roentgen Kymographic Evaluation of the Size and Function of the Heart, Am. J. Roentgenol. Rad. Ther. 44: 805, 1940. Diagnostico, pronostico y Keys, A., Violante, A., and Shapiro, M. J.: terapeutica de pacientes con persistencia de1 conducto arterioso, Arch. latinoam. de cardiol. y hemat. 10: 237, 1940. Kidd, P.: Embolic Aneurysm of the Pulmonary ilrtery; Infective Sortie Valvulitis, Aortitis, and Pulmonary Endarteritis, Patent Ductus Arterionus, London, Trans. Path. Sot. 44: 47, 1893. Krzyszkowski, J.: Aneurysma des Stammes der Pulmonalarterie und multiple Aneurysmen ihrer VerLstelungen bei Persistenz des Ductus Botalli, Wien. klin. Wchnschr. 4: 92, 1902. Lediberder: Organisation anormale du coeur, obliteration de l’art2re pulmonaire a sa naissance, absence du canal artbriel, Bull. de la ,Soc. Anat. Paris 8: 68, 1836. Lenz, W.: Ein Beitrsg zur Diagnose des offenen Ductus Botalli, Inaug:Diss. Konigsberg, 1910. Lissauer, M.: TTel)er dan Aneurysma am Stamme der Pulmonalarterie, Virchow’s Arch. f. path. Anat. 180: 462, 1903. Luys, M.: Persistance du canal arteriel chez une femme de rinquante-deux ans., Bull. Sot. rinat. *June, 3853 (citetl 1)~ -\lmagro on p. 35) 30: 229, 1855. Mallory, T. B.: Congenital Heart Disease-Patent Ductus Arteriosus (Cabot Case 24222), New England J. i\led. 218: 937, 1938. Mead, K. C.: Persistent Patencyof the Ductus Arteriosus, J. Amer. Med. Assoc. 55: 2205, 1910. Melka, J.: Prispevek ke Znalosti morfoloeie a obliterate ductus arteriosi Botalli, Bratisl: lekar. listy 5: 73, 1923 (German abstr. in Zbl. inn. Med. 47: 175, 1926). Moench, G. L.: sneurysmal Dilatation of the Pulmonar>.Artery With Patent Ductus Arteriosus,, J. A. M. A. 82: 1672, 1924. Moenkeberg, J. G.: Stiirungen des Ductus arteriosus und der Aorta in der Gegend des Ductus, In Handb. d. spez. pathol. Annt. u. Histol. ed. Henke and Lubarsch, 1924. II. Section “Herz und Gefssse,” pp. 161-165. Motzfeldt, K.: Drei Falle von Offenstahendem Duetus arteriosus Botalli, Deutsche med. Wchnschr. 39: %R7, 1913. Murray, H. M.: Two Cases of Malformation of the Heart, London, Trans. Path. Sot. 39: 67, 1888. Pallasse, E., and Chanaleilles: Persistance du canal arteriel chez un homme de 47 ans. Lyon med. 145: 373, 1930.

64. a. 66.

ii:: 69. 70. 71.

72. 73.

74. 75. 76. 77. 78.

i9.

80.

81.

82.

83. 84. Y.T. 86. 87. 88. 89. 90.

91. 92.

Paul, F.: Zwei seltene Missbildungen des Herzens. Z. l
Williams, (:.: A Study of Aneurysm of the Pulmonary port of a Case, Maryland M. J. 22: 321, 1890. A Case of Patent Ductus Arteriosus, 94. Williams, E. C.: Child. 4: 310, 1904. Physiology of the E’etus, Philadelphia, 95. Windle, W. E’.: co. (pp. 44-47).

93.

Artery Rept.

With

the

SXIC. Study

1%&U, W.

B.

ReDis.

Saunders

KEYS

AND

PATENCY

SHAPIRO:

OF

PATENCY

IN

ADULTS

179

A

APPENDIX SIMPLE

-4RTERIOSUS

DUCTUS

OF THE

DUCTUS

IN

ADULTS

These are brief notes on 57 patients, reported in the literature, In the age of 17 years or more, and were examined post mortem. of death is given at the right-hand side of the first line.

who survived to each case the cause

Tuberculosis (subacute8) 1. CHEVERM 1845 Adult woman Ductus-about half as long as usual ligamentum, admitted a “common director. ” Notes-small mass of vegetations at pulmonary orifice of ductus which would act as valve preventing inflow to aorta from pulmonary artery. Subacute 2. BABINGTON 1847 Y-i-yr:old woman Ductus-extremely short (inoperable?). Heart-great dilatation and hypertrophy of both ventricles. CompZicaZions-pligllt aortic stenosis and coarctation. Notes-rheumatic history. 3. LUYH Dtictzls-admitted Heart-right Notes-many

1855 little finger. ventricle dilated calcified plaques

4. ALMAGRO Dzcctzls-walnut-sized communication Heart-enormously cm. thick. Notes-left lung

5%yr:old

woman

failure

Congestive failure artery touched aorta and free of the two vessels (inoperabIe). ventricle, vvvsll of which was 2.5

1862 3%yr.-old man dilatation of pulmonary existed between the lumens enlarged, especially right atrophic.

6. HCHNITZLER

7. E’AGGE Ductus-short, Heart-extreme pulmonary hypertrophic.

endart.

and hypertrophic. in pulmonary artery.

5. DUROZIEZ 1862 40.yr.-old man Ductzls-admitted a large pea. Hen&--right auricle dilated, right ventricle atrophy of left ventricle. Notes-to murmurs heard in life.

Dzlctus-diam. Heart-hypertrophy Notes-many

Congestive

bact.

1864 5 mm. bony

43.yr.-old

at pulmonary right ventricle. plaques in both

greatly

woman

end,

(i mm.

aorta

and

1873 45.yr.-old widely patent. dilatation right auricle, orifice, and pulmonary

Congestive

woman great artery.

hypertrophied,

Congestive erysipelas at aorta.

pulmonary

failure

failure

slight

with

artery.

Congestive

failure

enlargement tricuspid orifice, Both ventricles dilated and

8. BUCHWALD 1878 2’1.yr:old woman Subacute bact. endart. Ductus-easily admitted thick catheter. Henrl-right side of heart almost normal, right ventricular wall thickness 3-4 mm., left side of heart much enlarged, ventricular wall 17 mm. Com2,Ziccctions-aneuryslll (size of hen’s egg) of pulmonary artery. 9. E’OULIS Dzlctzls-about aorta.

ys inch

1884 long,

22.yr.-old narrowest

woman external

Bubaeute bact. endart. diameter % inch, large end

at

180

AMERICAS

HP:LIKT

JOURNAL

Heat+--greatly enlarged, both ventricles hppertrophii, Extensive vegetations. Complications-saccular aneurysm ( sizr of large \valnut) within pericardium. Notes-murmurs disappeared almost entirely twenty-six

right

auricle

dilated.

of pulmonary

artcry

days

before

death.

IO. DARIIZR

1885 51 -Jr.-old woman Congestive failure Dmtus-round opening betvvern aorta and pulmonary artery which apposition at the normal site of the ductus. (Inoperable.) Heart-greatly enlarged, apex formed by both ventricles. Notes-six or seven attacks of polyarticular rheumatism. but all valves Fairly normal life until shortly heforc death.

11. W.

H.

WHITE

1885

53pr.-old

man

Ductus-size of anterior tibia1 artery. Hearf-smal1, apparently entirely normai. Complicntiolzs-:\ngina pectoris, with exacerbations Notes-died in attack of angina afrcr one hour. 12. MURRAY

1588

Dzcctzcs-funnel-shaped, Heart-no right-sided Notes--calcification 1::. RICKARDS Heart-435 gm.; CompZicatio,~s--mycotic 14.

\VILLIAM,S Notes-multiple

::(i-.vr.-old

woman

Rml(len

and

were

in

normal.

death

cyanosis.

Subacute

bact.

endart.

large end at aorta. cardiac hypertrophy. in wall of aort,ic side of ductus.

left

1889 1 i-yr.-old man Subacute bact. endart. v-entricle slightly hypertrophir. aneurysm of branch of right pulmonary artery.

1890 aneurysms

-10.pr.-old of pulmonary

woman artery

Pulmonary tuberculosis and its branches.

1893 31 -gr.-old woman 15. SACHS Subacute bact. endart. Dzlctzls-widely patent. Complicatiorbs-aneurysmal dilatation of main pulmonary artery, and aneurysm (2.5 cm. diam.) of right lower branch. Direct continuation latter obliterated. 1 S’13

16. KID11 Ducftis-opening

2-O.yr.-old

woman

Suhxcute

bact.

oval of

endart.

to left pulmonary artery size of goose quill. Both sides hypertrophied and dilated, especially the left. Hem-625 gm. Complio&iorrs-small saccular aneurysm of aorta close to ductus orifice. Saccular aneurysm, size of walnut, in lung, surrounded by healthy tissue. some softening to minute cavities, in Few small tuberculous nodules, lungs.

17.

JOSEFSON Dwtu,s-4

Heart-right Notes-this 18.

19.

mm. bore ventricle appears

ti(i-yr:old woman Sudden death 1897 at pulmonary orifice, (1 by 10 mm. at aorta. hypertrophic; right auriele dilated. to be the oldest patient on record.

L’S-yr.-old woman Suicide 1898 DRASCHE DzcotuJ-fistula-like hole, 3 mm. bore. (Inoperable.) Heart-small, flabby, thin-walled. No anomalies. dotes-always well until vomit,ed dark blood 6 months before suicide. Murmurs ht~~l, but ~~onsiilerod I ‘accidental. of thin nnexplaine
short,

:ll-yr.-old 1900 admitted 12-14

woman bougie.

Pneumonia

Cause ’’

KEYS

AXD

PATENCY

SHAPIRO:

Healt-right ventricle CompZicaticnz,~-delivered 20.

KRZYSZKOWSKI, Dzcctzls-diameter Heart-hypertrophy CompEications-aneurysm stem, multiple generation in Notes-all valves

21.

WEINBERGER

OF

DUCTUS

ARTERIOSUS

dilated and hypertrophie. of seven-month-old child

two

IN

weeks

181

ADULTS

before

death.


37.yr:old

woman

Congestive failure and pneumonia extending to wall of n~rta

Ductus-aneurysmal, thrombotic vegetations pulmonary artery to valve. Heart-pulmonary valve insufficient. Colnplicutions-repeated rheumatic and rardiac. fore pneumonia and failure.

attacks

for

four

and

weeks

be-

23yr.-old woman Subacute bact. endart. 22. HART 1904 Dzlctzcs-funnel-shaped, large end at aorta, patent to a middle-sized sound. Embolic xbHeart-practically normal size, slight dilatation left ventricle. scesses in myocardium. Notes-author considered infection developed : aortic valves to ductus to pulmonary artery. 22.

HART 1904 24.yr.-old woman Subacute bad. endart. DuctzLs-funnel-shaped, large end at aorta, fresh embolus at pulmonary end extending into pulmonary artery. Heart-both ventricles moderately dilated. Embolic abscesses in heart wall. Notes-author considered infection developed: aortic valves to ductus to pulmonary artery.

24.

LISSAUER

1905 24yr.-old man Congestive failure long, bore 6 mm. at pulmonary orifice, 4 mm. at aorta. At both folds of wall cut off about half of lumen. Heart-moderate hypertrophy both ventricles, especially right. Complications-bicuspid aortic valve. Aneurysm (size of hen’s egg) of pulmonary artery. Slight hypoplasia of aorta. Marked emphysema both lungs.

Ductus-15

23.

mm. orifices,

38.yr.-old woman Congestive 1907 mm. diam., extremely short, pulmonary artery and in apposition. (Inoperable?) Complications-Sudden onset of failure few moments after ond confinement. Died in twelve days.

failure aorta practically

GARIPUY

Ductzts-IO

26. DURNO

and

BROWN

1908

33.yr.-old

man

patent, walls atheromatous. marked hypertrophy of right ventricle. Complications-dissecting aneurysm of pulmonary cardium. Notes-two weeks before death, attack of severe death in sleep, without warning.

Ruptured aneurysm

delivery

in

see-

pulmonary

Dzcctus-widely

Eeart-very

27. WELLS

D?Mu6-16

mm.

long,

1908 5 mm.

42.yr.-old man bore at pulmonary

artery chest

ruptured pain

Acute yellow orifice, 8 mm.

with

into

peri-

vomiting;

atrophy at aorta.

Heart-3GO

Notes--cardiac

gm.; slight hypei-trophy right ventricle. symptoms unimportant in last illnc~ss.

23. HORDER

1909

Heart-510

4P-yr:old

woman

S11h:wute

had.

cudart.

gm.

Notes-clinical

diagnosis, mitral

dis~~ase.

39. MEAD Dw~w-4

1910 26yr:old woman (longestive failure mm. bore at pulmonary orifice, 10 mm. at aorta. Heart-39,5 gm. ; both ventricles moderately hypertrophic, three ruptures of right ventricle, two ounces fluid blood in pericardial sac. CompZication.s--slight sortie and mitral stenosis, rheumatic history. Scoliosis. Complete paralysis left vocal cord.

30. SOMMERS 1910 45.gr:old woman Subacute bact. endart. Ductzcs-cone shaped, size of hazelnut at aortic orifice. Heart-hypertrophy and dilatation of right ventricle. Notes-ulcerative endocarditis of aortic valves and vegetations covering wall of ductus and of pulmonary artery all way back to pulmonary valves. 31. MOTZFELDT

191::

33.yr:old

man

Sudden death; cause un. certain

Dzlctzls-small caliber. Heart-both ventricles slightly hppertrophic. Notes-no mention of any murmur in previous medical history. 32. MOTZFELDT Heart-700

1913 gm. Hypertrophy

55.yr:old woman Congestive failure and dilatation of right ventricle.

33. MOTZFELDT

1913 3%yr.-old man Tuberculous pneumonia mm. diameter, extremely short, practically fistula between aorta and pulmonary artery. (Inoperable.) Heart-590 gm. Both ventricles hypertrophic, especially right. Notes-cardiac symptoms nnimport,ant in last illness. Ductas-

34. HAMILTON ABBOTT

and

1914

19.yr:old

woman

Subacute bact. endart.

Du&us--7.5 mm. long, ‘ ‘ admitting a penholder. ’ ’ Healt-slight hypertrophy and marked dilatation right ventricle. All endocardial structures normal. Complications-mycotic aneurysm of pulmonary artery. Slight coarctation of aorta (6 cm. circumference at origin, 5 cm. at left subclavian, 4 cm. in descending portion).

35. STODDARD Ductus-

Heart-very ::ti.

li-yr:old 1915 mm. long; bore, 5 mm. slightly enlarged.

CAYLOR Ductus-diameter

woman

Subacute bact. endart.

1918 40.50-yr.-old woman Ruptured aortic aneurysm 3.5 mm. at pulmonary artery; 6 mm. at aorta. Heart-4S5 gm. ; wall thickness, left ventricle, 11 to 34 mm., right ventricle, 4 to 8 mm. Com@iuztions-ruptured aortic aneurysm, easily contained a whole fist,. Notes-diagnosis of patent ductus made twenty-one years before death, while still in apparently fair health; the thrill and machinery murmur disap peared, and were replaced only by poorly defined systolic murmur in pulmonary area.

KEYS ::7.

AND

SHAPIRO:

I’ATEXCY

OF

DUC’L’CS

ARTERIOSUS

Congestive BXUMLER 1919 3ti-yr.-old woman Ductus-wide, funnel-shaped, large end at aorta, no actual 0.5 mm. long). Heart-much enlarged right ventricle; left normal. CompZicntion.s--miliary and nodal tuhereulosis of lungs. Notes-this patient observed eightct~n Fears (when strong death.

IS

183

ADULTS failure vessel (less

and

well)

than

until

Ruptured aortic aneurysm 28. HUBENY 1920 37.yr.-old woman Heart-marked left-sided cardiac hypertrophy and dilatation. Complications-syphilitic aortic aneurysm observed, but not recognized in roentgenogram before rupture. Notes-diagnosis of patent ductus made twenty years before death. Shadow of aortic aneurysm seen shortly before death; but ascribed to patent ductus. 1922 Cerebrovascular accident 29. WELLS 50.yr.-old man Ductzcs-coneshaped, 10 mm. at aortic enz, 5 mm. near pulmonary orifice, Iatter closed to 1 or 2 mm. bore by fold of soft membrane protruding into pulmonary artery. Heart-400 gm.; both ventricles dilated. No anomalies. Notes-soft mitral murmur, not transmitted, only cardiac sign observed in few hours before death. 1924 29.yr.-old man Subacute 40. BOLDER0 and BEDFORD Ductusmm. long. Heart-greatly enlarged; both ventricles hypertrophic. Complicrctions-history of rheumatic fever. Notes-2 small calcified areas in aortic wall near ductus. 200/90 before onset of subacute bact. endarteritis. 41.

MOENCH

1924

29-yr.-old

woman

TERPLAN Ductus-bore Heart-hypertrophy

43. HAMMERSCHLAG Dzlctzls-true Heart-both Notes-histologic

1924

von

woman

Blood

pressure

of

pulmonary

symptoms

Subacute

bact.

endart.

1925 51.yr:old woman Subacute mycotic aneurysm of ductus. ventricles hypertrophic. studies proved true aneurysm of ductus.

bact.

endart.

except

2 mm. and

44. ROTH Dudusmm. dealt-moderately 45.

35yr:old

endart.

Ruptured pulmonary aneurysm

Dzlctus-admitted index finger. Heart-mitral valve thickened; pulmonary valve bicuspid. CompZicntio%s-aneurysmal dilatation (3 inches in diameter) artery, ruptured into pericardium. Lungs congested. Notes-small plaques of atheromata in aorta. No previous slight exertional dyspnea. 42.

bact.

long,

dilatation

1927 ulcerative enlarged,

of left

ventricle.

23-yr:old woman Subacute bact. endart. endarteritis at pulmonary orifice. fatty degenerative changes in myocardium.

SCHULEZ 1928 25yr:old woman Congestive failure Dzlctzcs-admitted pencil. Heart-very marked hypertrophy and dilatation of right ventricle. Complications-five months pregnant, surgical abortion planned after to compensation, but she died before this was achieved.

return

+I; . I’ . 1).

\VHIl’I

1

192s 6%gr:oh1 woman (‘c~~.cl,~o~:l~~ul:~~ :tcci(lcnt mm. long, 1 1,111,. bore at pullnon:lry arlny, 10 n,,,,. at :Iort;c. gm.; both vent,rieles hypertrophic. Hevcw sclerosis of coronaries, aortic and mitral valves, aorta, and papillxr,v muscles of left ren-

Ductzls--32.5

Heart-430 also tricle.

Notes-pulmonary nrtevy smooth nrrtl age of 40 ycmrs. 47.

KASAKOFE’ Dzlctun-5 Heart-both

Pirsl

normal.

O&yr.-old woman 1929 diameter, 5 mm. wall thickness hypertrophic:;

mm. long; ventricles

heart

nol~tl

Subacute :

trouble

bact.

rrt

cndart.

left , 23 mm.,

right,

10

mm.

48.

+lT-yr:old man Congestive failure PALLAHSE and 1 93 0 CHANALEILLES Ductrls-practically fistula between aorta and pulmonary artery, 12 mm. Organized clot almost obliterated free lumen. ( Inoperable.) Heart-700 Gm. Right ventricle more hypertrophic than left. Compl(ca,tio7~.~-rlleurnatisnl at age 7. 1 g3 I

4’). . WElSS c Heart-350 Kotes-patient calcified 50.

FISCHER

and

Ductus+asily Heart-left Notes-questionable 51.

52.

PERRY Notes--first

3::.yr:old

,vonian

Suhn~~utr

hart.

diam.

rntlnrt.

Gm. had plaque

five children, two miscarriages. at aortic orifice of ductus.

BCHUR patent ventricle

diagnosetl

SU-yr.-old 1932 to thick sound. hypertrophic. history of rheumatir

woman

XT-yr.-old

woman

19:::: patent

ancl

3%vr” . -old

1W-l

d ‘AUNOY and von HAAM

ductus

fever

\Vassermann

Hubacute

few

years

ha&.

I)isclike

cndart.

earlier.

Subacute

pulmonary

&.

bact.

endart.

hnct.

rntlarl.

luherculosis.

man

Suhacutr

Dzlctzls-15

mm. long. CompZicatio?ls-aneur~srll

53.

19:s

BRODY and RANDELL

Ductw-14 Heart-both iVotes-congenital palpitation

of

pulmonary 66yr:old

mm. long, diameter -1 mm. ventricles enlarged. polycystic kidney, until age of 62 years.

artery.

Syphilis.

woman

C’ongrstive

at pulmonary

artery,

ureter Died

failure 9 mm.

No symptoms absent. at age of 65 years, 111/

1935 1%yr.-old woman Subacute bact. WOOD about 2-3 mm. Heart-great dilatation of both sides; not much hypertrophy. Notes-pulmonary valve leaflets completely destroyed, pulmonary other valves normal, ductus almost filled with vegetations, polypoid vegetations on aortie side of ductus.

54. HINES

at aorta.

and

except months.

endart.

Ductwlbore

55.

MALLORY Dzlctzls-aorta a small erable.)

and round

2 1 -yr.-old woman 1938 pulmonary artery in apposition hole at the usual site of the

Subacute and ductus

bact.

artery two

and small

endart.

communicating arteriosus.

by (Inop-

KEYS

AND

SHAPIRO:

PATENCY

OF

DUCTUS

ARTERIOSUS

IN

Subacute

bact.

185

endart.

56.

GRENET, LEVENT 1939 l7-yr.-old and JOLY Dzcctus-5 to 10 mm. long; small caliber. Heart-both sides dilated and hypertrophic. Notes-no dilatation of pulmonary artery.

57.

40-yr.-old woman Congestive failure BETTINGER 1941 Wall rigid with calcifications. Duotw-8 mm. long; 7.5 mm. in diameter. Heart-extreme hypertrophy right ventricle (wall thickness up to 20 mm.). Complications-died of failure seven days after pelvic operation from which she failed to rally. k’PENDI?( ATYPICAL

PATENCY

OF THE

woman

ADULTS

B DUCTUS

IN

ADULTS

Pneumonia 1. CHEVERS 1845 Young man Ducts-about 4 mm. communication between aorta and pulmonary artery, %hich were in apposition at usual site of ductus. (Inoperable.) Complicntions-considerable constriction of aorta above site of communication with pulmonary artery. 1893 4U-yr.-old man Pulmonary tuberculosis 2. HEBB Ducttis-aneurysmal (size of walnut) filled with firm laminated clot. Heart-verrucose endocarditis of aortic valve. Com~licatiolzs-complete obliteration of left branch of pulmonary and marked stenosis of left branch at its origin. Notes-no cardiac anomaly suspected during life. 1893 24.yr.-old man 3. HOCHHAUS Dzlctzls-diameter about G mm. in middle, 7 mm. at aortic end. Heart-greatly dilated and hypertrophic. CompZicatio7ls-marked stenosis of aortic arch just Notes-there was a prominent diastolic murmur as systohc murmur.

Subacute

bact.

at pulmonary

artery

endart. end,

14 mm.

before orifice of the ductus. well as the usual prolonged

1903 4. WAGENER 38yr:old woman Pneumonia Ductusmm. long, 7 mm. bore except at pulmonary orifice, by membrane except for pinhole communication. Heart-normal. Notes-no dilat,ation of pulmonary artery.

which

was closed

5. WAGENER

1903 42-yr.-old man Postoperative peritonitis Dzlctw-funnel-shaped pouch in aorta projected into pulmonary artery; pouch was pierced by two very small holes. Considered patent ductus pathologist. Heart-chronic endocarditis of aortic valves, slight stenosis of aortic pulmonary valves. Notes-no murmurs in life.

this by and

6. MOENCKEBERG 1924 35yr.-old man Congestive fdlureB Ductus-aneurysmal (half size of apple), filled with clot, not patent throughout. No trace of ligamentmu nrteriosum. Heart-marked eccentric (right-sided) hypertrophy. Notes--marked paralysis of left vocal cord. Clinical diagnosis was “war nephritis. ’’

7. HALL 1920 Ductus-bore, :: mm. Heart-greatly enlarged (SO and insufficient. Complicntions-llealed ~liaswtin~

::L(-yr.-olll gm.),

(‘~1n:wtivc~

mall

chiefly

xuvurysm

left

n(31’

1930 xi-yr:old man s. PAUL Ductus-patent to a thick sound. Heart-770 gm., both sides equally enlarged. Complications-istllnlus stenosis of :torta sharply orifice of ductus. Notes-rheumatic fever at 38 years. 9. UI,RlCH 1932 LX-y-old man Dzlctws-formed principal sourw of blood supply Heart-870 Gm., both sides gwatlv enlarged, right ventricle wall thicknrss 1 I) to 20 mm., Complicatiorzs-aortic awlI grrallv . cwnstrivted insertion of ductus, hypoplastic descending (2,725 gm.) . Bundle branch block. Notes-worked as farm laborer without trouble 10. GRAHAM Dzlctus-aneurysmal, ated. Heart-moderate functionally Notes-preoperative

1940 2 I -yr.-old filled with part,ly llypertroplly closed), right diagnosis (NM

tliwrssiw~

011 pnge

rincr B ~lilatrr!

\-alvr.

E1rysipelns

~~~llfinc~l

to

Iwiut

uppositc

Suclden failure tlw (lescending aorta. but right more so than left ; left 1.5 to SO mm. betwvceil left sul&~vi:m au11 Cirrhosis of the liver aorta. to

until

man organized

left ventricle, aorTiv arch. was nlediastinal

Aortic

vcntrivlc.

of aorta

Failrlvtl

tlr~reloprumt

of ascites.

Hem. at operation clot, pulmonary end patent tumor. Z&Y. 1

foramen

ovale

obliter-

( probably