Multimodality imaging of patent ductus arteriosus with severe pulmonary hypertension following 3 pregnancies

Patent ductus arteriosus (PDA) typically presents in early childhood. Undiagnosed cases can progress to pulmonary vascular disease with significant morbidity and mortality. We present the case of a 46-year-old woman who presented with exertional chest discomfort and was subsequently diagnosed with severe pulmonary hypertension secondary to a large, previously unrecognized PDA. Multimodal imaging demonstrated right ventricular dilation and dysfunction, with pulmonary arterial pressures at systemic levels. Right heart and left heart catheterization revealed systemic level pulmonary vascular resistance with evidence of bi-directional shunting. The patient demonstrated mild symptomatic improvement with medical therapy; however, given the irreversibility of pulmonary hypertension, lung transplant referral was made. This case is notable for the patient's survival into the fifth decade without cardiac intervention despite having completed 3 pregnancies. This example illustrates the complementary roles of echocardiography, cardiac MRI, and CTA in diagnosing and characterizing congenital heart disease presenting in adulthood with advanced pulmonary vascular complications. Multimodality cardiovascular imaging approach to unrepaired patent ductus arteriosus presenting with Eisenmenger syndrome. The 3D CT angiographic reconstruction (center) demonstrates the ductal connection between the main pulmonary artery and descending thoracic aorta. Echocardiography, cardiac MRI, and invasive hemodynamics provide complementary diagnostic and prognostic information guiding management.