a 20-year - old refugee from liberia was referred to our hospital because of a loud murmur .
, he had been admitted to a hospital in his home country several times because of respiratory tract infections and  heart
problems. he had a low body weight of 45  kg at a height of 1.63  m. he was hypertensive with a 50  mmhg difference in systolic blood pressure between his upper and lower extremities : 170 vs. 120  mmhg .
the electrocardiogram showed sinus rhythm 84 beats / min with signs of left ventricular hypertrophy .
1 ) revealed a dilated , hypertrophied and hyperdynamic left ventricle due to a large pda with a continuous left - to - right shunt .
just distal to the pda , narrowing of the aorta was visible , with an increased systolic flow velocity .
the absence of a classic  sawtooth pattern in the continuous wave signal from the descending aorta as well as the presence of holodiastolic flow reversal in the abdominal aorta suggested non - severe coarctation .
the cardiac valves showed no abnormalities except for a mild pulmonary regurgitation with an early - diastolic flow velocity of around 3  m per second , suggestive of elevated pulmonary artery pressure .
the descending thoracic aortic wall had an irregular aspect and its narrowing was most severe just distal to the pda .
right ventricular and main pulmonary artery pressures were elevated ( systolic right ventricular pressure 55  mmhg , main pulmonary artery pressure 48/31  mmhg at a systemic blood pressure of 167/84  mmhg ) , but peripheral pulmonary artery pressures were normal .
a peak - to - peak gradient of 50  mmhg was measured in the descending aorta . 

1transthoracic echocardiography in patient a. a apical four - chamber view showing dilated and hypertrophied left ventricle .
b parasternal view of the pulmonary trunk and arteries showing turbulent flow due to a pda with left - to - right shunting ; a stenosis of the proximal right pulmonary artery is also visible ( asterisk ) . c suprasternal view showing pda ( asterisk ) as well as coarctation of the aorta .
d continuous wave doppler signal from the descending aorta , showing elevated systolic flow velocity of about 4  m per second .
2preoperative and postoperative magnetic resonance angiography . a preoperative magnetic resonance angiography ( mra ) of the aorta ( sagittal plane ) , showing large pda ( black arrow ) and irregular aspect of the descending aorta with coarctation distal to the pda ( white arrow ) .
b repeat mra of the aorta after surgical correction of the pda , showing irregular aspect and ( mild ) residual stenosis / coarctation of the descending aorta transthoracic echocardiography in patient a. a apical four - chamber view showing dilated and hypertrophied left ventricle .
b parasternal view of the pulmonary trunk and arteries showing turbulent flow due to a pda with left - to - right shunting ; a stenosis of the proximal right pulmonary artery is also visible ( asterisk ) . c suprasternal view showing pda ( asterisk ) as well as coarctation of the aorta .
d continuous wave doppler signal from the descending aorta , showing elevated systolic flow velocity of about 4  m per second .
a typical  sawtooth pattern is lacking preoperative and postoperative magnetic resonance angiography . a preoperative magnetic resonance angiography ( mra ) of the aorta ( sagittal plane ) , showing large pda ( black arrow ) and irregular aspect of the descending aorta with coarctation distal to the pda ( white arrow ) .
b repeat mra of the aorta after surgical correction of the pda , showing irregular aspect and ( mild ) residual stenosis / coarctation of the descending aorta the patient was referred for surgery .
closure of the ductus arteriosus was performed and the pulmonary artery was reconstructed ( fig . 
after ligation of the pda , the pressure gradient in the descending aorta had decreased from 50 to 20  mmhg and this ( mild ) residual coarctation was left untreated . whether it will need ( percutaneous ) treatment in the future remains to be seen .
he had previously been diagnosed with severe hypertension with a poor response to medical therapy .
approximately eight years prior to referral to our hospital , echocardiography had already revealed left ventricular hypertrophy .
moreover , it showed a pda with a continuous left - to - right shunt . a murmur had never been heard . at that time
when he was referred to our outpatient clinic he did not have any cardiac complaints , although his exercise capacity had gradually deteriorated over the past year .
in addition to the pda , echocardiography now showed not only left , but also right ventricular hypertrophy and an estimated right ventricular systolic pressure of 57  mmhg .
he was referred for treatment of his pda on the assumption that it had contributed to the development of pulmonary hypertension .
it must be noted that the pda was silent and did not appear very large on echocardiographic and mri .
moreover , diastolic dysfunction due to left ventricular hypertrophy may have played an important role in the development of pulmonary hypertension as well .
however , a contribution of the pda to the development of pulmonary hypertension could not be excluded and the patient was therefore accepted for percutaneous closure of the pda .
angiography of the aortic arch and the occluded pda with coil in situ can be seen in fig . 
in due time , echocardiography will be repeated to document whether his pulmonary artery pressure will decrease . 

mri visualised the jet of the pda flow entering the pulmonary bifurcation ( black arrow)fig . 
mri visualised the jet of the pda flow entering the pulmonary bifurcation ( black arrow ) angiography of the aortic arch .
pda is usually diagnosed shortly after birth , and treated surgically or percutaneously to prevent the development of pulmonary hypertension and heart failure .
the first case represents a more complex form of pda , associated with additional congenital cardiovascular anomalies and with left ventricular volume overload as one of its main characteristics . in the second patient ,
pulmonary hypertension was the sole reason for closure of the pda , and left ventricular dilation had not developed .
a difference in shunt size is probably the main reason for this difference . in addition
, it may be possible that patient b s severe left ventricular hypertrophy due to hypertension prevented left ventricular dilatation .
closure of a pda is only feasible when irreversible pulmonary hypertension has not yet developed . in adults ,
a , surgical correction of the pda was performed because of its large size and concomitant anomalous aortic anatomy .
pda patients who are beyond surgical or percutaneous closure should be treated according to the guidelines for eisenmenger syndrome .
 patent ductus arteriosus ( pda ) is a rare diagnosis in adults , since symptoms and signs usually occur in infancy and most cases are treated shortly after diagnosis . 
 we present two patients who were first diagnosed with pda during adulthood . 
 the first case represents a more severe form of pda , where the need for closure of the pda is obvious . in the second case 
 the sequelae of the pda are less clear . in both 
 patients , closure of the pda ( surgically in one case , percutaneously in the other ) was successful . 