心外科概论.ppt

,单击此处编辑母版标题样式,.,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,心外科概论,心外二科：谢飞,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,我第一次看到跳动的心脏，真是激动人心的经历，那仿佛是在寻找通往天堂之门。,-,丹顿,阿瑟 库利,胸外科年鉴,，,1986,年第,41,卷第,1,期第,20,页,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,1896,年,9,月，第,1,例心脏外伤缝合。,Ludwig Rehn,（德国）,1938,年,8,月，第,1,例动脉导管结扎。,Robert Edward Gross,（美国）,1944,年,11,月，第,1,例,BT,分流术。,Alfred Blalock,（美国）,1952,年,9,月，第,1,例心脏直视手术。,F.John Lewis,（美国）,1953,年,5,月，第,1,例体外循环手术。,John Heysham Gibbon,（美,国）,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,Helen B.Taussig,（,1898-1986,）,Alfred Blalock,（,1899-1964,）,Vivien Thomas,（,1910-1985,）,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,编码,:150001,哈,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心内手术基础设施,体外循环,哈尔滨治疗心脏病医院 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,体外循环简介,体外循环（,CPB,）是将回心的上、下腔或右心房的静脉血引出体外，经人工肺进行氧合和排除二氧化碳（气体交换），再经人工心泵入体内动脉的血液循环。,人工心肺机,：完成体外循环的装置。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,体外循环机,哈尔滨治疗心脏病医院哪家好 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,人工心肺机的构件和功能,体外循环的预充和血液稀释：,排气，降低血液粘滞度，改善微,循环，增进组织灌注，减少红细胞损伤，减轻凝血机制紊乱。,血泵（人工心）,氧合器（人工肺）,变温器,血液浓缩器,微栓过滤器,哈尔滨治疗心脏病专科医院 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,主泵,体外循环机,氧合变温器,储血器,CPB,系统建立方法,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,体外循环的监测,混合气体,储血器,氧合变温器,主泵,右心吸引,左心吸引,停跳液灌注,体外循环机,变温水箱,停跳液变温系统,血氧饱和度监测,动脉泵压监测,停跳液,泵压,监测,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,流速探测器,血氧饱和度、,血球压积监测,鼻咽温,肛温,.,.,.,ACT,*,动脉压、中心静脉压、泵压、血气分析、电解质,pH 7.452,PCO2 35mmHg,PO2 456mmHg,Hb 7.2 g%,BE 3.1mmol/L,SE 3.3mmol/L,K+4.9mmol/L,Na+142mmol/L,CL-101mmol/L,Ca+1.21mmol/L,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心脏外科疾病,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,常见心脏外科疾病,先天性心脏病,动脉导管未闭,房间隔缺损,室间隔缺损,法鲁氏四联症,获得性心脏病,风湿性瓣膜病,感染性心内膜炎,心包疾病,心脏肿瘤,缺血性心脏病,冠状动脉粥样硬化性心脏病,左室室壁瘤,室间隔穿孔,大血管疾病,主动脉夹层,主动脉瘤,大动脉炎,哈尔滨治疗先天性心脏病哪家医院好,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,室间隔缺损,房间隔缺损,心内膜垫缺损,肺静脉异位引流,三房心,无顶冠状静脉窦综合征,动脉导管未闭,主,-,肺动脉间隔缺损,主动脉缩窄、主动脉弓离断,主动脉瓣与主动脉瓣下、主动脉瓣上狭窄,双腔右心室,法洛氏四联症,右室双出口,左室双出口,三尖瓣下移畸形,三尖瓣闭锁,单心室,肺动脉闭锁,先天性二尖瓣疾病,共同动脉干,左心发育不良综合征,矫正性大动脉转位,完全性大动脉转位,先天性肺动脉瓣狭窄,冠状动脉瘘,冠状动脉起源异常,大动脉异位,先天性心脏病（简称：先心病）,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,瓣膜病,二尖瓣疾病：二尖瓣狭窄、二尖瓣关闭不全；,主动脉瓣疾病：主动脉瓣狭窄、主动脉瓣关闭不全；,二尖瓣、主动脉瓣联合病变；,三尖瓣疾病：三尖瓣狭窄、三尖瓣关闭不全,心房纤颤的外科治疗,感染性心内膜炎,心包疾病,原发心脏肿瘤,肥厚型梗阻性心肌病（理论上外科手术）,慢性栓塞性肺动脉高压,终末期心脏病,获得性心脏病,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,冠状动脉粥样硬化性心脏病（冠心病）,左室室壁瘤,心肌梗死后室间隔穿孔,冠心病合并颈动脉狭窄,冠心病合并瓣膜病（冠心病合并缺血性二尖瓣关闭不全,冠心病合并瓣膜退行性变、冠心病合并风湿性心脏病）,缺血性心脏病,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,大血管疾病,胸主动脉瘤,主动脉夹层,腹主动脉瘤,大动脉炎,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,临床比较常见先天性心脏病,哈尔滨动脉导管未闭专科医院,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,一、动脉导管未闭,(patent ductus arteriosus,PDA),Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,胚胎学,动脉导管是胎儿期连接降主动脉峡部与左肺动脉根部的正常结构，胎血由肺动脉经此通道流入主动脉。,出生后肺动脉阻力下降，,前列腺素,E1,和,E2,减少和血氧分压增高，,85%,婴儿在生后,2,月内导管平滑肌收缩，,导管闭合为动脉韧带。,愈期不闭即成为,PDA,。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,解剖分型,PDA,可单独存在，也可合并其他先心畸形,主动脉缩窄,室间隔缺损,法洛四联症,按形态分型,管型,漏斗型,窗型,动脉瘤型,哑铃型,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,出生后主动脉压升高，肺动脉压降低，,PDA,使主动脉血持续流向肺动脉，形成,LR,分流。分流量大小与导管粗细及主,-,肺动脉的压差有关。,LR,分流增加肺血流量，既使左心容量负荷增加，左室肥大甚至心衰；又使肺小动脉反应性痉挛，长期痉挛导致肺小动脉管壁增厚和纤维化,右心阻力加重和右室肥大。,病理生理,随着肺阻力进行性增高，肺动脉压接近或超过主动脉压时，出现双向或逆向分流，病人出现发绀，称艾森门格,Eisemangers,综合征，终致右心衰而死亡。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,临床表现,症状,导管细者，常无症状（分流小）,导管粗者，气促、咳嗽、乏力、多汗、心悸，喂养困难、发育不良,体检,心音：,P,2,亢进,特征性杂音,L,2,DM+SM,和,周围血管征,并发症：肺炎、细菌性心内膜炎、充血性,心衰,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,PDA,特征性体征,杂音：,L,2,SM+DM,胸骨左缘第,2,肋间连续性机器样杂音,占据全收缩,-,舒张期，呈大菱形（收缩末期最响亮）,常伴震颤,LR,分流大者，二尖瓣相对狭窄，心尖舒张期杂音,肺动脉高压者，杂音消失或仅有收缩期杂音,周围血管征,原因：动脉舒张压降低，常出现脉压增宽,表现：甲床毛细血管搏动、水冲脉、股动脉枪击音,差异性发绀：肺动脉压,主动脉压，,RL,分流，下半身发绀和杵状趾,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心电图、,X,线,ECG,典型者，正常或左心室肥大,肺动脉高压者，左右心室肥大,CXR(Chest X Ray),肺充血,心影增大，左心缘向左下延长,漏斗征：主动脉结突出，肺动脉段隆出,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,超声心动图,左室径增大,二维切面显示,PDA,多普勒：从主动脉弓降部向肺动脉的,LR,分流,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,诊断和治疗,一般,根据体征：杂音性质,-,位置、周围血管征,结合,UCG,、,CXR,、,ECG,，不难诊断,不典型者,右心导管,/,主动脉造影,肺动脉血氧增高,右心导管进入降主动脉,主动脉造影，,PDA,及肺动脉显影,鉴别：,PDA,需鉴别,主,-,肺动脉间隔缺损,主动脉窦瘤破裂,冠状动,-,静脉瘘,肺动静脉瘘,冠脉,-,心腔漏,室缺伴主动脉瓣反流,The 2nd Affiliated Hospital of Harbin Medical University,PDA,逆行升主动脉造影,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,PDA,PDA,Aorta,Aorta,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术适应证,适应证：确诊既有手术指征,时机,婴幼儿反复肺炎、呼吸窘迫、心竭或喂养困难者，应即时,手术,无明显症状者，学龄前手术，亦可早期手术,发绀型,+PDA,勿单扎导管，需同期矫治畸形,禁忌证：艾森门格征,并发症：出血、喉返神经损伤、导管再通,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术方法,根据基本技术、手术入路和导管处理方式不同,结扎,/,钳闭术,左侧标准剖胸切口,切断缝合术,左侧标准剖胸切口,内口缝合法,正中剖胸体外循环,胸腔镜钳闭,左胸小切口内镜,导管封堵术,外周动脉介入治疗,小切口封堵,左胸第二肋隙介入,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,PDA,结扎手术,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,经皮穿刺股静脉和股动脉，置入右心和左心导管，将右,心导管经肺动脉和,PDA,，放入降主动脉。逆行主动脉造,影显示,PDA,形态与位置，确定是否适合封堵并选择器材。,经右心导管换入导丝，以导丝为轨道，引导送入适当封,堵伞至,PDA,，释放封堵伞闭塞动脉导管。,此法创伤小，适用于,PDA,细长而肺动脉压不高的病例。,导管封堵术,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,二、房间隔缺损,(atrial septal defect,ASD),哈尔滨治疗房间隔缺损多少钱,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,解剖学分型,房缺依位置分型，与诊断治疗相关,原发孔,/,第一孔型,继发孔,/,第二孔型,原发孔缺损位于,冠状窦前下方，靠近二尖瓣环,，常伴二尖瓣大瓣裂缺,继发孔缺损位于冠状窦后上方，分,中央,/,卵圆孔型、上腔,/,静脉窦型、下腔型和混合型,缺损直径,24cm,。如伴肺静脉异位引流入右房，称部分性肺静脉异位引流,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,上腔（静脉窦）型,ASD,冠状静脉窦,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,LR,分流：病理生理,正常左房压,810mmHg,超过右房压,35mmHg,。,左房血液经房缺向右心房分流,(LR),分流量取决于缺损大小、心,房间压力差。,长期,LR,分流致右房室和肺动脉扩张；肺血量增加导致,动力性肺,动脉压高压,，肺小动脉反应性痉挛；长期痉挛使肺小动脉管壁增,厚和纤维化，最终导致,梗阻性肺动脉高压。,当右房压,左房压，出现,RL,分流，发绀，即艾森门格,Eisemangers,综合征，终因右心衰死亡。,继发孔房缺的进展较慢，原发孔房缺常伴二尖瓣返流，病程进展较,快。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,临床表现,典型症状体征：劳力性气促心悸,乏力,肺易感,继发孔房缺儿童期多无明显症状，青年期逐渐出现,原发孔房缺症状早表现重,L,2-3,SM,，,P,2,亢进、固定分裂,后期症状体征：梗阻性肺动脉高压期，出现,发绀,右心衰竭,L,2-3,SM,，,P,2,、固定分裂,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,体格检查,典型体征,P,2,亢进，固定分裂,胸骨左缘第,23,肋间,级缩鸣,分流大者有心尖舒张期杂音,原发孔房缺伴二尖瓣裂缺，心尖,级缩鸣,病程晚期体征,心房纤颤,肝大、下肢水肿,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心电图,继发孔房缺,电轴右偏,不全性,/,完全性右束支阻滞（,QRS,间期延长）,P,波高大，右心室肥大,原发孔房缺,电轴左偏,一度房室阻滞（,P-R,间期延长）,晚期出现心房纤颤，左室高电压,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,X,线检查,右心增大，肺动脉段突出，主动脉结小，呈典型梨形心。,肺充血，透视下可见肺门“舞蹈”征。,原发孔缺损左心室扩大，肺门血管影增粗。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,超声心动图,继发孔缺损可明确显示,ASD,位置大小,（房间隔,连续性中断,）,心房水平,LR,过隔分流,频谱,右房右室扩大,原发孔,ASD,可见,右心左心扩大,二尖瓣裂缺及其所致的二尖瓣返流,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,UCG ASD,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,诊 断,根据体征和,UCG,，结合,ECG,和,CXR,，不难诊断,诊断困难可行右心导管检查,导管进入左心房,右房血氧含量较上下腔静脉高,1.9%,容积,测得肺动脉压和算出肺血管阻力,判断肺动脉高压的手术适应证,鉴别：高位室缺、肺动脉瓣狭窄、原发性肺动脉扩张,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术适应证,无症状但右心房室扩大，应手术治疗,适宜的手术年龄为,35,岁,尽早手术：原发孔,ASD,、继发孔,ASD+,肺高压,50,岁以上、房颤、能控制的心衰非手术禁忌,禁忌证,艾森门格综合征,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术方法,正中开胸、体外循环、心脏停跳或跳动下,修补缺损：直接缝合、补片修补,右肺静脉异位引流，补片需将肺静脉口隔入左房,原发孔：停跳修补二尖瓣裂，补片修补房缺,并发症：气栓、房室阻滞,导管伞堵术,不需开胸，创伤小恢复快，费用较高,适用于有选择的病例,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,三、室间隔缺损,(ventricular septal defect,VSD),哈尔滨治疗室间隔缺损医院哪家好,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,是胎儿期室间隔,发育不全,所致的心室间异常交通，引起血液自,LR,分流，血流动力学异常,室缺可单独存在，也可是复杂心脏畸形的一部分,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,VSD,分型,解剖位置分型，三大类若干亚型,膜部缺损，最为常见,漏斗部缺损，较为常见,肌部缺损，较少见,多数室缺为单个,肌部缺损有时为多个,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,病理生理,收缩期左右心室间压力差，室缺发生,LR,分流,(,收缩期,),缺损大小决定分流量多少和有无症状,小缺损分流量少,大缺损左室容量负荷加重，左房室扩大,肺血流量高，冲击肺动脉痉挛产生,动力性肺动脉高压,，,右室阻力增大导致右室肥大,病程进展形成,梗阻性肺动脉高压,，最后,R L,分流,Eisemangers,综合征,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,临床表现,症状：劳累后气促、心悸、活动耐力差,室缺小，分流小，一般无症状,分流大者生后即有症状,反复呼吸道感染、充血性心衰,喂养困难、发育迟缓,甚至逐渐发绀、右心衰,并发症：室缺病人易并发,呼吸道感染,感染性心内膜炎,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,体格检查,典型杂音,胸骨左缘,24,肋隙的,+,缩鸣，伴震颤,杂音变化,位置变化：杂音位置与缺损位置有关,肺动脉高压：杂音变柔短促，,P,2,亢进,分流大者：心尖闻及确舒张期杂音,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心电图,典型,ECG,电轴左偏，左室高电压,不典型,缺损小：正常心电图，或电轴左偏,缺损大：左心室肥大,肺动脉高压：双室肥大、右室肥大劳损,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,VSD X,线检查,典型,CXR,肺血增多,左心缘向,左下延长。,不典型,缺损小，分流小者，,X,线改变轻。,缺损大，心影扩大，肺动段突出，肺充血。,哈尔滨治疗肺动脉高压医院,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,VSD,肺动脉高压,CXR,梗阻性肺动脉高压,肺门增粗肺纹细小,肺门和外周血管影呈“残根状”改变,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,超声心动图,典型超声表现,左室左房增大，或双室扩大,室间隔连续性中断（缺损部位及大小）,多普勒判断分流方向和分流量,室水平收缩期,LR,过隔血流,频谱了解肺动脉压力,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,VSD UCG,室间隔连续性中断,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,诊断,根据心脏杂音的部位及性质特点，结合超声心动图、心电图和,X,线检查结果，不难诊断。,严重肺动脉高压者有时需行右心导管检查，计算出肺动脉压力、心内分流血量和肺血管阻力，帮助把握手术适应证。,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术适应证,小缺损（约半数在,3,岁前可自然闭合）,无症状,/,房室不大，长期观察，预防感染,房室扩大，学龄前手术,大缺损（分流量大）尽早手术,喂养困难、反复肺部感染、充血性心衰、肺动脉高压,肺动脉瓣下缺损，应及时手术,易并发主动脉瓣脱垂致关闭不全,艾森门格综合征，禁忌手术,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,手术方法,导管伞堵法,新方法，创伤小，严格选择,远期结果有待观察,手术治疗法：,正中切口体外循环,心脏停跳修补室缺,小缺损者直接缝合,大缺损或肺动脉瓣下者补片修补,避免损伤主动脉瓣和房室传导束,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,四、心脏瓣膜病,哈尔滨治疗心脏瓣膜病医院,邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,定义,由于炎症、粘液样变性，退行性改变、先天性畸形、缺血性坏死、创伤等原因引起的单个或多个瓣膜结构,(,包括瓣叶、瓣环、腱索或乳头肌,),的功能或结构异常，导致瓣口狭窄及,(,或,),关闭不全。,心室和主、肺动脉根部严重扩张也可产生相应房室瓣和半月瓣的相对性关闭不全。二尖瓣最常受累，其次为主动脉瓣,.,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,一,.,病理解剖：,二尖瓣炎症，水肿 瓣膜增厚、粗糙、粘连、融合 瓣口狭窄,(1).,隔膜型,:,瓣体病变轻,弹性较好,.,(2).,隔膜漏斗型：瓣膜广泛受累、腱索粘连,.,(3).,漏斗型,:,粘连增粗并纤维化、钙化瓣下结构缩短变硬,形成漏斗状,.,二尖瓣狭窄,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,二尖瓣口面积,4-6cm,2,二尖瓣,口,狭窄,:,轻度,:1.5 2cm,2,压差,10 mmHg,中度,:1.0 1.5 cm,2,压差,10-20mmHg,重度,:20mmHg,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,二尖瓣口狭窄 左房进入左室血流,受阻 血流淤积于左房 左房,扩大压力升高 血流缓慢,左心耳,左,房血栓形成 肺静脉,肺毛细血管压,升高 肺动脉扩大 右室阻力升,高右室肥厚右心衰竭,.,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,二,.,临床表现与诊断,:,1,、,呼吸困难：,劳力性呼吸困难,静息时呼吸困难,阵发性呼吸困难,端坐呼吸,急性肺水肿,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,2,、咯血,：,1,）鲜血,(,支气管静脉破裂,),2,）血性痰,(,微血管破裂,),3,）粉红色泡沫痰,(,急性肺水肿,),4,）暗红色血,(,肺梗死伴咯血,),3,、咳嗽：,支气管粘膜淤血和左房增大,4,、声嘶：,（少见）扩大左房压迫左喉返神经,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心脏外体征,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,心脏体征,(,典型和诊断价值,),心尖部,舒张期隆隆样杂音,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,右心衰竭体征,颈静脉征,肝脏肿大,下肢水肿,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,M,型：二尖瓣前叶活动双峰消失，舒张早期形成,E,峰，形成城墙样改变，二尖瓣前后叶同向运动,超声心动图,Contact Us,哈尔滨市南岗区学府路,246,号 邮政编码,:150001,P.123 456 7890/email,The 2nd Affiliated Hospital of Harbin Medical University,X,线检查,左心房增大、右心