动脉导管未闭课件.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,*,先天性心脏病,Congenital Heart Disease,(CHD),陈小荣,包头医学院第二附属医院儿科,第十三章,概述,Overview,CHD is defined as an abnormality in circulatory structure or function that is present at birth,even if it is discovered much later,CHD is present in 0.687%in China,先天性心脏病是胎儿时期心脏血管发育异常而导致的先天性畸形,出生后1年内先天性心血管发育畸形出现率占活产婴儿的6.87,By the progression of all kinds of inspection techniques and interventional therapy,the prognosis of CHD has taken on a new look.,概述,Overview,由于多种心血管检查技术（尤其是彩色多普勒超声心动图）的应用，深低温麻醉和体外循环下心内直视手术的发展，先心病介入性治疗进展，临床上对先心病的诊断和治疗发生了很大变化，预后大为改观。,目的规定 Objective and Request,掌握室间隔缺损、房间隔缺损、动脉导管未闭、法洛四联症的血流动力学、临床体现及常见并发症,To master the hemodynamics and clinical situation and the diagnosis of common complications in VSD,ASD,PDA and TOF,熟悉先天性心脏病的病因、分类、防止及治疗原则,Familiar with the etiology and classification of CHD,病因,Etiology,遗传原因(内在原因)与基因突变、染色体畸变有关,Genetic factor(internal factor),CHD result from gene mutation or chromosome aberration,环境原因(外界原因)与宫内病毒感染有关,Environmental factor(external factor),CHD is mainly correlation to the intrauterine infection,防止,Prevention,加强孕妇保健,The health protection of pregnant woman should be enhanced,防止接触药物、辐射等高危原因High risk factors should be avoided,妊娠初期适量补充叶酸,Suit dosage Folic Acid should be filled up in early pregnancy stage,室间隔缺损,Ventricular Septal Defect,（,VSD,）,室间隔缺损,Ventricular Septal Defect,（,VSD,）,室间隔缺损,Ventricular Septal Defect（VSD）,由胚胎期室间隔(流入道,小梁部和流出 道)发育不全所致,是最常见的先天性心脏病,约占我国先心病的50%.最多见为膜周部缺损.,病理生理,分流量多少取决于缺损面积.心室间压差及肺小动脉,大体可分为三种类型:,小型室缺:缺损直径不不小于5mm或缺损面积1.0cm/m体表面积.伴随肺血管病变进行系性发展则渐变为不可逆的阻力性肺动脉高压.,当右室收缩压超过左室收缩压,左向右分流逆转为双向分流或右向左分流,出现紫绀,即艾森曼格(Eiseenmenger)综合症.,室间隔缺损,血流动力学示意图,Hemodynamics Figure of VSD,PV,SVC,RA,PA,IVC,RV,PV,LA,AO,LV,肺静脉,上腔静脉,右心房,肺动脉,下腔静脉,右心室,肺静脉,左心房,积极脉,左心室,VSD,murmur,室间隔缺损,血流动力学变化,Hemodynamics of VSD,小室缺,可无血流动力学变化,Small VSD,no hemodynamics changes,大室缺,大量左向右分流,Large VSD,Large left-to-right shunts,动力型肺动脉高压,Dynamic PH,梗阻型肺动脉高压,Obstructed PH,艾森门格综合征,Eisenmenger Syndrome,肺动脉高压,Pulmonary Hypertension(PH),VSD临床体现Clinical findings of VSD,症状,Symptoms,反复呼吸道感染，生长发育落后、乏力、气短、声嘶,frequent respiratory infections,grow slowly,very poor weight,dyspnea,exercise intolerance,fatigue,congestive heart failure,体征,Signs,LSB,3-4,可闻,3-4/6,级粗糙全收缩期吹风样杂音，向周围广泛传导，伴震颤,A grade,-,/,medium-to-high pitched,harsh pansystolic murmur at the left sternal border(LSB)in the 3rd and 4th intercostal spaces,肺动脉瓣第二音亢进,The pulmonary component of S,2,is accentuation in intensity,合并积极脉瓣关闭不全时可闻舒张期杂音 A diastolic murmur indicate VSD combine with aortic regurgitation,室间隔缺损并发症,Complication of VSD,支气管肺炎,Bronchopneumonia,充血性心力衰竭,Congestive heart failure,肺水肿,Pulmonary edema,感染性心内膜炎,Infective endocarditis,房间隔缺损,Atrial,Septal Defect,（,ASD,）,房间隔缺损,房间隔缺损(atrial septal defect)是小儿时期常见的先天性心脏病,该病的发病率约为活产婴儿的1/1500,占先天性心脏病发病总数的5%-10%.女性较多见,男女性别比例为1:2.,病理解剖,原发孔型房间隔缺损 部分型心内膜垫缺损,继发孔型房间隔缺损 中央型,静脉窦型房间隔缺损 上腔型和下腔型,冠状静脉窦型,又称冠状静脉窦型缺损 无顶冠状窦,PV,LA,PA,LV,PV,SVC,RA,AO,IVC,RV,肺静脉,肺静脉,上腔静脉,右心房,积极脉,下腔静脉,右心室,左心房,肺动脉,左心室,房间隔缺损,血流动力学示意图,Hemodynamics Figure of ASD,ASD,murmur,上、下腔静脉血 肺静脉,右心房（扩大）左心房,右心室（增大）左心室（血量 减少）,肺血流量明显增长（肺充血）,肺小动脉痉挛、增厚 体循环供血局限性,右向左分流 （消瘦、乏力、心悸、气短等）,艾森门格综合征(少数病人晚期）,ASD,房间隔缺损,血流动力学变化,Hemodynamics of ASD,症状,Symptoms,同室缺相似,Symptoms of ASD are similar with that of VSD,体征,Signs,LSB,2-3,可闻1-3/6级柔和收缩期喷射音，无震颤,A grade,-,/,ejection SM is heard best at the LSB in the 2nd intercostal space,，,no thrill,P,2,固定分裂,S,2,at the pulmonary area is widely split and often fixed,肺动脉瓣第二音亢进,The pulmonary component of S,2,is accentuation in intensity,三尖瓣区可闻舒张期杂音,A mid-diastolic murmur can often be heard in tricuspid area,ASD临床体现Clinical findings of ASD,房间隔缺损并发症,Complication of ASD,支气管肺炎,Bronchopneumonia,充血性心力衰竭,Congestive heart failure,感染性心内膜炎,Infective endocarditis,辅助检查,X线体现 透视下可见肺动脉总干及分支随心脏搏动而一明一暗的”肺门舞蹈”征,心影略呈梨形.原发孔型房缺伴二尖瓣裂缺者,左心房及左心室增大.,治疗,不不小于3mm的房间隔缺损多在3个月内自然闭合,不小于8mm的房缺一般不会自然闭合.,反复呼吸道感染,发生心力衰竭或合并肺动脉高压者应尽早手术.房间隔缺损也可通过介入性 心导管术,应用双面蘑菇伞关闭缺损.,动脉导管未闭,Patent ductus arteriosus,(,PDA,）,动脉导管未闭,为小儿先天性心脏病常见类型之一,占先天性心脏病发病总数的15%.胎儿期动脉导管被动开放是血液循环的重要通道,出生后,大概15小时既发生功能性关闭,80%在生后3个月解剖性关闭.到一年,在解剖学上应完全关闭.若持续开放,并产生病理,生理变化,即称动脉导管未闭.,病理分型,管型:导管长度多在1cm左右,直径粗细不等,漏斗型:长度与管型相似,但其近积极脉端粗大,向肺动脉端逐渐变窄;,窗型:肺动脉与积极脉紧贴,两者之间为一孔道,直径往往较大.,PV,SVC,RA,PA,IVC,RV,PDA,PV,LA,AO,LV,肺静脉,肺静脉,上腔静脉,下腔静脉,右心房,积极脉,肺动脉,右心室,左心房,左心室,动脉导管未闭,血流动力学示意图,Hemodynamics Figure of PDA,动脉导管,PDA,murmur,右心室血流,体循环 舒张压,肺动脉 积极脉 供血减少 脉压增宽,肺血流量 肺动脉高压 艾森门格综合征,左房、左室扩大 （差异性紫绀）,（右心室肥大）,PDA,动脉导管未闭,血流动力学变化,Hemodynamics of PDA,症状,Symptoms,与VSD及ASD相似 Symptoms of PDA are similar with that of VSD and ASD,体征,Signs,LSB2闻及粗糙、响亮的持续性机器样杂音，占据整个收缩期及舒张期 A characteristic thrill and continuous and rough“machinery”murmur with a late systolic accentuation,心尖区可闻及舒张中期隆隆样杂音,A diastolic flow murmur is often heard at the apex,周围血管征,Peripheral vascular sigh,下半身青紫(差异性紫绀)和杵状趾,Differential cyanosis and clubbing,PDA临床体现Clinical findings of PDA,差异性紫绀,当肺动脉压力超过积极脉压时,左向右分流明显减少或停止,产生肺动脉血流逆向分流入积极脉,患儿展现差异性紫绀(differential cyanosis),下半身青紫,左上肢有轻度青紫,右上肢正常.,PDA,堵闭前心音图,S1,S2,PDA,堵闭后心音图,S1,S2,动脉导管未闭并发症,Complication of PDA,支气管肺炎,Bronchopneumonia,感染性心内膜炎,Infective endocarditis,充血性心力衰竭,Congestive heart failure,感染性动脉炎,少见的并发症有肺动脉和动脉导管瘤样扩张,动脉导管钙化及血栓形成.,治疗,早产儿动脉导管未闭的处理视分流大小,呼吸窘迫综合症状况而定.生后一周内使用消炎痛治疗,仍有10%的病人需手术治疗.采用介入疗法选择弹簧圈,蘑菇伞等关闭动脉导管.,但在有些病例中,如完全性大血管转位,肺动脉闭锁,三尖瓣闭锁,严重的肺动脉狭窄中,动脉导管为依赖性者,对维持患婴生命致关重要,此时应当应用前列腺素E以维持动脉导管开放.,左向右分流先心病共同临床特点,Common features of left-to-right shunting CHD,一般状况下无青紫 In general there are noncyanosis,心前区有粗糙的收缩期杂音 A rough systolic murmur is heard in precordium,肺循环血量多，易患肺炎 Pulmonary flow increase and easy to suffer from bronchopneumonia,体循环血量少，影响生长发育 Systemic flow decrease and the patient grow slowly,法洛四联症,Tetralogy of Fallot,（,TOF,）,法洛四联症,法洛四联症(tetralogy of Fallot,TOF)是婴儿期后最常见的青紫型先天性心脏病,约占所有先天性心脏病的10%.1888年法国医生Etienne Fallot详细描述了该病的病理变化及临床体现,故而得名.,法洛四联症四种解剖畸形,The four malformations of TOF,右室流出道梗阻,室间隔缺损 Ventricular septal defect,积极脉骑跨 Overriding of the aorta,右心室肥厚 Right ventricular hypertrophy,以上四种畸形中仅室间隔缺损 及右心室流出道狭窄是必须存在,室间隔缺损必须足够大使左右心室的压力相等;右心室流出道狭窄是决定患儿的病理生理,病情严重程度及预后的重要原因.并且,狭窄可随时间推移逐渐加重.,PV,SVC,RA,PA,IVC,RV,PV,LA,AO,LV,肺静脉,肺静脉,上腔静脉,右心房,肺动脉,下腔静脉,右心室,左心房,积极脉,左心室,法洛四联症,血流动力学示意图,Hemodynamics Figure of TOF,TOF,murmur,法洛四联症四种解剖畸形,The four malformations of TOF,肺动脉狭窄Obstruction to right ventricular outflow,室间隔缺损 Ventricular septal defect,积极脉骑跨 Overriding of the aorta,右心室肥厚 Right ventricular hypertrophy,右 心室（肥厚）左心室,肺动脉狭窄 积极脉,（血流量 、扩张）,肺血流量减少（肺野清晰）混合血进入循环,（青紫、发育落后、乏力,血氧合局限性（杵状指趾等）蹲踞、阵发性昏厥）,分流,分流,法洛四联症,血流动力学变化,Hemodynamics of TOF,青紫：本病最突出的症状,Cyanosis is the main symptoms,气促和缺氧发作,Dyspnea and hypoxemic spells,蹲踞症状,Squatting posture,心脏体征 LSB,2-4,闻及 2-4/6级收缩期喷射性杂音,There is a grade,-,/,rough,ejection-type SM that is maximal at the LSB in the 2,nd,to 3rd intercostal space and that radiates well to the back,杵状指趾,Clubbing of the terminal digits,TOF临床体现Clinical findings of TOF,杵状指,Clubbing of fingers,杵状指趾,Clubbing of fingers and toes,脑血栓,Cerebral embolism,脑脓肿,Cerebral abscess,感染性心内膜炎,Infective endocarditis,法洛四联症并发症,Complication of TOF,X Ray of TOF,X线检查,右室大、心尖上翘呈靴形，肺动脉段凹陷，肺野清晰,治疗,一般护理 平时应常常饮水,防止感染,及时补液,防治脱水和并发症.,缺氧发作的治疗 发作轻者使其取胸膝位即可缓和,重者应立即吸氧,予以新福林 每次0.05mg/kg静注,或心得安每次0.1mg/kg.必要时也可皮下注射吗啡每次0.1-0.2mg/kg,纠正酸中毒,予以5%碳酸氢钠1.55.0ml/kg静注,常常有缺氧发作者,可口服心得安1-3mg/(kg.d).,外科治疗,先天性心脏病的诊断,Diagnosis of CHD,病史,History,体查,Physical examination,心电图,Electrocardiogram,心脏X线检查,Chest X-ray,超声心动图,Echocardiogram,心导管检查和心血管造影,Cardiac catheterization and angiocardiography,临床上有诊断意义的心脏杂音,Clinical significance heart murmur,全收缩期杂音 Pansystolic murmur,收缩晚期杂音 Late systolic murmur,舒张期杂音 Diastolic murmur,持续性杂音 Continuous murmur,强度3/6级的杂音Grade 3/6 murmur,先天性心脏病的治疗,Treatment of CHD,内科治疗,Medical management,治疗心衰，良好护理,Anticongestive heart failure measures,good nursing,外科治疗,Operation treatment,开胸心脏修补手术,Repair the defect through transthoracic cardiac surgery operation,介入治疗,Interventional treatment,运用堵闭器材导管关闭继发孔ASD和PDA Catheterization closure with an interventional device is generally recommended for ostium secundum ASD and PDA,ASD,介入治疗,Interventional treatment of ASD,ASD,闭合器,PDA,介入治疗,Interventional treatment of PDA,PDA,闭合器,Thank You,